This chapter describes the totality of ADHD symptoms, that is, the subjective or observable effects of ADHD in the areas of behavior, perception, and sensation.
We have collected about 45 symptoms that can be directly triggered by ADHD.
⇒ Symptom total list according to manifestations.
ADHD is often misunderstood because it does not have 100% specific symptoms. If all ADHD sufferers had red and white striped earlobes, or if the symptoms could be reproducibly triggered by very specific stimuli (as in PTSD, for example), ADHD would be easier to diagnose.
All ADHD symptoms are at the same time (still) functional symptoms of “mere” severe acute stress, while in other disorders, such as depression, some of these stress symptoms have become dysfunctional. While all ADHD symptoms are also stress symptoms, not all stress symptoms are also ADHD symptoms. See more at ⇒ ADHD symptoms are stress symptoms.
From the total number of symptoms of ADHD presented here, the diagnosis-relevant symptoms according to DSM or ICD must be distinguished. DSM 5 lists only 8 symptoms:
- Inattention (distractibility and concentration problems, but not task switching problems)
- Inner drivenness
- Excessive talking
These are the symptoms that particularly distinguish ADHD from non-affected individuals and from other disorders. These are neither the symptoms that occur most frequently in ADHD (according to our data - which, however, come predominantly from adults - affected persons report procrastination more frequently than hyperactivity in ADHD-HI or than inattention in ADHD-I), nor are they the symptoms that most clearly distinguish ADHD from non-affected persons (i.e., without other disorders) (according to our data, these would be learning problems).
It is indisputable that DSM 5 as well as ICD 10 do not cover all symptoms of ADHD. For example, some Wender-Utah criteria are completely disregarded. Until DSM IV, the criteria catalogs were tailored exclusively to children, although it has long been known that the symptoms change in adults (hyperactivity decreases or disappears, inner drive comes to the fore).
⇒ ADHD in adults
There is no symptom of ADHD that occurs in all affected individuals. There is ADHD without attention problems (children: ADHD-HI with predominant hyperactivity; adults: ADHD-HI with predominant inner restlessness and inability to recover) and there is ADHD without hyperactivity (ADHD-I with predominant inattention). ADHD-C (inattention and hyperactivity/internal agitation) is the most common.
ADHD is therefore not characterized by the occurrence of a few specific symptoms, but by the frequent occurrence of a large number of symptoms from a much larger symptom cluster. The symptoms mentioned by DSM / ICD may or may not be included.
Less knowledgeable doctors and therapists sometimes fail to recognize ADHD because sufferers have an unusual symptom mix. When this results in sufferers being denied adequate treatment, it is tragic.
DSM and ICD are indeed important quality assurance tools for medical diagnosis. Nevertheless, they are primarily diagnostic guidelines and should not be misunderstood as exclusive diagnostic prescriptions (so also Allen Frances, the chairman of the DSV-IV Commission).
⇒ DSM and ICD - statistical tools, not diagnostic scales.
The diagnosis of ADHD cannot be made by identifying a specific symptom (categorical), but is made based on the set of applicable symptoms and their intensity (dimensional).
- On average, unaffected people have 1 to 2 of 18 symptoms often (about 5%)
ADHD sufferers often have an average of 12 of these 18 symptoms (about 66%)
While in the case of “merely” severe acute stress the symptoms caused by it disappear again after the stressors (the stress triggers) are removed, in the case of ADHD the symptoms persist even without an adequate stressor. In our view, ADHD could possibly be described as a chronic overreactivity of the stress regulatory systems (triggered genetically or by gene-environment interactions), so that ADHD symptoms occur even when the affected person is not exposed to acute or chronic severe stressors. More accurate, however, might be the account that ADHD and severe chronic stress have very similar symptoms and mediate their symptoms neurophysiologically in a very similar manner (dopamine and noradrenaline deficits). Thus, the distinction between ADHD and chronic stress is often not easy to make.
This is the reason why for an ADHD diagnosis an occurrence of the symptoms over a longer period of time and in several areas of life must occur. However, we doubt whether the 6 months required by ICD are already sufficient for this.
Someone who has been in a severe life crisis for some time, i.e., has had severe self-esteem- or existence-threatening (= cortisol-genic) stress for a year or two, will typically have stress symptoms throughout this long period of time at a severity and frequency that this can be mistaken for ADHD.
To distinguish ADHD from symptoms of severe chronic stress, the particular life history must be looked at. From the similarity of the symptoms of ADHD and severe chronic stress and from the neurophysiological mediation of these symptoms to distinguish is that ADHD can be caused by early childhood stress, which activates / manifests a genetic disposition. If the affected person has already had the (at that time still child-) typical symptoms of massive cortisol-tolerant stress in childhood/school time without corresponding stressors being present the entire time, ADHD can be assumed with some probability. If, however, the symptoms were not recognizable in the first 12 years of life, and if they first appeared in the last 6 to 12 months, since a certain stressor has been present, a “merely” acute stress overload is more likely.
Whereas ADHD is often misrecognized in adults because many therapists and physicians still only know the ADHD symptoms typical of children and therefore mistakenly apply DSM and ICD unmodified to adults as well, it is much more difficult to distinguish whether children suffer from ADHD or from chronic severe stress (which may come from the school environment or from the parental home) because one cannot look back on a complete school career and further years. ⇒ ADHD Diagnostic Methods.
Regardless, for stress symptoms in younger children, behavioral therapies for parents or school have been shown to be helpful, while behavioral therapies for young children have usually been shown to be of little help. The younger the child, the more effective are assistance interventions for parents and caregivers to prevent manifestation of ADHD. ⇒ ADHD - Treatment and therapy; ⇒ ADHD - Prevention and screening - What parents can do; ⇒ Secure attachment beats genetic disposition in ADHD
The question about ADHD subtypes does not help with the diagnosis either. The classical subtypes ADHD-HI (with predominant hyperactivity/impulsivity, without attention problems), ADHD-C (with hyperactivity and inattention), ADHD-I (predominant attention problems without hyperactivity) are, according to this view, nothing more than phenotypic reactions to the intense stress triggered by the dysfunctional stress systems. The ADHD-HI subtype has to relieve stress (impulsively) externally, the ADHD-I subtype rather eats the stress inside. SCT is now understood as a disorder in its own right and is no longer considered an ADHD subtype. Depending on the situation (and the stressor), one or the other subtype comes to the fore in some sufferers. Again, this does not distinguish ADHD from massive stress. See more at ⇒ ADHD subtypes-the different types of ADHD. Fortunately, the DSM 5 has again abandoned the distinction of ADHD by subtype.
To state it again in no uncertain terms, even though ADHD and chronic stress neurophysiologically mediate their symptoms along the same pathway, ADHD is something other than a mere reaction to existing stressors.
ADHD, as we understand it, can be described as chronic over-responsiveness of the stress regulatory systems, or such that the symptoms of ADHD are mediated by the same neurophysiological mechanisms (primarily dopamine. and norepinephrine deficiency) as chronic stress.
The stress systems that are overreactive in ADHD respond with a stress response even to life circumstances that are not stressful for unaffected individuals.
⇒ ADHD as a chronicized stress regulation disorder
ADHD sufferers thus show stress reactions (actually suffered) even when others enjoy life unencumbered.
With ADHD, a normal day at the office is like having your desk in the middle of the busiest pedestrian mall with a streetcar running right next to it every 3 minutes.
And although this sounds so drastic, it is not at all easy to find out whether this could affect you. What should you compare it to if you don’t know any other life?
ADHD is more than just a disorder of the stimulus filter, as it is also discussed in schizophrenia, mania or autism spectrum disorders, among others. In addition to the increased sensitivity (which is always present in ADHD and can be understood as a stimulus filter disorder), information processing (especially working memory in the dlPFC, which controls executive functions (planned tasks) and the reinforcement system in the striatum, which regulates motivation, drive and inhibition - and thus also hyperactivity) and stress regulation are further impaired.
The symptoms of ADHD are arranged in the following overall collection according to their perceptibility from the outside, not according to their neurophysiological correlates. For some symptoms, there is a reference to the description of the causative neurophysiological mechanisms.
To illustrate that ADHD symptoms show up identically to stress symptoms, most symptoms in the overall collection are accompanied by references to the fact that it is also a symptom of severe stress.
Stress and stress symptoms are not mere disease markers. Stress has concrete benefits in emergency situations, so it is initially functional. If individual stress symptoms become dysfunctional, they are perceived as a separate disorder. Depression: the functional dysphoria only at inactivity (stay active, fight the stressor = functional) when danger is imminent has become a massive mood drop not only at inactivity and leads together with severe anhedonia to a dysfunctional life impairment. Anxiety disorder: the functional increased caution (anxiousness) when danger is imminent has become so strong here that it restricts the ability to act - this has become dysfunctional.
To make the benefits of functional stress symptoms vividly comprehensible, we describe the respective advantages that the respective stress response might have had in evolutionary biology. In the following, we refer to these advantages as “stress benefits”.
⇒ Stress benefits - the survival-promoting purpose of stress symptoms Describing stress benefits is difficult because they have not yet been systematically studied scientifically; at best, they are mentioned in passing in the literature. The accounts given on this side are therefore largely hypothetical in nature.