Review: Dipl.-Psych. Waldemar Zdero
The World Health Organization (WHO) points out in the ASRS ADHD screening test it developed: “The symptoms of this disease are often misdiagnosed as stress.” Nigg formulates: “…adversity can cause a child to look just like he has ADHD.” and says nothing other than that stress can generate symptoms that are very similar to ADHD. Individual studies also address the connection between stress and ADHD symptoms.
Most ADHD symptoms are congruent with “normal” symptoms of severe stress. However, ADHD and stress are by no means the same thing. Chronic uncontrollable stress, i.e. severe (and often psychological) stress that is perceived as threatening or frightening, can trigger almost identical symptoms to ADHD. Martin Winkler reports one such case anecdotally in a lecture. Cognitive impairments can be caused by both mental and physical stress.
Conversely, however, not all stress symptoms are also ADHD symptoms - even if the degree of similarity is quite impressive. In this article, we only present ADHD symptoms that are also stress symptoms.
The fact that ADHD symptoms can also be caused by causes other than ADHD has always been taken into account by carrying out a differential diagnosis when taking an ADHD history. ⇒ Differential diagnosis for ADHD
We have added the manifestation of the corresponding ADHD symptoms in italics.
The sources refer to the symptom as a stress symptom.
At ⇒ Symptoms of ADHD We have also integrated the sources from the stress literature for each ADHD symptom, which prove that the respective symptom is also known as a stress symptom.
Stress symptoms have a benefit in coping with challenges. At ⇒ Stress benefits - the survival-promoting purpose of stress symptoms We explain the term stress benefit and describe the stress benefit of the respective stress symptom.
ADHD mediates its symptoms by causing shifts in those neurotransmitters that also mediate stress symptoms. In ADHD, a disorder of the stress systems (e.g. the HPA axis) may be the cause of the symptoms (such as in the ADHD animal model of SHR, in which the HPA axis shutdown is defective, leaving it chronically overactivated). However, there are also other causal pathways. In the case of ADHD, people with ADHD react with symptoms of significant stress (which are then called ADHD symptoms) even without an external stressor. More on this in our article ⇒ ADHD as a chronic stress regulation disorder. To avoid misunderstandings: this does not mean that ADHD is merely a consequence of ongoing chronic stress and would end with the elimination of the stressor. This is the essential difference between ADHD and chronic stress: stress goes with the stressor, ADHD stays.
1. Cognitive symptoms¶
1.1. Attention problems¶
Attention problems as symptoms of stress.
- Almost every mental Disorder causes attention problems, e.g.:
- Psychosis
- Tourette’s
- Mania
- Panic disorders
- Obsessive-compulsive disorders
Specific to ADHD is the (attentional) impairment to carry out a pre-planned future directed action. Although people with ADHD are distracted by unimportant stimuli from the environment, their selective attention is barely impaired.
In our opinion, however, task switching problems are common in ADHD and are a consequence of impaired controllability of attentional focus.
The increased noradrenaline and dopamine levels during acute stress impair the functionality of the PFC above a certain level. While slightly elevated noradrenaline levels increase the ability to think, very high noradrenaline levels reduce this ability and behavioral control is transferred from the PFC to the posterior cortex.
Stress directly influences
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Arousal
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Vigilance
- focused attention.
1.2. Concentration problems¶
Concentration problems as symptoms of stress.
For information on the change in the functions of the PFC due to the very high noradrenaline level during stress, see 1.1 Attention problems.
Identical for ADHD.
1.3. Forgetfulness¶
Forgetfulness or memory problems as a symptom of stress:
- Implicit memory impaired
- Declarative memory impaired
- Impaired working memory
- For information on the change in the functions of the PFC due to the very high noradrenaline level during stress, see 1.1 Attention problems
All of the symptoms mentioned also occur in people with ADHD, but not in all people with ADHD.
1.4. Thinking blocks¶
Thinking blocks are a symptom of stress.
For the change in the functions of the PFC due to the very high noradrenaline level during stress, see 1.1 Attention problems. The shutdown of the PFC is blocked by very high noradrenaline and dopamine levels during severe stress
- The ability to think analytically
- Decision-making processes
Thinking blocks are a typical ADHD symptom.
1.5. Brooding; thoughts focus on the stressor¶
Brooding is a symptom of stress.
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for ADHD: circles of thought
1.6. Deteriorated self-perception to the point of inability to recover¶
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Low emotional self-control, spontaneity of feelings or avoidance of feelings (coolness, emotional dysregulation) is a symptom of stress.
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with ADHD: not being able to enjoy
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for ADHD and procrastination: aversion to mindfulness / reduced mindfulness
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See also: Alexithymia under feelings
1.7. Delay aversion / Delay aversion¶
Delay aversion is a stress symptom. It is understood as an impulsivity reaction. It correlates with impulsivity under stress and, in women, with an increasing heart rate.
Stress-reducing measures also reduce delay aversion.
Forms of expression:
- Impatience
- Not being able to wait
Occurs identically with ADHD.
Although not included in the ICD 10 / DSM IV symptom lists, delay aversion is one of the core symptoms of ADHD.
1.8. Delay discounting / devaluation of later rewards¶
Delay discounting is a stress symptom. This is also known as Discounting of Delayed Rewards, Temporal Discounting or Reward Prediction Error (RPE).
Immediate rewards are preferred to the same extent as by people without stress.
Rewards that are distant in time are seen as less attractive than by people without stress.
Delay discounting has various forms of expression:
1.8.1. Procrastination¶
1.8.2. Addictive tendencies¶
1.8.3. Disorder¶
1.8.4. Self-regulation ability impaired¶
The ability to self-regulate is an even greater predictor of professional success than intelligence.
1.9. Decision problems¶
Decision-making problems are well-known symptoms of stress.
identical for ADHD
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ADHD-HI: impulsive, unthought-out, spontaneous decisions
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ADHD-I: Difficulty making decisions
2. Behavior¶
2.1. Increased locomotor activity (urge to move, restlessness)¶
Hyperactivity is a symptom of stress.
Increased locomotor activity is a direct effect of the stress hormone CRH.
In ADHD-HI, this symptom is called hyperactivity (occurs primarily in children).
2.2. Restlessness¶
(Inner) restlessness and restlessness are symptoms of stress.
Inner restlessness is a typical symptom of the approaching final state of burnout.
In ADHD-HI: Inner drivenness, always having to do something (mainly adults)
2.3. Aggression¶
Aggression is a symptom of stress.
Aggression often occurs as a comorbidity in ADHD-HI (with hyperactivity).
2.4. Weak drive¶
Lack of drive is a symptom of stress
Lack of drive is a typical symptom of the approaching final state of burnout.
With ADHD: Dysphoria with inactivity
2.5. Social withdrawal¶
Social withdrawal is known to be a typical symptom of severe stress.
A restriction of social contacts during stress is attributed to the fact that
- No positive or even negative response is expected (avoidance or aggression, see the article on Rejection Sensitivity)
- The need for security and control is too great (too much closeness, ambivalence, closeness-distance pendulum)
Increased withdrawal behavior is a direct effect of the stress hormone CRH.
An increasing reduction in social contacts is a typical symptom of burnout.
Social withdrawal is common with ADHD.
2.6. Performance impaired¶
Performance is impaired under severe stress.
Impairment of effort due to lack of satisfaction from success or lack of expectation of success (lack of drive, switching off, refusal) are symptoms of stress.
Easy exhaustion, lack of energy and daytime tiredness are typical symptoms of the approaching final state of burnout.
Occurs identically with ADHD.
2.7. Drug / nicotine / alcohol abuse (addiction)¶
Drug / nicotine / alcohol abuse (addiction) is a symptom of stress
Smoking correlates with stress.
For ADHD:
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significantly higher rate of smokers
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frequent comorbidity with addictive disorders
2.8. Riskier decisions¶
Riskier decisions are a symptom of stress.
Occurs identically in ADHD-HI (with hyperactivity):
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Risk affinity
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spontaneous, rash decisions
2.9. Impulsiveness¶
Impulsiveness is a symptom of stress.
Occurs identically in ADHD-HI (with hyperactivity).
2.10. Sexual problems / loss of libido (not an ADHD symptom)¶
Sexual problems / loss of libido are a symptom of stress
Suppression of the libido is a direct effect of the stress hormone CRH.
Sexual problems or listlessness are not typical ADHD symptoms, but they do occur with ADHD.
Disordered sexuality tends to be mentioned as a common comorbidity in ADHD. Sexuality is further mentioned as an addictive item and a means of tension relief in ADHD. One study found less sexual satisfaction, more sexual desire, more sexual dysfunction and riskier sexual behavior in people with ADHD.
The number of sexual partners with ADHD is typically increased and the first sex takes place earlier on average than in those not affected. A decrease in libido is sometimes mentioned in connection with medication for ADHD or depression.
3. Emotional symptoms¶
3.1. Mood swings (often sad / depressive)¶
Mood swings are a symptom of stress.
Frequent sadness is known as a stress symptom.
Frequent depression is also a symptom of stress.
Despair is a direct effect of the stress hormone CRH. Noise or movies, on the other hand, rarely trigger cortisolergic stress.
In ADHD: Dysphoria with inactivity as the main symptom; in addition, genuine depression often occurs as a comorbidity.
3.2. Self-esteem problems¶
Self-esteem problems are typical symptoms of severe stress.
- Low self-esteem
- Self-hatred
- Suicidal tendency
- Guilt and shame
This also applies to listlessness, which could be seen as the equivalent of dysphoria when inactive and feeling depressed.
In particular, a threat to self-esteem that is perceived as uncontrollable leads to the release of cortisol.
Feelings of inferiority and failure are typical symptoms of the final state of burnout.
In ADHD: emotional dysregulation is a typical symptom.
3.3. Irritability¶
Frequent irritability is a symptom of stress. Irritability is a typical symptom of the approaching final state of burnout.
With ADHD and extraverted personality (ADHD-HI, ADHD-C): frequent
3.4. Anger / Anger¶
Anger / rage are well-known symptoms of stress.
In ADHD and extraverted stress phenotypes (ADHD-HI, ADHD-C): frequent
3.5. Listlessness/motivation problems¶
Listlessness/motivation problems are common symptoms of stress. Listlessness is presented here as the emotional side of listlessness.
For listlessness, see above under 2.4.
Motivation and drive problems are common with ADHD.
3.6. Feeling of being overwhelmed¶
Feeling overwhelmed is a symptom of stress.
This also occurs frequently with ADHD.
3.7. Fear/anxiety¶
Increased anxiety is a symptom of stress.
Increased anxiety, increased fear conditionability and increased caution in unfamiliar environments, in the open field, in the elevated plus maze and during conflicts are a direct effect of the stress hormone CRH.
Anxiety is often elevated in ADHD, especially in ADHD-I. Anxiety disorders are a common comorbidity of ADHD and can develop from untreated ADHD.
3.8. Increased sensitivity¶
Increased sensitivity is a symptom of stress.
ADHD always involves (at least partial) high sensitivity.
3.8.1. Jumpiness¶
Increased startle reactions are a direct effect of the stress hormone CRH.
3.8.2. Increased alertness / attention¶
Increased alertness and attention is a direct effect of the stress hormone CRH.
3.8.3. Increased acoustic perception¶
Increased acoustic perception is a direct effect of the stress hormone CRH.
3.8.4. Sensory overload¶
Overstimulation is a symptom of stress.
Increased sensitivity can also be referred to as high sensitivity.
For ADHD: stimulus filter too wide open.
3.9. Alexithymia (reduced emotional perception)¶
- Reduced awareness of one’s own feelings
- Low emotional self-control, spontaneity of feelings or avoidance of feelings (coolness, emotional dysregulation)
- A typical symptom of the final stage of a burnout is a flattening of emotions (with persistent sickliness).
In contrast to many other symptoms mentioned here, alexithymia does not appear to be a directly neurophysiologically mediated symptom, but rather a frequent consequence of or associated with an insecure-avoidant attachment style.
Emotional poverty / inner emptiness / alexithymia is a possible symptom of ADHD.
3.10. Frustration intolerance¶
Frustration intolerance is a typical symptom of the final state of burnout.
Frustration intolerance is a typical ADHD symptom.
3.11. Easier to offend¶
Increased sickliness is a typical symptom of the final stage of burnout.
Increased offending behavior is a very common ADHD symptom. We refer to it as rejection sensitivity.
4. Physical symptoms¶
Somatic complaints could be the only type of stress that occurs significantly less in people with ADHD than in people without ADHD. This fact would be highly surprising and not plausible without more detailed research and explanation. As we know, this does not apply to sleep disorders. However, our own studies also indicate - to our own astonishment - that somatic stress symptoms are significantly underrepresented in adult persons with ADHD. The only exceptions are sleep disorders (very clear) and states of exhaustion and muscle tension (still clear). In contrast, all other somatic stress symptoms are (still significantly) lower than in non-affected persons.
4.1. Sleep disorders¶
Sleep disorders are a symptom of stress.
Increased alertness and reduced deep sleep is a direct effect of the stress hormone CRH.
Frequent nightmares are also mentioned as a stress symptom.
Sleep disorders are very common with ADHD.
4.2. Muscle twitching¶
Muscle twitching is a symptom of stress.
In ADHD: often similar muscle twitching to a mild form of restless legs when falling asleep
4.3. Increased muscle tension¶
Increased muscle tension is a symptom of stress.
Increased muscle tone can, for example, lead to back pain and even vertebral blockages.
In combat, increased muscle tone protects against injuries.
4.4. Increased sensitivity to pain¶
Increased sensitivity to pain is a symptom of stress.
4.5. States of exhaustion¶
Exhaustion is a symptom of stress.
4.6. Cardiovascular complaints¶
Cardiovascular complaints are a symptom of stress.
ADHD-HI and ADHD-C (less ADHD-I) often correlate with elevated blood pressure and susceptibility to heart problems.
4.7. Loss of appetite / ravenous appetite¶
Eating disorders are a symptom of stress.
Loss of appetite is a direct effect of the stress hormone CRH.
Obesity is at least twice as common in people with ADHD as in those without. Eating disorders are up to 8 times more common in people with ADHD than in those without. More on this in the article ⇒ ADHD, obesity and eating disorders.
4.8. Headache¶
Headaches are a well-known symptom of stress.
4.9. Abdominal pain¶
Abdominal pain is a common symptom of stress, especially in children.
Nausea is also known as a stress symptom.
4.10. Frequent colds¶
Frequent colds are a symptom of stress.
An increased susceptibility to infections is a typical symptom of the approaching final state of burnout.
Stress hormones (adrenaline, CRH, ACTH) are able to artificially boost the immune system for a certain period of time. For the Homo sapiens species, it was simply conducive to survival when not exactly simple (avoidable) diseases occurred in situations of need, in which survival had to be fought for with great effort. The stress hormones adrenaline and CRH therefore cause a (temporary) inflammation-promoting increase in the activity of the immune system.
However, on the one hand, this increase is exhausting and, on the other hand, during the first stress break it leads to the body taking the necessary time to regenerate and actively combat illness - e.g. through fever and other mechanisms with which the body protects itself against pathogens.
This is the reason why many people fall ill during the first week of their vacation - when the stress subsides.
In addition to its stress symptom-mediating effects, cortisol also has the task of ending the stress reaction (by inhibiting the hormones released at the beginning of the stress chain and thus limiting its own release over time). Cortisol also reduces the pro-inflammatory effect of adrenaline and CRH and instead promotes other immune reactions, which are primarily directed against bacteria and parasites. Depending on the direction in which the stress systems are out of balance, excessive inflammation (e.g. of the intestinal mucosa in Crohn’s disease or of the skin in neurodermatitis) or excessive immune reactions against external pathogens (e.g. allergies) can occur.
4.11. Increasing respiratory rate¶
Panting is a symptom of stress.
An increased breathing rate is not known as an ADHD symptom.
