Attention Deficit Disorder & Adrenal Hormones
I take issue with the word “disorder” in attention deficit disorder (ADD). It’s not a stretch to suggest that the disorder of ADD is actually a normal physiological response to the many insults of the modern world. The hyper-vigilance, distractibility, and impulsivity of ADD could all be predictable evolutionary adaptations intended to help us be safer and more successful in stressful environments.
Stress is not just mental, it quickly jumps to a physiologic effect. When the brain perceives stress, it sends both chemical and nerve signals to the adrenal glands ordering them to make two short-term stress hormones [epinephrine and norepinephrine] and the long-term stress master hormone cortisol. Not eating regularly enough and getting low blood sugar also spike cortisol levels. Cortisol is now known for promoting the dreaded stress-gut that gives chronically stressed people that apple shape.
Epinephrine and norepinephrine both promote the “fight or flight” response to the world by stimulating increased tone in the sympathetic nervous system. Other attributes of the “sympathetic state” are the tendency to freeze up, tense muscles, shallow breathing, and divert blood flow away from the extremities and digestive tract toward the large muscles. The sympathetic nervous system also interrupts digestion and makes it harder to concentrate and integrate and make new memories. If you have ever had trouble getting someone else (or yourself) to see a new point of view in a heated argument, you can probably thank the sympathetic nervous system for that gem of human psychology.
It all makes perfect sense if you think about it; if your body senses a threat (stress) it gets everything ready for a fight or flight from danger. Cortisol helps us prepare for stress by mobilizing resources to raise blood glucose and cholesterol. This sugar boost is good if you’re about to sprint away from an angry rhinocerous, but not so good (AKA promoting diabetes and heard disease) if the stress is an email or a phone call.
Here’s the problem: Unless you are actually being attacked, we don’t benefit from our sympathetic fight or flight response to modern stress. We just get ADD, cold hands and feet, impulsive carbohydrate eating and poor digestion. Stress hormones also directly promote the “modern epidemics” of abdominal obesity, high blood pressure, elevated cholesterol, diabetes, and heart disease. These conditions are crippling our “disease-care” system. (It’s too big of a stretch to call it “health care” anymore.)
Different people develop the symptoms of ADD for different reasons. As we learn more, it’s becoming clear that ADD is a mulch-factorial syndrome, not a single-cause disorder. We’ve been tossing all the different routes and version of ADD under a single umbrella diagnosis. This happens all the time in medicine–we want the convenience of understanding and explaining things simply (e.g. “my finger hurts because there is a splinter of wood in it”). The problem is that ADD and most neurological disorders are more complex than this.
In this way, conventional doctors can simply connect the dots between identifying symptom-A and then writing down drug-X on the prescription pad in the hopes that symptom-A goes away. This is called “symptom suppression” or “allopathic medicine”. Sadly, this point and shoot drug prescription is still the mainstay of conventional medicine.
Lets talk genetics. One explanation for why some people exhibit more ADD symptoms (and are more likely to get the ADD diagnosis) is that they may have a variant in the COMT enzyme. COMT (standing for Catechol-O-methyl transferase if you must know) breaks down the excitatory neurotransmitters: epinepthrine, norepinephrine and dopamine. If you have a variance in this enzyme, these excitatory neurotransmitters hang around in your synapses longer and can promote hyperactivity, short attention, anxiety and hypervigalance. See below.
We all experience ordinary and predictable stressful events (e.g. disagreements, bills, phone calls, traffic jams) that amount to stressful stimuli and lead to the production of catecholamines. One of the differences in people with genetic COMT defects is that the neurotransmitters spawned from the stimuli can easily pile up make little things amount to nerve-jangling “emergencies”. I think this is part of what is going on with at least a subset of ADD patients. The supplements SAMe (S-adenosyl methionine) can help support people with COMT mutations. If you also have a genetic variant of the MTHFR gene, then methyl-folate (a more advanced form of the vitamin folic acid) can help. There’s more, much more, but this begins to show the advantages of testing your genetics.
If neurotransmitters are the software, then our nueroanatomy is the hardware. There are developmental changes in the brain’s circuitry that make the symptoms of ADD more likely to present. Let’s talk about how some of that neuroanatomy gets set up and how it relates to the presentation of ADD. We know now that before we are born, our mothers begin to condition us to stress. High levels of maternal cortisol can actually cause predictable changes in brain anatomy that hard-wire us for the hyper-vigilance, distractibility and impulsivity we call ADD. Direct effects on brain anatomy include: decreased hippocampus size and function, increased amygdala size and reactivity, and decreases in the size of the anterior cingulate cortex (ACC). The good news is that we can rewire our brains with interventions like cognitive therapy, high dose DHA supplements.
- Amygdala—The brain’s “fear hub,” which activates our natural “fight-or-flight” response to confront or escape from a dangerous situation. The amygdala also appears to be involved in learning to fear an event, such as touching a hot stove, and learning not to fear, such as overcoming a fear of spiders. Studying how the amygdala helps create memories of fear and safety may help improve treatments for anxiety disorders or post-traumatic stress disorder (PTSD).
- Prefrontal cortex (PFC)—Seat of the brain’s executive functions, such as judgment, decision making, and problem solving. Different parts of the PFC are involved in using short-term or “working” memory and in retrieving long-term memories. This area of the brain also helps to control the amygdala during stressful events. Some research shows that people who have PTSD or ADHD have reduced activity in their PFCs.
- Anterior cingulate cortex (ACC)— the ACC has many different roles, from controlling blood pressure and heart rate to responding when we sense a mistake, helping us feel motivated and stay focused on a task, and managing proper emotional reactions. Reduced ACC activity or damage to this brain area has been linked to disorders such as ADHD, schizophrenia, and depression.
- Hippocampus—Helps create and file new memories. When the hippocampus is damaged, a person can’t create new memories, but can still remember past events and learned skills, and carry on a conversation, all which rely on different parts of the brain. The hippocampus may be involved in mood disorders through its control of a major mood circuit called the hypothalamic-pituitary-adrenal (HPA) axis.
Lets talk about drugs. The strategy of masking symptoms with drugs without identifying or addressing the cause of a health problem is the sad mainstay of modern allopathic medicine. Practically everyone in medicine is doing it–so most people (and their doctors) fail to recognize the short-sighted insanity of the practice. Meanwhile the pharmaceutical industry has been getting stronger and more influential in politics, regulation, marketing and spewing out reams of compromised medical research.
Many things can worsen the symptoms of ADD, depression and anxiety. Poor quality or inadequate sleep are a “no brainer” here. Nutrient deficiencies and artificial food additives from processed food and poor digestion can certainly make mental matters worse. Toxins in our food and environment are well known to exacerbate cognitive problems. Perhaps less well established, but also true is that food sensitivities and allergies, and hormonal changes like puberty or menopause can all exacerbate cognitive problems too.
The side effects of symptom suppression are often accumulative as the real problems fester or get driven deeper. With ADD medications, these stimulants may well be whipping already tired adrenals deeper into fatigue. ADD meds can do an admirable job of masking symptoms–for a while. The benefits also often come at a hefty price. Meds aside, heavy coffee drinkers might be treating ADD as a “solution” to fatigue and poor focus.
To find out if you really have adrenal issues, we can run a 4-sample salivary cortisol:DHEA stress index test. If you are in Washington where I have my medical license, I can order the test for you. I don’t order the testing on everyone because of the cost (~$150), and also because most of us in the modern world are probably experiencing some degree of adrenal fatigue. Sometimes though, seeing a graph of where your adrenal function is at can help motivate us to make lifestyle changes, track progress, and monitor setbacks.
Here’s my four-step program to address come likely causes of adrenal fatigue, and related ADD/depression/anxiety with the additional benefits of evading the “modern epidemics” (abdominal obesity, high blood pressure, elevated cholesterol, diabetes, and heart disease):
- Sleep: 7.5-9 hours a night, in an environment that is as dark, quiet, and undisturbed as possible. Go to bed as early as possible without phones or laptops or other stimulation. Using melatonin to induce better sleep is a fine idea if you have trouble falling or staying asleep.
- Exercise: regular moderate exercise is a great way to reduce stress, promote health, loose weight, feel better, improve sleep, balance immune function, and make better food choices.
- Nutrition: Eat frequently and regularly. Choose whole, fresh, nutrient-dense foods free of added sugar, preservatives and pesticides. Wild or pasture-fed animal products in moderation and plenty of whole fresh fruits and vegetables is the best way to eat. Things to avoid include corn-fed factory animal products, wheat, sugar, fast food and processed food. Also good to avoid are “naked carb’s”–this means “clothing” carbohydrates by eating them with fat and protein which slow the gush of sugar.
- Harmony: Meditation, yoga, tai chi, Qigong, heart math breathing. This is where neuroplasticity comes in handy. Neuroplasticity basically means that e can re-wire our brains to interpret and react to the cues in our environment so that we don’t “stress-out”. Even if we were hard-wired to be anxious or have ADD, we can change the way our brains work through various practices of stress reduction and mindfulness. The one I’m trying now is “heart math breathing”, and it is as simple as focusing attention on measured breaths: 5 seconds in, 5 seconds out. You don’t need any expensive equipment to benefit. I even found a free ap’ for my Android phone: MyCalmBeat. I think that starting ones day with 10-20 minutes of some mindfulness practice aimed at promoting mental calm can have enormous benefits.
On supplements: These can help too and ought to be considered on an individual basis, but I think it’s a mistake to focus on supplements to the neglect of the sleep, exercise, nutrition and harmony practices listed above. These practices are the foundation of helping your adrenals get back to ideal functioning.
Thyroid hormone issues often follow adrenal stress. Your thyroid gland sets the metabolic thermostat for almost every cell in your body. High thyroid makes you hot, nervous & jittery. Low thyroid hormones can make you feel tired, cold, sore, irritable and slow (i.e. brain fog). TSH, FT4, FT3, RT3 are the four tests I order most commonly for people with low thyroid symptoms. I’ve got a special deal with where I can run those four tests for $70 (without insurance, this might cost almost $600). The RT3 is a key thyroid test. Most MD/allopaths don’t check this one. If you don’t check RT3, the other lab tests may look totally normal and hide a major problem. High thyroid symptoms merit the same tests plus two anti thyroid antibody tests for an extra $47 (normally over $160).
Next down the chain of hormonal problems related to stress are the sex hormones—including Testosterone, DHEA, Estrogen, and Progesterone. When these are off, people can experience depression, irritability, low libido, and women might experience long, irregular or painful menstrual cycles, digestive problems like IBS, male pattern hair growth, and poly cystic ovarian syndrome (PCOS).
For the ladies, I can run an 11 sample salivary hormone profile that tracks the cycling hormones over an entire cycle (~$200). Once again, allopathic medication has swooped in to save the day with medications (birth controll pills, etc.) that try to mask the symptoms—without treating the causes. Carefully tracking symptoms and specific lab tests can reveal where the problems lie, and target more effective natural treatments to get you back on the road to feeling better. But guess what? Sleep, stress reduction, exercise and nutrition are the best long-term cures to ballance sex hormone problems too.
The mantra of treating hormonal problems in naturopathic (and “functional medicine”) is to start with adrenals then to address thyroid issues and finally to address the sex hormones. If your thyroid or sex hormones are off, it’s important to “treat” your adrenals to a better stress-busting lifestyle.
OK, let’s get back to ADD for a little bit. Did I get distracted there?
Years ago as I started medical school, I took the ADD medications for a short time myself. They had a truly miraculous effect with regard to improving my focus on one hand, and vicious side effects like insomnia and amphetamine addiction on the other. I quickly became exhausted, and was quickly in the habit of waking myself at 6AM, taking the meds, going back to sleep, and letting the amphetamines wake me up an hour later—not unlike a reanimated zombie. I was a naturopathic medical student at the time, and seeing the road ahead, I stopped taking them after three months–even though the short term effect on my ability to focus was profound. I could see that things were not headed in a good direction.
The medications may seem like a godsend as we struggle to train our children to adapt to schooling and the modern commercial world. I am also deeply concerned about the ultimate cost. I don’t doubt that ADD medications have helped turned lives and families around. I think children have more resilience in their adrenal glands and can handle the extra wear and tear on the adrenal glands and other systems from the medication for longer than adults can. I routinely get messages form people who have been taking the stimulant medications for over ten years and they are typically chronically fatigued, no longer getting any benefit from the medications and thoroughly addicted to them.
We live in an age when ADD, anxiety and depression are so prevalent that they are becoming commonplace. Also commonplace is the allopathic practice of using medications to suppress these *critically* important symptoms. All three conditions are the natural response to stress as mediated by the adrenal stress hormones in ourselves (and our mothers as we developed). I fear that eventually, society as a whole will pay some catastrophic costs if we don’t start recognizing and addressing the source of our stress: the profound discord between what human life evolved to need and the increasingly bizarre expression of technology and corporate greed we have been forced to swallow in a teetering and overpopulated world.
The cause, as I have mentioned, is in large part modern stress. To promote health and human welfare in human society, we will need to reduce stress by tackling the monumental task of reducing human population. Also key to reducing stress will be shifting the allocation of our subsidies and resources to help more people spend more of our time doing what humans were meant to do: exercising in nature and having a natural relationship to our food. We can probably further reduce our stress by choosing to cook and eat own home-grown food with people we care about. That way we may go to sleep feeling good, and greet each day with more stress-busting gratitude, mindfulness and ease.
That’s enough for today, I’m going to go walk in my parking strip and back yard gardens now.
May we all be well!
Dr. T.R. Morris is a licensed naturopathic medical doctor (ND). He is currently serving as faculty and consultant to the Institute for Functional Medicine (IFM). The IFM mission is to revolutionize medicine by teaching the latest genetic, nutritional, hormonal and other biochemically-based integrative medicine techniques to MDs and other practitioners looking for new tools to prevent and treat chronic disease. In the past, T.R. served as the medical director of a large integrative clinic and taught (genetics, physiology, biochemistry, microbiology, cellular & molecular biology) for 10 years for various medical programs in the Puget Sound. He sees patients in person (or long-distance via Skype consultations) from his home office in Seattle.
Contact Dr. Morris