The Chicken or the Egg
The Chicken or the Egg
How a diagnosis of C-PTSD and PTSD might delay an ADHD diagnosis in adulthood
Disclaimer: I am not a mental health professional or a doctor (a minor in psychology does not count). This is not a substitute for an evaluation or diagnosis. If you suspect you have C-PTSD, PTSD or ADHD, please consult a professional!
When I first began seeing my psychiatrist, one of the things that made her delay my evaluation for ADHD is that I have C-PTSD (Complex Post-Traumatic Stress Disorder) from childhood trauma. What distinguishes C-PTSD from PTSD is that it tends to be the result of prolonged trauma vs. one traumatic incident. In my case, there was a singular traumatic event that I think kicked off PTSD symptoms, and then the next several years were a consistent stream of trauma in my home.
If I had to point to a single incident where my PTSD symptoms began, it was the loss of my grandmother in 1994. My grandmother died of a heart attack very suddenly, and I was the one who found her. I won’t go into elaborate detail, as I have written about it elsewhere, but suffice to say that she was one of the closest people in my life and someone I loved dearly. That event was so traumatic that my memory of it is fractured and hazy. I was almost 13 at the time, and after that happened I began having anxiety attacks. My mother also suffered from anxiety, so it was assumed that I just had something that ran in the family. When I was 16, I was put on antidepressants, as crippling depression had joined the party. Between the ages of 13-18, I experienced a lot of trauma as my parents' marriage fell apart (they divorced when I was 17). My father suffered from severe alcoholism, and my mother tried to commit suicide. There was also emotional, physical, and narcissistic abuse. Add that to the normal bullshit of being a teenager, and it was an awful lot for me to handle at such a young age. I am a fortunate person who defied the odds, but so many years of sustained trauma took their toll, and I was diagnosed with C-PTSD in my early thirties after I nearly had a nervous breakdown.
I have been in therapy for almost twelve years. Unraveling my trauma and family dysfunction has been a long, difficult journey. For years, I attributed what I now know were ADHD symptoms to C-PTSD. The truth of the matter is that PTSD/C-PTSD and ADHD share a lot of symptoms in common, and this can be a common roadblock to diagnosis of ADHD - especially in women, since as I’ve mentioned, we present differently from men. I have been on SSRIs for depression and anxiety multiple times, only to have my symptoms return. I know now that SSRIs were not the right medication for me (although depression and anxiety are often comorbid disorders with ADHD, and it is not uncommon for a person with ADHD to be on both ADHD medication and an antidepressant), but I was always confused why with so much therapy and medication, nothing ever seemed to resolve the increasingly frustrating symptoms I was having. After so much intense and painful work, I understood my trauma, my triggers, and the why and how of my journey. Why wasn’t it working?
After so many years of seeking an accurate diagnosis, the Cliff’s Notes version of my trauma history is second nature to me. When I started with my new psychiatrist in November of 2022, I basically told her all of this as casually as putting in an order at Starbucks. I was in an active mental health crisis at the time, and my anxiety was worse than ever. Which of course made her go “whoa whoa whoa, okay, let’s slow down here” when I told her I thought I might have ADHD. I was super frustrated by this, since I’d done enough reading on ADHD at that point to be pretty sure that I had it. But upon further reading, I understand why she took her time and we did not formally evaluate me for ADHD until April 2023, when she felt confident we left no stone unturned.
According to a study in the National Library of Medicine, the exposure of stressful life events in childhood can predict the onset of ADHD symptoms, and also makes it more likely that those symptoms will persist into adulthood. The study also states that some 20-50% of children with childhood trauma have clinical levels of ADHD, and that the trauma can result in altered cognitive processing. Trauma is bad for the developing brain, and this alteration in cognitive processing can exacerbate existing ADHD symptoms. In fact, having ADHD makes you more susceptible to being abused, victimized, and traumatized, in part because of how our brains process things differently. As with most cases, I developed ADHD before the age of 12, but the trauma I endured as a teenager made the symptoms worse. To make things even more confusing, not every person who experiences trauma goes on to have PTSD, and while childhood trauma does not cause ADHD, studies have shown that having ADHD can make you up to four times more likely to also have PTSD, and you’re also more likely to develop ADHD if you had early childhood trauma. It’s a real “chicken or the egg” situation.
ADHD and PTSD often have overlapping symptoms. If you have ADHD, you’re probably struggling to finish reading this as it is, so I provide you with this handy dandy chart (taken from the Child Development Clinic in Sydney, Australia):
As you can see, this is a complex presentation of symptoms that put doctors and practitioners in a tricky situation. If a patient presents with depression, anxiety, and sustained childhood trauma, a C-PTSD diagnosis comorbid with Major Depressive Disorder, Generalized Anxiety Disorder, or a personality disorder is not incorrect. I had C-PTSD and GAD with a dash of depressive episodes. I was treated accordingly, with talk therapy and medication, as would be the case for most people presenting with this. Difficulty concentrating, disorganization, difficulty sleeping, and being easily distracted are symptoms I have always struggled with - and they are symptoms of both ADHD and PTSD. In fact, PTSD can go undiagnosed sometimes because of how it can mimic ADHD. According to the Child Development Clinic, the hyper-vigilance of someone with PTSD can actually be confused with the hyperactivity of ADHD, so it is entirely possible that a child can be misdiagnosed with ADHD when they really are responding to trauma. Conversely, an adult with undiagnosed ADHD who presents with C-PTSD or PTSD (raises hand) are often only diagnosed with the latter. It’s also not widely known that PTSD can also affect things like working memory and executive function, both of which are ADHD hallmarks.
Doctors in medical school are often taught the expression “if you hear horse hooves, don’t go looking for a zebra”. In the case of an adult who presents with childhood trauma and the accompanying symptoms, PTSD is the herd of horses. Therapists and doctors know how to treat it - with medication, EMDR, therapy, etc. - and make what they think is an obvious diagnosis without considering that there may be a second underlying issue. ADHD is often the “zebra” for undiagnosed adults with PTSD - no one is necessarily looking for it. At first, I was really angry that none of my previous doctors had considered that I had ADHD, but now I have a better understanding of why ADHD in a C-PTSD patient is more difficult to pinpoint. It’s also not as if having ADHD means that my C-PTSD is cured. ADHD medication doesn’t take away my trauma symptoms, but it does make them a hell of a lot easier to manage.
Being a woman or AFAB (Assigned Female at Birth) presents another layer of challenges. It is no secret that there is a gender gap in the treatment of mental health and disease. How many stories do we read about a woman’s pain being ignored, only to find out later she was in a life threatening situation? And if you are a woman of color, chances are that you face even more of a challenge being taken seriously, and the health outcomes are downright staggering as a result. The burden - for now - lies with us. Learning to become your own advocate is of utmost importance. If you have been diagnosed with C-PTSD or PTSD, but suspect you may have ADHD, you are going to have to speak up on your own behalf. Read everything you can get your hands on, and come in prepared to talk about what you’ve learned about ADHD (please don’t self diagnose on TikTok, although in some cases it can be a good tool to point you in the direction of resources). Chances are that you will come upon resistance. ADHD seems to carry more of a stigma than some other mental health disorders, and it is true that there is a big media focus on people drug seeking and/or being over-diagnosed, but that’s another post for another day.
Do not be afraid to ask for an ADHD evaluation. If you are uninsured, or underinsured, there are resources out there for you. CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorder) is an excellent website in general and a great place to start if you suspect you may have ADHD.
Here are all the links I referenced in this post for ease of access. Many of these websites have a ton of terrific information. I hope this was helpful! If there is anything about this issue you want me to talk more about, please let me know in the comments!
Links cited:
What to Know About Complex PTSD and its Symptoms - WebMD
Comorbid ADHD and Depression: Assessment and Treatment Strategies - Psychiatric Times
ADHD symptoms in healthy adults are associated with stressful life events and negative memory bias - National Library of Medicine
ADHD vs. PTSD - Neurodivergent Insights
Adult ADHD and PTSD: What’s the Link? - WebMD
The Inattentive, Impulsive and Hyperactive Child: Is Childhood Trauma Buried Amongst ADHD? - Child Development Center (Sydney, Australia)
From heart disease to IUDs: How doctors dismiss women’s pain - The Washington Post
How discrimination can harm black women’s health - Harvard School of Public Health
Coping With the Stigma of ADHD - ADDitude Magazine
As someone who has both complex PTSD and ADHD I really appreciate it this entry. I look forward to reading more on your substack. Thank you so much for sharing your story!