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What You Need to Know About Adult ADHD & Compulsivity

Updated: Jan 27

The incidence of attention deficit hyperactivity disorder (ADHD) in UK adults is between 3 and 4 percent, with a higher incidence in men than women (3:1 ratio). Attention deficit hyperactivity disorder is defined as a persistent pattern of inattention and/or hyperactivity or impulsivity that interferes with functioning or development.


I have encountered many people in healing and recovery circles who have ADHD. I myself have recently been diagnosed with ADHD. This led me to want to find out more about ADHD and its mental health associations, in particular with its associations with compulsivity. Compulsive Sexual Behaviour Disorder (CSBD) occurs in about 5 percent of the population. A staggering two thirds of people with CSBD report patterns of ADHD. It's time to find out more about the link between these two conditions...


Adult ADHD and mental health conditions - what you need to know


The three subtypes of ADHD

·      The inattentive subtype accounts for 20% to 30% of cases.

·      The hyperactive-impulsive subtype accounts for around 15% of cases.

·      The combined subtype accounts for 50% to 75% of cases.


Adult ADHD is characterised by inattention, hyperactivity, and impulsivity

Inattention is manifested by wandering off task, lacking persistence, having difficulty sustaining focus and being disorganised.

Hyperactivity In an adult is manifest by extreme restlessness or wearing others out with their activity. Many people had pointed this out to me prior to my recent ADHD diagnosis and being commenced on ADHD medication by my Consultant Psychiatrist.

Impulsivity refers to hasty actions that occur in the moment without forethought and that have high potential for harm to the individual (for example, darting into the street without looking). Impulsive behaviour may manifest as social intrusiveness (for example, interrupting others excessively) and/or making important decisions without considering the long-term consequences (for example, taking on a job without adequate information, and self-sabotage).


The causes of ADHD

These involve the interplay of multiple genetic and environmental factors that are thought to lead to altered brain neurochemistry and structure.

Associations and comorbidities

ADHD is associated with psychiatric or neurodevelopmental comorbidity, including  substance use disorder, behavioural addictions such as gambling, eating disorders (three times higher risk), and compulsive sexual behavioural disorder (CSBD - also known as 'sex and love addiction'), and mood disorders, such as major depression and severe generalised anxiety, which I suffer from. 


The reason for the link between ADHD and addiction may be an altered reward pathway in the brains of ADHD individuals, self-medication, and increased psychosocial risk factors. This makes the evaluation and treatment of ADHD more difficult, with serious substance misuse problems usually treated first due to their greater risks.


In November 2018 Cyberpsychology published a systematic review and meta-analysis of 5 studies that found evidence for a relationship between problematic smartphone use, ADHD, and impulsivity traits. In December 2023, the Journal of Psychiatric Research published a meta-analysis of 24 studies with 18,859 subjects with a mean age of 18.4 years that found significant associations between ADHD and problematic internet use.


ADHD and trauma

ADHD, trauma, and adverse childhood experiences are also comorbid, which could in part be potentially explained by the similarity in presentation between different diagnoses. The symptoms of ADHD and Post-Traumatic Stress Disorder (PTSD) (which I also suffer from) can have significant behavioural overlap - in particular, motor restlessness, difficulty concentrating, distractibility, irritability, emotional constriction or dysregulation, poor impulse control, and forgetfulness are common in both. This could result in trauma-related disorders or ADHD being mis-identified as the other. Additionally, traumatic events in childhood are a risk factor for ADHD; they can lead to structural brain changes and the development of ADHD behaviours. Finally, the behavioural consequences of ADHD symptoms cause a higher chance of the individual experiencing trauma (and therefore ADHD leads to a concrete diagnosis of a trauma-related disorder).


Features of ADHD

Suspect attention deficit hyperactivity disorder (ADHD) if there are at least five inattention symptoms and/or at least five hyperactivity-impulsivity symptoms that have:

·       Occurred in two or more settings such as at home and work.

·       Been present for at least 6 months.

·       Clearly interfered with, or reduced the quality of social, academic or occupational functioning.

Inattention symptoms include:

·       Failing to give close attention to detail or making careless mistakes in work, or other activities.

·       Difficulty in maintaining concentration when performing tasks.

·       Appearing not to listen to what is being said, as if the mind is elsewhere, without any obvious distraction.

·       Failing to follow through on instructions or finish a task (not because of oppositional behaviour or failure to understand).

·       Difficulty in organising tasks and activities.

·       Reluctance, dislike, or avoidance of tasks that require sustained mental effort.

·       Losing items necessary for tasks or activities such as pens, mobile phones, keys, or wallets.

·       Easy distraction by extraneous stimuli.

·       Forgetfulness with regard to daily activities. 

Hyperactivity-impulsivity symptoms include:

·       Fidgeting with or tapping hands or feet, or squirming when seated.

·       Leaving the seat where remaining seated is expected, such as at work.

·       A feeling of restlessness.

·       Being constantly on the move.

·       An inability to engage in leisure activities quietly.

·       Being 'on the go' or acting as if 'driven by a motor'. Others may experience the person to be restless or difficult to keep up with. This was very much the case for me. I always felt like I had a nuclear reactor driving me.

·       Talking excessively.

·       Blurting out an answer before a question has been completed. Guilty!

·       Difficulty waiting his or her turn.

·       Interrupting others and finishing off their sentences.

·       Often struggles to wait their turn, including waiting in lines.

·       In adults, hyperactivity is usually replaced by inner restlessness, which I very much identify with.

 

ADHD and high IQ

In individuals with high intelligence, there is an increased risk of a missed ADHD diagnosis, possibly because of compensatory strategies in those individuals.


Systematic reviews in 2017 and 2020 found strong evidence that ADHD is associated with increased suicide risk across all age groups, as well as growing evidence that an ADHD diagnosis in childhood or adolescence represents a significant future suicidal risk factor. A 2019 meta-analysis indicated a significant association between ADHD and suicidal spectrum behaviours (suicidal attempts, ideations, plans, and completed suicides); across the studies examined, the prevalence of suicide attempts in individuals with ADHD was 19%, compared to 9% in individuals without ADHD, and the findings were substantially replicated among studies which adjusted for other variables. As you know I have had three suicide attempts in my life.


Pathophysiology

Current models of ADHD suggest that it is associated with functional impairments in some of the brain's neurotransmitter systems, particularly those involving dopamine (which is also implicated in addiction) and norepinephrine.


Management

The management of ADHD typically involves counselling or medications, either alone or in combination. While there are various options of treatment to improve ADHD symptoms, medication therapies substantially improves long-term outcomes. Medications are the most effective treatment, and any side effects are typically mild and easy to resolve although any improvements will be reverted if medication is ceased.


To quote one systematic review, "Recent evidence from observational and registry studies indicates that pharmacological treatment of ADHD is associated with increased achievement and decreased absenteeism at school, a reduced risk of trauma-related emergency hospital visits, reduced risks of suicide and attempted suicide, and decreased rates of substance abuse and criminality."


Methylphenidate and amphetamine or its derivatives are often first-line treatments for ADHD. About 70 percent respond to the first stimulant tried and as few as 10 percent respond to neither amphetamines nor methylphenidate. Stimulants may also reduce the risk of unintentional injuries in children with ADHD. 


Magnetic resonance imaging studies suggest that long-term treatment with amphetamine or methylphenidate decreases abnormalities in brain structure and function found in subjects with ADHD.


Data also suggest that combining medication with CBT is a good idea: although CBT is substantially less effective, it can help address problems that reside after medication has been optimised.


Prognosis

Individuals with ADHD are significantly overrepresented in prison populations. Although there is no generally accepted estimate of ADHD prevalence among inmates, a 2015 meta-analysis estimated a prevalence of 26 percent, and a larger 2018 meta-analysis estimated the frequency to be 26 percent.


ADHD and compulsive sexual behaviour disorder (CSBD)

CSBD is also known as ‘sex and love addiction.’ For those grappling with CSBD, it may actually be a byproduct of a primary condition of ADHD.


Research has shown that a staggering 67% of people with CSBD reported patterns of ADHD.


Results from an anonymous survey conducted on over 14,000 participants revealed that the higher the levels of ADHD symptoms were, the higher the levels of CSBD were, too. These findings appeared to be consistent for both males and females.


In some cases, those with CSBD struggle with an inability to focus for an extended period of time due to the nature of intrusive thoughts relating to sex or sexual fantasies. In these cases, the symptoms of ADHD may be present due to the primary condition of CSBD.

Another theory, proposed by Dr. Rory Reid of UCLA, offers that CSBD in those with ADHD may not be a result of one of the defining characteristics of ADHD, such as impulsivity. Rather, he offers that people who struggled with ADHD in childhood also struggled with low self-esteem and poor self-concept. These children then become adults who self-medicate via sexual fantasy and sexual behaviours in order to cope with low self-confidence, or the trauma they endured as a child diagnosed with ADHD.


Research shows that ADHD can lead to symptoms of CSBD. CSBD can look like an increased sex drive, or it can look like engaging in high-risk sexual behaviours.


Some of the reasons why ADHD might lead to CSBD:

  • Those with ADHD have a constant need for stimulation. This can prompt them to seek something new or constantly seek something to satisfy that need. Individuals with ADHD tend to be overly active and have trouble paying attention and controlling impulsive behaviour.

  • Research shows that those with ADHD are more likely to engage in risky behaviours, including substance use. The increased likelihood of engaging in risky behaviours can lead someone to engage in risky addictive sexual behaviours.

  • People with ADHD and CSBD may use sex as a means of coping with the stress and anxiety that they experience as a result of their ADHD.

  • ADHD may be inclined to addictive behaviours to make up for the lack of dopamine in their brains, as they have lower levels of the chemical than people who don’t have ADHD.


When it comes to substance abuse, Dr Howard Schubiner, ADHD researcher said that “I think everybody in the field agrees, if you can get a toehold on the addiction, you should think about treating the ADHD relatively quickly. If you treat ADHD aggressively and you monitor for substance abuse, you’re going to reduce delinquency.”

 

ADHD, addiction, and dopamine dysfunction

One of the core characteristics of ADHD is a dysfunction in the brain's reward system, which parallels the mechanisms seen in addiction. In both conditions, there is an intensified pursuit of substances, activities and behaviours that trigger the release of dopamine - a neurotransmitter essential for pleasure and motivation. In ADHD this can be more subtle, sometimes known as "stimming" (stimulating) - or can sometime present as the individual only being interested in the things that they find 'fun'. Individuals with ADHD often have lower levels of dopamine or impaired dopamine receptors, leading them to engage in a cyclical pattern of seeking behaviours that momentarily spike dopamine levels. This quest for dopamine release is not just about seeking pleasure; for some with ADHD, particularly those with certain subtypes, it's a necessary means to maintain focus and engagement, even simply to feel ‘normal’. Once I started my ADHD medication, my anxiety levels plummeted and my ability to carry out tasks massively increased. I felt normal for the first time.


People with ADHD often have unstable dopamine levels, which compels them to seek activities that boost dopamine as a way to maintain focus and manage tasks. This constant pursuit of stimulation and rewarding experiences can become a compulsive behaviour that's hard to regulate and might lead to addiction in all its forms. The search for immediate gratification, whether through substances like nicotine, alcohol, or drugs or through behaviours such as escaping into fantasy, sexual activities, binge eating, or gambling, may be satisfying at first but soon turns into a relentless cycle of dissatisfaction and an increasing need for more intense stimulation. This striking similarity with characteristics of addiction suggests a high-risk genetic or other predisposition which amplifies the likelihood of developing substance use disorders and addictive behaviours in ADHD, as these activities or drugs also trigger a temporary increase in dopamine, which briefly eases the cravings.

 

The impact of rejection sensitive dysphoria (RSD)

Heightened sensitivity associated with RSD can lead to substantial distress. Individuals with RSD may experience profound discomfort and emotional pain, often from situations that might seem minor or insignificant to others. This can complicate personal and professional relationships, leading to avoidance behaviours and a heightened risk for depression and anxiety. In the broader conversation about addiction, the role of RSD is particularly pertinent.


The emotional turmoil associated with RSD can drive individuals to seek relief in unhealthy ways, including substance use or addictive behaviours, as a coping mechanism or self-soothing, to temporarily alleviate their emotional pain. Understanding and addressing RSD is crucial for those with ADHD and other overlapping disorders, as it can be a pivotal factor in both the development and recovery from addiction.


Emotional dysregulation in ADHD

ADHD is frequently associated with emotional dysregulation, a condition that affects how individuals manage and respond to feelings and emotions. This dysregulation often manifests as an inability to handle heightened emotions. Individuals with ADHD may find themselves unable to manage their responses effectively, experiencing intense feelings of frustration, anger, or sadness for seemingly little or no reason. This can make typical daily interactions and responsibilities challenging, as the emotional responses may not match the context or severity of the situation. A typical solution for someone with addictive tendencies may be to want to self-sooth or self-medicate – which, ironically, can often lead to addictive behaviours that would end up being labelled or becoming, self-destructive – the opposite of the original intention.


The impact of overstimulation 

For many with ADHD, the world feels overwhelmingly intense; noises can be louder, lights brighter, and experiences more emotionally charged. This constant overstimulation can lead to a state of chronic stress or anxiety, where even ordinary environments feel hostile or unmanageable. This can often be misinterpreted as social anxiety. The strain of continual overstimulation often pushes individuals toward finding quick relief. Unfortunately, this need for immediate escape from discomfort can lead them to engage in self-soothing behaviours that are potentially harmful, such as using potentially addictive substances or behaviours to seek temporary relief. These behaviours provide a reprieve from the relentless influx of sensory and emotional input that they are otherwise unable to filter or moderate, but can also lead to the development of addiction.

 

Personal insights into ADHD and recovery 

My own journey of recovery has included many examples of how sustained efforts, working the programme, and being a member of a like-minded community and loving fellowship really do work. However, there were certain things that I continued to struggle with - for example, heightened sensitivity and intense emotional responses seemed resistant to the strategies, tools and healthy coping mechanisms I had learned over the years. The diagnosis of ADHD later in life, quite recently, provided a crucial context for these experiences, revealing that my emotional and behavioural patterns were not merely remnants of past struggles, personality failures or somehow working the programme incorrectly -  but were deeply influenced by undiagnosed ADHD.


ADHD affects the brain’s executive functions and emotional regulation, making it difficult for those with the disorder to manage their time, complete tasks, and handle their emotions. This can lead to a perpetual cycle of unmet expectations and frustrations.


Coping strategies and the risk of addiction 

So it’s very clear that in order to manage their emotional and sensory overload, individuals with ADHD might turn to substances like alcohol, drugs, or activities such as gambling, sexual fantasy, or binge eating, which can quickly become addictive. These substances or behaviours often offer a momentary boost in dopamine or a temporary numbing effect, making them attractive solutions to someone struggling with constant dysregulation. Over time, what starts as a coping mechanism can evolve into a dependency, as the body and mind begin to rely on these substances or behaviours to manage everyday emotional and sensory challenges. This cycle of dysregulation and self-soothing through potentially addictive means highlights the critical need for targeted medical interventions that address both the symptoms of ADHD and the potential for addiction.

 

Low self-esteem and its relationship with addiction 

Chronic issues such as failing to complete tasks, habitual lateness, and misplacing everyday items can erode self-esteem over time. For someone with undiagnosed ADHD, these repeated failures can contribute to a persistent sense of inadequacy, embarrassment and shame, which are high-risk factors for developing addictive behaviours. Substance use, in this context, can be a coping mechanism to momentarily alleviate these feelings of low self-worth.


Ongoing research and perspectives 

As research into ADHD and addiction becomes more comprehensive, and the experiences of those with both conditions become more commonplace, the undeniable link between these disorders becomes clearer.


This growing area of knowledge highlights that effectively diagnosing and managing ADHD is critical not only in its own right, but quite possibly for preventing addiction from developing, and for supporting those in recovery.


The debate surrounding the best treatment strategies for individuals with ADHD who are at risk of addiction is ongoing and critical. It highlights the necessity of treatment plans that are medically sound and customised to the individual needs of each person. Ongoing exploration, openness and discussion are crucial. They empower the development of better-informed, holistic approaches that address the unique challenges at the crossroads of ADHD and addiction. As our understanding of these complex relationships expands, so must our open-minded strategies for support and intervention, ensuring they are both effective and considerate.

 

Conclusions


People with ADHD often have unstable dopamine levels, which compels them to seek activities that boost dopamine as a way to maintain focus and manage tasks. This constant pursuit of stimulation and rewarding experiences can become a compulsive behaviour that's hard to regulate and may lead to behavioural addiction.


Research shows there is a high rate of ADHD diagnoses among individuals with CSBD.  There is also evidence for an association between CSBD, sensation seeking and attachment difficulties. This is associated with sensation seeking and attachment difficulties. A staggering two thirds of people with CSBD report patterns of ADHD. Results from an anonymous survey conducted on over 14,000 participants revealed that the higher the levels of ADHD symptoms were, the higher the levels of CSBD were, too. Recent findings also indicate that consumption of internet pornography in ADHD individuals and other sexual activities may serve as a mood-altering 'self-medication' which may help to cope with stressful events and decrease depression and anxiety.


Addiction is a multifaceted health issue, deeply rooted in neurobiological, psychological, and societal elements - the bio-psycho-social model. Moreover, addiction frequently co-occurs with other conditions, particularly those involving mental health and as it’s now coming to be understood, neurodiversity, such as ADHD. Conditions such as ADHD, anxiety, and depression often run parallel to addictive behaviours, all of which I have suffered from, suggesting a growing area of common ground. 


One of these specific pathological influences that may negatively affect normal development of sexual functioning and behaviour is ADHD mainly because executive dysfunctions usually related to ADHD may cause various problems mainly related to impulsivity and CBSD, and other problems which may negatively affect psychological development of sexual identity and sexual functioning (2019). ADHD has significant effects in interpersonal relationships  (2013, 2019, 2019). In this context, some studies also reported lower relational satisfaction, impaired quality of romantic relationships, and higher rate of separations.


Distraction, self-comfort, and a need to stabilise mood and emotion are hallmarks of the relationship between ADHD and compulsive sexual expression. CSBD is a  frequent comorbid disorder related to ADHD (2013, 2019). Some studies also show positive associations between impulsivity and CSBD (2011, 2019) and inattentive symptoms also may be related to CSBD (2004, 2013). In addition findings suggest that sexual activities may serve as mood-altering 'self-medication' process in some individuals with ADHD (2011, 2013, 2019). The basic mechanism for this 'self-medication' might be reward deficiency that is typical of ADHD (2008) which can be related to addictive, impulsive, compulsive and risky sexual behaviours (2013, 2014, 2019, 2019). In this context, some findings suggest that risky sexual behaviours in ADHD individuals represent a dysfunctional form of emotional regulation (2012, 2019, 2019). In addition, research studies show that people with ADHD have increased tendencies to promiscuity and according to recent findings ADHD individuals have more sexual partners than people without ADHD (2023).



Speak in such a way that others love to listen to you: Listen in such a way that others love to speak to you.


George Bernard Shaw wrote that “Progress is impossible without change, and those who cannot change their minds cannot change anything.” Are you ready to change your mind?


Namaste.


Sending you love, light, and blessings brothers.


Olly



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