Psychiatry (3)



Christian Jonathan Haverkampf M.D.

Psychiatry is the medical specialty devoted to the diagnosis, prevention, study, and treatment of mental disorders. These include various abnormalities related to mood, behaviour, cognition, and perceptions. Working on internal and external communication is a central focus in psychiatric treatment.

Keywords: psychiatry, psychotherapy, communication, medicine


Introduction. 3

Communication. 4

Biological and Social Science. 5

Approaches. 5

Software and Hardware. 5

The biopsychosocial Model 6

Diagnostic systems. 6

Diagnostic manuals. 7

Assessment. 8

Medication. 8

Psychotherapy. 9

Medication and Psychotherapy. 10

Ethics. 10

Health. 11

Into the Future. 11

References. 12


The question what psychiatry is begins with the definition of the term ‘psyche’. The term “psychiatry” was first coined by the German physician Johann Christian Reil in 1808. The ancient Greek term ‘psyche’ is often translated as ‘soul’. However, it can also mean ‘butterfly’. While psychiatry was up until about a century ago more an occult art than a science, this has changed dramatically in the twentieth century. Within the last century, psychiatry began to make its terms, observations and inquiry much more structured and ‘scientific’.

Psychiatric illnesses all have in common that communication with others and the own person is disturbed. (Haverkampf, 2010b) These maladaptive communication patterns lead to the symptoms which are commonly observed. For example, in a case of schizophrenia the source of incoming information can no longer be correctly attributed to the outside world or the inside, and in a case of anxiety emotional signals are no longer correctly identified and processed. Communication, the transmission of messages, adheres to rules like any other natural phenomena and is relied on in nature from information carried in a beam of light to cells exchanging DNA. Humans can observe and reflect on these flows of information, also on information flows within themselves. The sense of self and the attribution of a mind to someone or oneself is a result of the ability to observe these flows of information, and as such of the communication one has with oneself or the world around.

Psychiatry refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans. It is devoted to the diagnosis, prevention, study, and treatment of mental disorders. These include various abnormalities related to mood, behaviour, cognition, and perceptions. Psychiatry focuses on the interaction between patients and therapists in a way, which no other medical specialty does. While it is true that psychiatry has become more biologically based over the last century, it has also begun to look at the finer details of information transmission in the neuronal networks of the brain. Fortunately, gone are the times of lobotomies, where parts of the brain were removed, to make way for much more specific and finer treatment interventions, whether with psychotherapy or medication that works on specific neurotransmitter receptors or mimics certain neurotransmitters. The elaboration of the information transmission at the synaptic level has given us clues on how psychiatric illness is maintained, and medication works, within the larger system of an individual’s neuronal network.

The 20th century introduced a new psychiatry into the world, with different perspectives of looking at mental disorders. For Emil Kraepelin, the initial ideas behind biological psychiatry, stating that the different mental disorders are all biological in nature, evolved into a new concept of “nerves”, and psychiatry linked up with neurology and neuropsychiatry. Sigmund Freud, who early in his career searched intensively for explanations of psychiatric phenomena on a neuronal level, initiated the development of psychoanalysis, which shifted the emphasis on communication as an important instrument in the healing process. The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices at a time when effective psychiatric medication was still in its infancy.

Psychopharmacology became an integral part of psychiatry starting with Otto Loewi’s discovery of the neuromodulatory properties of acetylcholine, which became the first neurotransmitter to be described. The discovery of chlorpromazine’s effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disorder, as did lithium carbonate’s ability to stabilize mood highs and lows in bipolar disorder in 1948. Neuroimaging became an investigatory tool in psychiatry in the 1980s.


Psychopharmacological changes in the neurotransmission systems, the information interfaces where electrical signals are translated into chemical signals, and back again, affect how and what information is being transmitted. This in turn has an effect on a person’s internal communication and his or her communication with the external world, which are also the target of psychotherapy. (Haverkampf, 2010a, 2017c) Medication and psychotherapy can thus work together synergistically.

Unlike physicians in other medical specialties, psychiatrists specialize in the doctor–patient relationship and should be trained extensively in the use of psychotherapy and other therapeutic communication techniques. Unfortunately, this is not always the case, which can reduce the effectiveness in treating a mental health condition significantly, because treatment of a mental health condition implies working with and understanding communication on different levels. The patient uses communication with other people and the self-talk with him or herself to meat own needs, values, wishes, desires and aspirations, requiring a holistic approach to the communication patterns and mechanisms a patient uses.

Since communication plays such a central role in psychiatric treatment, the author has developed communication-focused therapy (CFT), which focuses on internal and external communication patterns to relieve the symptoms of a wide variety of mental health conditions (Haverkampf, 2017a, 2018c).

Biological and Social Science

Psychiatry is the most multidisciplinary medical specialty using research in the field of neuroscience, psychology, medicine, biology, biochemistry, even physics, and pharmacology. Since psychiatry looks at the patient who is interacting with the larger world around, the social and communication sciences, including even behavioural economics, and the humanities can make important contributions to the field of psychiatry. If one considers psychiatry as a specialty that focuses on improving meaningful communication within wider information systems, the biological and social viewpoints merely represent looking at the same processes with different magnifications.

Psychiatry addresses internal and external communication issues, which are usually multifactorial in their aetiology. Compliance and the effects of medication and psychotherapy depend on the interactions between the patient and the environment. There are branches of psychiatry which look at different environments and how they influence the mental well-being of a patient. Unfortunately, psychiatric hospitals and various public health clinics have been notoriously slow at implementing any recommendations from this research.


Psychiatric illnesses can be conceptualized in several different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. However, unlike the other fields of medicine, psychiatric diagnoses say little about underlying causes on a biological level but are mostly groupings of symptoms which seem to appear together. This is not to say that such groupings are not helpful. They can make it easier to describe conditions and often make it easier to pick specific therapeutic approaches and types of medication. However, since individual symptoms overlap and due to the complexity of the neural networks, it is usually not possible to follow a group of symptoms back to a specific biological variation. Since the brain is highly plastic, synapses rearrange their connections with each other all the time and assign varying weights to them. This means that a symptom of anxiety, for example, can be triggered by information stored over millions of nerve cells, and merely understanding how a biological component, such as a receptor, works does not help in understanding or treating the symptom.

Software and Hardware

Psychiatry is both ‘software’ and ‘hardware’ oriented, where ‘software’ refers to the information stored in the neural network and ‘hardware’ to the cellular network on a biological level. In the latter, there is an overlap with neurology and other medical sciences. What sets psychiatry apart is particularly the concern with information, the flows of information and how information is processed. New diagnostic systems and schemata have been developed on the psychotherapy side, which pay greater attention to the information dynamics. These models and systems can provide additional information to an experienced clinician who can then integrate these additional aspects with the diagnostic systems from the traditional medico-psychiatric side.

The biopsychosocial Model

The biopsychosocial model is commonly used to describe the three factors that play a role in the development and maintenance of a psychiatric condition:

  • Biology
  • Psychology
  • Environment (social)

What is striking about these three domains is that all consist of the transmission of information in one way or another. Some describe more the internal communication (biology, neuroscience, psychology), while others describe the external communication (psychology, sociology, economics and others), but all work in parallel all of the time. Psychiatry thus works with very complex systems, which are much more elaborate than in any other field of medicine. This may also be the reasons why psychiatry was the field within medicine to develop rather late, because it uses the insight gained in several other fields.

Diagnostic systems

Psychiatric diagnoses take place in a wide variety of settings and are performed by many different health professionals. Therefore, the diagnostic procedure may vary greatly based upon these factors. Typically, though, a psychiatric diagnosis utilizes a differential diagnosis procedure where a mental status examination and physical examination is conducted, with pathological, psychopathological or psychosocial histories obtained, and sometimes neuroimages or other neurophysiological measurements are taken, or personality tests or cognitive tests administered. In some cases, a brain scan might be used to rule out other medical illnesses, but at this time relying on brain scans alone cannot accurately diagnose a mental illness or tell the risk of getting a mental illness in the future. A few psychiatrists are beginning to utilize genetics during the diagnostic process but on the whole, this remains a research topic.

The problem with most diagnostic systems in psychiatry is that they do not address the underlying causes of an illness but focus instead on bundles of symptoms. As a descriptive system this makes sense in many instances. However, from a treatment perspective this is often unhelpful. Since medication works on underlying neurotransmission system within a vast network of interconnected neurons, a system that makes diagnosis based on properties within that system and on the individual neuronal level would be more helpful. From a psychotherapeutic perspective, a focus on internal and external communication would be helpful. Both perspectives could lead to systems that would be compatible with each other or even to one system that combines features of the two.

Diagnostic manuals

Three main diagnostic manuals used to classify mental health conditions are in use today. The International Classification of Diseases (ICD-10) is produced and published by the World Health Organization, includes a section on psychiatric conditions, and is used worldwide. The Diagnostic and Statistical Manual of Mental Disorders (DSM-V), produced and published by the American Psychiatric Association, is primarily focused on mental health conditions and is the main classification tool in the United States, although the ICD-10 has official status there as well. It is currently in its fifth revised edition and is also used worldwide. As already mentioned, the diagnostic systems are based on bundles of symptoms. Psychiatry has “a syndrome-based disease classification, which is not based on mechanisms and does not guide treatment, which largely depends on trial and error” (Stephan et al., 2016). The author of this article would not go so far. Greater clarity about a diagnosis or several diagnoses, even if we do not understand fully the underlying biological and psychological mechanisms, can be an important tool in formulating a treatment plan, which often also includes medication (Haverkampf, 2018a)

The diagnostic manuals overlap to a significant degree. One reason is that they describe groups of symptoms which are often seen together, and over time the use of their diagnostic terms has made it easier to provide treatment and conduct research. However, both suffer from the critiques mentioned above. They can give a rough idea of the symptoms, a suitable therapy and the prognosis. However, since the diagnostic systems say nothing about the underlying causes, the actual therapy needs to be individualized and its success depends on several factors inside the person and in the environment. Looking at the patient’s internal and external communication can help individualize the therapy. (Haverkampf, 2010b, 2012, 2013a, 2013b)

It is important to keep in mind the purpose served by diagnosis. It is ultimately to help a patient and raise his or her quality of life. While there may be other uses of it for forensic, insurance or other purposes, they should not lead to a different interpretation of what a diagnosis is for in a treatment context. Diagnoses can at least help to raise the probability that a specific medication or group of medication will alleviate certain symptoms (Haverkampf, 2018a, 2018f).


The first step in treatment is traditionally assessment. This usually involves interviewing the person and often obtaining information from other sources such as other health and social care professionals, relatives, associates, law enforcement personnel, emergency medical personnel, and psychiatric rating scales. A mental status examination is carried out, and a physical examination is usually performed to establish or exclude other illnesses that may be contributing to the alleged psychiatric problems. A physical examination may also serve to identify any signs of self-harm; this examination is often performed by someone other than the psychiatrist, especially if blood tests and medical imaging are performed.

However, especially in psychotherapeutic treatment, assessment can still take place after the therapy has commenced. While it is important to have a working hypothesis for the condition, it is important to remain open to any new insights gained from observing and interacting with the patient over time. For this, it is important to be in the interaction with the patient, yet also to be able to take a step outside of the interaction and reflect on the communication dynamics.

Assessment with a focus on the internal and external communication can identify problems which are leading to the symptoms. This information is then helpful to make better decisions with respect to medication and psychotherapy. Communication-Focused Therapy, as developed by the author, focuses on communication patterns an individual uses, whether in everyday life or in a therapeutic setting (Haverkampf, 2010b, 2017a). Rather than looking primarily at the content of what is being communicated, the how it is communicated assumes an additional particularly important role. Since people, and all other living organisms, meet their needs and aspirations through the exchange of information withing themselves and with the world, it is important to encourage awareness, reflection and experimentation with communication to make it more efficient and satisfying for the individual. As life aligns more with the basic parameters, the needs, values and aspirations, as a result of better communication, the symptoms of a mental health condition often receded (Haverkampf, 2017f, 2017b, 2017d) .


Psychiatric medication represents a very heterogenous group of substances, which are among the most widely prescribe in the world. Psychiatric medication was usually available before one had an understanding for its effects on a cellular or neural network level. However, in all cases it has been shown that psychiatric medication affects the information transmission in the brain. This is a point where psychotherapy and medication could go well with each other hand in hand (Haverkampf, 2018f).

The efficacy of medication can often very significantly among individuals. One antidepressant from the most popular group of antidepressants, the selective serotonin reuptake inhibitor (SSRI), for example, may help against the symptoms of depression and anxiety, while another from the same group does not work in the same patient. The outcome is not always easy to predict, although one can have a sense of the medication that is most likely to work. It requires a proper assessment in the first place, but also a solid understanding of the desired changes and the expectations of the patient.

Like most medications, psychiatric medications can cause adverse effects in patients, and some require ongoing therapeutic drug monitoring, for instance, full blood counts serum drug levels, renal function, liver function, and thyroid function. Electroconvulsive therapy (ECT) is sometimes administered for severe and disabling conditions, such as those unresponsive to medication. Although the literature reports on successes in treatment-resistant cases, its use remains controversial. Often, the available treatment options with medication and psychotherapy have not been fully exhausted when considering ECT.

To summarize, one may say that the support available form medication can be life-changing in some cases and increase the quality of life significantly. In contrast, in others, it may do little or lead to side effects, or there can be both positive and negative effects side by side. Several parameters have been studied to shape the recommendations of the professional. For example, in a study on the variables that could predict a successful treatment outcome in depression, chronic depression, older age, and lower intelligence, each predicted relatively weak response across psychotherapy and medication. On the other hand, marriage, unemployment, and having experienced a higher number of recent life events each predicted superior response to cognitive therapy relative to antidepressant medications (Fournier et al., 2009).


As already mentioned, increasingly psychiatrists are limiting their practices to psychopharmacology (prescribing medications), as opposed to previous practice in which a psychiatrist would provide traditional 50-minute psychotherapy sessions, of which psychopharmacology would be a part, but most of the consultation sessions consisted of “talk therapy.” This shift began in the early 1980s and accelerated in the 1990s and 2000s. A major reason for this change was the advent of managed care insurance plans, which began to limit reimbursement for psychotherapy sessions provided by psychiatrists. The underlying assumption was that psychopharmacology was at least as effective as psychotherapy, and it could be delivered more efficiently because less time is required for the appointment. For example, most psychiatrists schedule three or four follow-up appointments per hour, as opposed to seeing one patient per hour in the traditional psychotherapy model. Because of this shift in practice patterns, psychiatrists often refer patients whom they think would benefit from psychotherapy to other mental health professionals, e.g., clinical social workers and psychologists.

However, this approach is short-sighted. It may be easier to prescribe medication, which is a concept familiar to most patients, than to explain how psychotherapy works, whose basic premises, tools and approaches are less well known. Psychotherapy often delivers a lasting effect in the long-term in cases of anxiety, mild to moderate depression and several other conditions, which goes beyond the ongoing support medication can offer (Haverkampf, 2017a). The reason is that changes in the internal and external communications usually bring about changes in a patient’s symptoms (Haverkampf, 2018d). While medication also has an effect on these communication patterns and, through learning effects, it can even last for some time after the drug is discontinued, the changes are usually less specifically tailored to the needs and personal history of the patient.

Medication and Psychotherapy

Psychiatric treatments have changed over the past several decades. In the past, psychiatric patients were often hospitalized for six months or more, with some cases involving hospitalization for many years. Today, people receiving psychiatric treatment are more likely to be seen as outpatients. In many cases, a combination of psychotherapy and medication can prevent relapse longer than either treatment type on its own. (Haverkampf, 2018f, 2018e) There is a substantial synergism between the two. Medication can provide the support which facilitates psychotherapy, while psychotherapy can increase the compliance with medication.


Most unethical treatments in psychiatry have been a result of neglecting the importance of communication in treatment and seeing properties of interactions as being localized in a particular area of the brain rather than occurring in a network internally and through interactions with the world externally. Much unethical behaviour in psychiatry can be summarised by saying that the physician failed to interact, communicate and understand a patient in any meaningful way. When knowledge about psychiatric conditions is seen separate from the interaction with the patient, it becomes akin to playing the lottery of sorts. Treatment requires a focus on how the patient communicates internally and externally and how the world responds to these messages.

When a psychiatrist is connected on emotional and cognitive levels with himself or herself as well as the patient and has healthy boundaries in place, ethical lapses become less likely. However, this often requires substantial experience and skills in a psychotherapeutic technique that focuses on insight. It requires an interest in and experience with human communication.


To have a definition of illness, one needs a definition of health. Psychiatry is not only concerned with psychiatric illness but largely also with the maintenance of mental health. Insight into the aetiology and pathogenesis of burnout, for example, helps to prevent it, (Haverkampf, 2013a, 2013c, 2017g, 2018b) which is not only good for the individual but society and the economy as a whole. (Haverkampf, 2013c) Knowledge about which work and communication environments are helpful in preventing a relapse of psychosis can help a person arrange life in ways which keep him or her mentally healthy for as long as possible. (Haverkampf, 2017e) Skills in connecting with oneself can help to understand the information contained in emotional signals underlying episodes of anxiety. (Haverkampf, 2012)

Into the Future

The biopsychosocial model reduces to the communication model. Internal communication and external communication are, to some extent, arbitrary distinctions because communication still adheres to the basic rules and laws of communication, whether it unfolds in a person or without. However, this requires an integrated and more universal view of mental health. What makes us all human are the mental processes which give us the ability to observe and reflect on these flows of information. Psychotherapy and medication are the tools to bring about change in these communication patterns, internal and external ones. Other supportive therapies, such as occupational therapy, meditation and various forms of bodywork, can provide crucial additional support towards a satisfied, content and happy life, one in which personal needs, values, wishes, desires and aspirations can be met.

Dr Jonathan Haverkampf, M.D. (Vienna) MLA (Harvard) LL.M. psychoanalytic psychotherapy (Zurich) trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at or on the websites and


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The Misdiagnosis of ADHD in Adults (1)


The Misdiagnosis of ADHD in Adults

Christian Jonathan Haverkampf, M.D.

Adult attention deficit hyperactivity disorder (ADHD) in adults is a childhood-onset, persistent, neurobiological disorder associated with high levels of morbidity and dysfunction estimated to afflict up to 5% of adults worldwide. It includes a combination of persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior, which can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems.

The diagnosis is important to design an effective treatment plan with the patient, which often includes medication and psychotherapy or counselling. There is a wide variety of approaches in the diagnosis of adult ADHD, and this article aims at giving an overview of some of the more common ones. However, there is a high risk of misdiagnosing this condition. The ability to concentrate, for example, can also be affected in depression, PTSD, anxiety, psychosis and other conditions, as can the capacity for organizing and seeing through tasks, various aspects of memory and information retrieval and irritability.

Awareness for the communication patterns in the interaction with the patient, and how the patient communicates internally, are important tools in the diagnostic process and in treatment, improving the individualization of treatment and building and maintaining compliance. While the actual interaction with the patient is of primary diagnostic importance, standardized questionnaires and neuropsychological testing batteries are important to support a diagnosis and to adjust treatment.

Keywords: attention deficit hyperactivity disorder, ADHD, diagnosis, treatment, psychotherapy, psychiatry


Introduction. 4

Attention. 5

Executive Functioning. 5

Communication. 5

From Childhood to Adulthood: Hyperactivity vs Inattention. 6

Measurement Problems. 6

Misdiagnosis of ADHD.. 6

Autism.. 7

Trauma. 7

OCD.. 7

Bipolar Disorder. 7

Symptoms. 8

Diagnosing ADHD.. 9

Subtypes. 10

Assessment. 10

Communication. 10

The Clinical Interview.. 11

Semi-Structured Interviews. 11


DIVA. 12

Computer-Assisted Diagnosis. 13

Questionnaires. 13

Self-Report Rating Scales. 14

Conners’s Adult ADHD Rating Scales (CAARS) 14

Current Symptoms Scale. 15

Adult ADHD Self-Report Scale–version 1.1 (ASRSv1.1) 15

Retrospective Assessments. 16

Wender Utah Rating Scale (WURS) 16

Non-Self Report Assessments. 16

Brown Attention-Deficit Disorder Rating Scale for Adults (Brown ADD-RS) 16

ADHD Investigator Symptom Rating Scale (AISRS) 17

Neuropsychological Testing. 17

Neurobiological Parameters. 20

Malingering. 20

Differential Diagnosis. 21

Comorbidity. 22

Psychosocial Functioning. 22

Conclusion. 23

References. 25



Adult attention deficit hyperactivity disorder (ADHD) in adults is a childhood-onset, persistent, neurobiological disorder associated with high levels of morbidity and dysfunction estimated to afflict up to 5% of adults worldwide (Kessler et al., 2006). It includes a combination of persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior, which can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems. Due concerns about overdiagnosis and overtreatment, many children and youth diagnosed with ADHD still receive no treatment or insufficient treatment (Giuliano & Geyer, 2017).

Using DSM-IV criteria, in a study by Wilens and colleagues, 93% of ADHD adults had either the predominately inattentive or combined subtypes-indicative of prominent behavioral symptoms of inattention in adults. (Wilens et al., 2009) ADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group. (Kooij et al., 2010)

The diagnosis of ADHD in adults is a complex procedure which should refer to the diagnostic criteria of a diagnostic manual, such as the DSM or ICD. It normally includes the following information:

  • retrospective assessment of childhood ADHD symptoms
  • current adult ADHD psychopathology including symptom severity and pervasiveness,
  • functional impairment
  • quality of life
  • comorbidity

In order to obtain a systematic database for the diagnosis and evaluation of the course ADHD rating scales can be very useful. However, the interaction with the patient in the clinical interview should remain the central part of the diagnosis. (Haverkampf, 2017c, 2017a) Integrating elements of semi-structured questioning into the clinical interview can be helpful, while awareness for the communication patterns the patient uses is crucial. (Haverkampf, 2018c) Still, specific diagnostic criteria that are more sensitive and specific to adult functioning are needed. (Davidson, 2008)


When focusing on the diagnostic details, one may sometimes run the risk of losing sight of the bigger defining symptoms of ADHD. Attention deficit needs to be present for the diagnosis. Studies of adults with ADHD suggest that the most prominent symptoms of ADHD relate to inattention as opposed to hyperactivity and impulsivity. In a meta-analysis, Schoenlein and Engel integrated 24 empirical studies reporting results of at least one of 50 standard neuropsychological tests comparing adult ADHD patients with controls. Complex attention variables and verbal memory discriminated best between ADHD patients and controls. In contrast to results reported in children, executive functions were not generally reduced in adult ADHD patients. (Schoechlin & Engel, 2005)

Executive Functioning

Attention deficit hyperactivity disorder (ADHD) is associated with deficits in executive functioning. ADHD in adults is also associated with impairments in major life activities, particularly occupational functioning. Executive functioning deficits contribute to the impairments in occupational functioning that occur in conjunction with adult ADHD. Barkley and Murphy concluded in their study that ratings of executive functioning in daily life contribute more to such impairments than do executive functioning tests. The investigators hypothesize that one reason could be that each assesses a different level in the hierarchical organization of EF as a meta-construct. (Barkley & Murphy, 2010)


The exchange of information, internally and externally, is the process that is generally affected and gives rise to several of the observed symptoms. ADHD interferes with effective and helpful communication internally and externally, which causes several of the observed symptoms. (Haverkampf, 2010b) Internal and external communication patterns should thus be observed in diagnosis and worked with as an important focus later in treatment.

From Childhood to Adulthood: Hyperactivity vs Inattention

Prevalence of ADHD in adults declines with age in the general population, although the unclear validity of DSM–IV diagnostic criteria for this condition may have led to reduced prevalence rates by underestimation of the prevalence of adult ADHD. (Kessler et al., 2006) Symptoms start in early childhood and continue into adulthood. In some cases, ADHD is not recognized or diagnosed until the person is an adult. Adult ADHD symptoms may not be as clear as ADHD symptoms in children. In adults, hyperactivity often decreases, but struggles with impulsiveness, restlessness and difficulty paying attention usually continue. It is mostly these latter symptoms which can interfere significantly with an individual’s daily life.

Hyperactive–impulsive symptoms seem to decline more with increasing age, whereas inattentive symptoms of ADHD tend to persist. In a study by Millstein and colleagues, inattentive symptoms were most frequently endorsed in over 90% of ADHD adults. An assessment of current ADHD symptoms showed that 56% of adults had the combined ADHD subtype, 37% the inattentive only subtype, and 2% the hyperactive/impulsive subtype. Whereas females had fewer childhood hyperactive-impulsive symptoms than males, there were no gender differences in their ADHD presentation as adults. This suggests that the vast majority of adults with ADHD present with prominent symptoms of inattention. (Millstein, Wilens, Biederman, & Spencer, 1997) Decision-making is another important cognitive process which seems impaired in adults with ADHD (Mäntylä, Still, Gullberg, & Del Missier, 2012), and which can lead to impairment in several domains in life.

Measurement Problems

The decrease in ADHD symptoms over time may indicate true remission of symptoms, but it may also indicate that the symptom criteria are less robust in older rage groups. Michielsen and colleagues, for example, concluded in their epidemiological study on ADHD in older persons in the Netherlands that ADHD does not fade or disappear in adulthood. (Michielsen et al., 2012)

Misdiagnosis of ADHD

Rising rates of ADHD have led to the concern that ADHD is often misdiagnosed. The ability to concentrate, for example, can also be affected in depression, PTSD, anxiety, psychosis and other conditions, as can the capacity for organizing and seeing through tasks, various aspects of memory and information retrieval and irritability. There is evidence of medically inappropriate ADHD diagnosis and treatment in school-age children and less so for adults. In a study by Evans and colleagues, for example, age relative to peers directly affected a child’s probability of being diagnosed with ADHD. The relative age effect was present for both ADHD diagnosis and treatment with stimulants (Evans, Morrill, & Parente, 2010).


Because of the high frequency of ADHD symptoms in autism, children with autism may initially be misdiagnosed with ADHD. The core symptoms of ADHD (attention deficit, impulsivity, and hyperactivity) are part of autism, and autism and ADHD have similar underlying neuropsychological deficits (Mayes, Calhoun, Mayes, & Molitoris, 2012). On the other hand, the rate for children with autism spectrum disorder to be also diagnosed with ADHD is as high as 60% (Stevens, Peng, & Barnard-Brak, 2016).


Trauma may also be misinterpreted as ADHD, particularly in children. Hyper-vigilance and dissociation, for example, could be mistaken for inattention. Impulsivity might be brought on by “a stress response in overdrive” (Ruiz, 2014). Cognitive and emotional disruptions that occur in response to trauma, such as difficulty concentrating, dysregulated affect, irritability, and hyperarousal, either overlap with ADHD symptomatology or exasperate it (Szymanski, Sapanski, & Conway, 2011).


Manifestations of OCD-related inattention may be misdiagnosed as ADHD symptoms, particularly again in children. In OCD only, current ADHD symptoms correlate with obsessive-compulsive symptoms There is a risk of misdiagnosis, especially in children when primarily relying on informants (Abramovitch, Dar, Mittelman, & Schweiger, 2013).

Bipolar Disorder

Bipolar disorder is also a neurodevelopmental disorder with onset in childhood and early adolescence and commonly persists into adulthood. Both disorders are often undiagnosed, misdiagnosed, and sometimes over diagnosed. The differentiation of these conditions is based on their clinical features, comorbidity, psychiatric family history, course of illness, and response to treatment (Marangoni, De Chiara, & Faedda, 2015). Children with bipolar disorder are more likely to present with

  • aggression and lack of remorse, while in ADHD a destructiveness is more likely due to carelessness.
  • severe temper tantrums, often of more than an hour in duration, which are less intense and shorter in ADHD
  • intentional misbehavior, which is in ADHD more likely to be due to inattentiveness
  • underestimating risk, while in ADHD there may be unawareness of risk
  • anger for longer periods of time, holding a grudge and being unforgiving, while in ADHD calm is usually restored within half an hour or considerably more quickly and the reasons for the anger forgotten
  • stimulation seeking due to boredom, while in ADHD the stimulation seeking is more general
  • amnesia for anger outbursts
  • flight of ideas (manic phase), while in ADHD the talkativeness is due to a lack of inhibition and can be influenced and redirected
  • decreased need for sleep
  • sleep inertia and slow awakening (unless in a manic phase)
  • rapidly changing mood shifts
  • suicidal ideation
  • symptoms that routinely improve on lithium, mood stabilizers, antipsychotics
  • symptoms that do not improve on stimulants

If both conditions are present, the mood disorder symptoms and the course of the bipolar condition are usually more severe, and the functional scores lower. Since the symptoms of a separate ADHD are often mistakenly assumed to be part of the bipolar conditions, patients with comorbid ADHD and BD are routinely underdiagnosed and undertreated (Klassen, Katzman, & Chokka, 2010).


Many people with ADHD have fewer symptoms as they age, but some adults continue to have major symptoms that interfere with daily functioning also in later stages of life. In adults, the main features of ADHD may include difficulty paying attention, impulsiveness and restlessness. This can make it more difficult to acquire new information, process it together with existing information and communicate with others.

Adults with ADHD may find it difficult to focus and prioritize, leading to missed deadlines and forgotten meetings or social plans. The inability to control impulses can range from impatience waiting in line or driving in traffic to mood swings and outbursts of anger. The difficulties in persisting with a task is probably a consequence of ineffective information transmission internally.

Adult ADHD symptoms may include:

  • Impulsiveness
  • Disorganization and problems prioritizing
  • Poor time management skills
  • Problems focusing on a task
  • Trouble multitasking
  • Excessive activity or restlessness
  • Poor planning
  • Low frustration tolerance
  • Frequent mood swings
  • Problems following through and completing tasks
  • Hot temper
  • Trouble coping with stress

Diagnosing ADHD

Extensive psychometric studies have provided empirical support for the symptom thresholds used to diagnose ADHD in children, and there is general agreement that ADHD can be reliably diagnosed in children using these formal diagnostic criteria. However, the reliability of the diagnosis of ADHD in adults is less clear. The task would become easier if there were a greater focus on operationalizing internal and external communication patterns, that can be observed, described by the patient or inferred from these observation and descriptions by an experienced therapist. These patterns have been described by the author in for ADHD (Haverkampf, 2017e, 2017a) as well as for several other mental health conditions (Haverkampf, 2010b, 2017d, 2018b). Diagnosis of adult attention-deficit hyperactivity disorder (ADHD) adults is difficult, as neither symptom report nor neuropsychological findings are specific to ADHD. However, the most information can still be gained in the clinical interview if the clinician is receptive to the various levels of information flows and integrates them into the overall assessment.


It is unclear whether the three subtypes recognized in the diagnostic manuals have a different underlying ethology or any other justification to separate them. However, they are frequently used in clinical practice and offer a rough symptom description which can also be useful for many non-medical questions, such as support in school or disability. The subtypes are:

  • ADHD combined type (ADHD-C; both inattentive and hyperactive–impulsive symptoms)
  • ADHD predominantly inattentive type (ADHD-I)
  • ADHD predominantly hyperactive–impulsive type (ADHD-H)


The diagnosis of adult ADHD is a clinical decision-making process, where the emphasis lies on the clinical interview and anything that can support the information gained in it. There are no objective, laboratory-based tests that can establish this diagnosis. (Haavik, Halmøy, Lundervold, & Fasmer, 2010) Given the difficulties with the formal diagnostic criteria for ADHD, determining the diagnosis of ADHD in adults presents different challenges than determining the diagnosis in children (Riccio et al., 2005). There is no single neurobiological or neuropsychological test that can determine a diagnosis of ADHD on an individual basis (Rosler et al., 2006).

In most situations, an ADHD assessment should include a comprehensive clinical interview, as rating scales, an assessment of a broader spectrum of psychiatric and somatic conditions and information from third parties if available.


How patients exchange meaningful information with themselves and others to get their needs and aspirations met or in response to an interaction or a perception or sensation is of very high diagnostic values in most psychiatric conditions, including especially so also ADHD. Unfortunately, there is often a lack of focus on a patients’ internal and external communication, which could be diagnostically helpful in the diagnosis and treatment of ADHD. For example, the effectiveness of ADHD coaching in improving patients’ everyday life has been demonstrated. (Kubik, 2010) Since communication is the basic process by which individuals get their needs and aspirations met in everyday life, increasing their quality of life and integrating them into the community, which in itself can have a protective effect, exploring a patient’s communication patterns should be a primary goal of an assessment for the severity of ADHD. (Haverkampf, 2017f, 2017e, 2017b)

The clinical interview, and thus the interaction with the patient, is at the center of the diagnosis of ADHD. This may make the process more difficult to operationalize for randomized controlled studies if they fail to conceptualize information and communication in a clinical interview. A greater elucidation of communication processes has been described as beneficial by the author and several different techniques and approaches suggested.  (Haverkampf, 2010a)

The Clinical Interview

A comprehensive clinical interview is one of the most effective methods to make a diagnosis of ADHD (Adler, 2004; Jackson & Farrugia, 1997; Murphy & Adler, 2004; Wilens, Faraone, & Biederman, 2004). Open-ended questions about childhood and adult behaviors can be used to elicit information necessary to diagnose ADHD. Interviews also include questions regarding developmental and medical history, school and work history, psychiatric history, and family history of ADHD and other psychiatric disorders (Barkley, 2006).

The clinical interview also gives inside into the communication the patient uses, internally and externally, and how he or she attends to and processes meaningful information. (Haverkampf, 2010a, 2018a) This is important for the diagnosis and treatment of any mental health condition, but particularly also ADHD. (Haverkampf, 2017a)

Semi-Structured Interviews

Although many clinicians use unstructured interviews to assess adult ADHD, semistructured interviews do exist. One does not necessarily have to choose between either one, but it can be helpful to at least integrate semistructured elements into a clinical interview, which still offers the latitude to explore more freely, which can be important in assessing any comorbidities. Research suggests that semistructured clinical interviews can reliably and accurately be used for determining a diagnosis of ADHD in adults (Epstein & Kollins, 2006).

Comprehensive diagnostic interviews not only evaluate diagnostic criteria, but also assess different psychopathological syndrome scores, functional disability measures, indices of pervasiveness and information about comorbid disorders. Comprehensive procedures include the Brown ADD Diagnostic Form and the Adult Interview by Barkley and Murphy. The Wender Reimherr Interview which follows a diagnostic algorithm different from DSM-IV. The interview contains only items delineated from adult psychopathology and not derived from symptoms originally designed for use in children. (Rösler et al., 2006)

From a communication perspective, the etiology of ADHD consists generally of the same maladaptive communication and information handling patterns, whether in a child or an adult. However, given differences in developmental stages and environmental factors the symptoms and impairments can be different. Also, the chronicity and entrenchment of a particular patterns, in connection with developmental progress, can influence the phenomenology of the condition. To consider all these factors a certain flexibility and openness in the clinical interview is of paramount importance.


The Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID), for example, assesses for the presence of the ADHD symptoms listed in the DSM-IV and collects information related to history, developmental course, ADHD risk factors, and comorbid psychopathology. Epstein and Kollines examined the test-retest reliability and concurrent validity of the CAADID for DSM-IV in a sample of thirty patients referred to an outpatient clinic. Kappa statistics for individual symptoms of inattention and hyperactivity-impulsivity were in the fair to good range for current report and retrospective childhood report. Kappa values for overall diagnosis, which included all DSM-IV symptoms, were fair for both current (adult) ADHD diagnosis (kappa = .67) and childhood report (kappa = .69). Concurrent validity was demonstrated for adult hyperactive-impulsive symptoms and child inattentive symptoms. (Epstein & Kollins, 2006)


Another semi-structured interview is the Diagnostic Interview for ADHD in adults, which has gone through improvement updates. It has been compared to the CAADID and other ADHD severity scales, following the DSM-IV criteria. Ramos-Quiroga and colleagues carried out a transversal study on 40 out-patients with ADHD to check the criteria and concurrent validity of the DIVA 2.0 compared with the CAADID. The DIVA 2.0 interview showed a diagnostic accuracy of 100% when compared with the diagnoses obtained with the CAADID interview. The concurrent validity demonstrated good correlations with three self-reported rating scales: the Wender Utah Rating Scale (WURS), the ADHD-Rating Scale, and Sheehan’s Dysfunction Inventory. (Ramos-Quiroga et al., 2016) One advantage of the DIVA is that it is free to use.

Computer-Assisted Diagnosis

Supportive methods in diagnosing ADHD are being explored. Using computerized clinical decision support modules can in higher quality of care with respect to ADHD diagnosis including a prospect for higher quality of ADHD management in children. (Bergman et al., 2009) This is different from using computers for neuropsychological testing, where the patient interacts with the computer. Computer-assisted diagnosis tools could, for example, provide decision trees that are based on empirical insights. While this can be a valuable support for the clinician, it is important to keep in mind that the interactions with the patient is probably the most important instrument in the assessment of ADHD.


Questionnaires may be underutilized in clinical practice. They often are easy to administer, score and interpret, while their reliability and validity can be quite high.

  • The Connors Adult ADHD Rating Scales (CAARS)
  • the Current Symptoms Scales by Barkley and Murphy (CSS)
  • the Adult Self Report Scale (ASRS) by Adler et al. and Kessler et al. and
  • the Attention Deficit Hyperactivity Disorder—Self Report Scale (ADHD-SR by Rösler et al.)

are self-report rating scales focusing mainly on the DSM-IV criteria, although the CAARS and CSS also have other forms.

  • The Wender-Utah Rating Scale (WURS) and

the Childhood Symptoms Scale by Barkley and Murphy aim at making a retrospective assessment of childhood ADHD symptoms.

  • The Brown ADD Rating Scale (Brown ADD-RS) and
  • the Attention Deficit Hyperactivity Disorder-Other Report Scale (ADHD-OR by Rösler et al.)

are instruments for use by clinicians or significant others.

Both self-rating scales and observer report scales quantify the ADHD symptoms by use of a Likert scale mostly ranging from 0 to 3, which makes comparison of follow-up tests easier.

Self-Report Rating Scales

Self-report checklists are commonly used in the assessment of ADHD. In addition to self-report rating scales, rating scales completed by an individual’s spouse or significant other can provide useful information in determining the individual’s overall life functioning. They are easy to administer, and a number of reliable and valid measures exist. Problems may be bias or malingering, which are difficult to control for. Distorted memories probably play a negligible role in rating scales that focus on current symptoms, but could become important in those screening for symptoms in childhood and adolescence.

Research has demonstrated that rating scales can accurately reflect the frequency and intensity of symptoms (Wadsworth & Harper, 2007) and, when used retrospectively, are valid indicators of symptomatology (Murphy & Schachar, 2000). Murphy and Schachar (2000) examined the validity of self-reported ratings of current and childhood ADHD symptoms by adults. In one study, participants’ ratings of their childhood ADHD symptoms were compared to their parents’ ratings of childhood symptoms. In a second study, participants’ ratings of their current ADHD symptoms were compared to a significant other’s rating of current symptoms. All correlations between self-ratings and parent ratings were significant for inattentive, hyperactive–impulsive, and total ADHD symptoms, as were correlations between self-ratings and significant other ratings.

Belendiuk and colleagues examined in 2007 the concordance of diagnostic measures for ADHD, including self-ratings and collateral versions of both rating scales and semistructured interviews. Results supported the findings of Murphy and Schachar, showing high correlations between self-reports and collateral reports of inattentive and hyperactive–impulsive symptoms. Results also demonstrated high correlations between self-report rating scales and diagnostic interviews. (Belendiuk, Clarke, Chronis, & Raggi, 2007)

Conners’s Adult ADHD Rating Scales (CAARS)

The CAARS (Conners, Erhart, & Sparrow, 1999) assesses ADHD symptoms in adults and comprises short, long, and screening self-report and observer rating scale forms. The CAARS produces eight scales, including scales based on DSM-IV criteria and an overall ADHD index. Internal consistency is good, with Cronbach’s alpha across age, scales, and forms ranging from .49 to .92 (Conners et al., 1999; Erhardt, Epstein, Connors, Parker, & Sitarenios, 1999). Test–retest reliability (1 month) estimates are high, ranging from .85 to .95 (Conners et al., 1999; Erhardt et al., 1999). The ADHD index produces an overall correct classification rate of 85%, and the sensitivity of the ADHD index has been estimated at 71% and the specificity at 75% (Conners et al., 1999).

Adler and colleagues compared the reliability, validity, and utility in a sample of adults with ADHD and also as an index of clinical improvement during treatment of self- and investigator ratings of ADHD symptoms via the CAARS. They analyzed data from two double-blind, parallel-design studies of 536 adult ADHD patients, randomized to 10-week treatment with atomoxetine or placebo. The CAARS demonstrated good internal consistency and inter-rater reliability, as well as sensitivity to treatment outcome. (Adler et al., 2008)

Taylor and colleagues retrieved 35 validation studies of adult ADHD rating scales and identified 14 separate scales. The majority of studies were of poor quality and reported insufficient detail. Of the 14 scales, the Conners’ Adult ADHD Rating scale and the Wender Utah Rating Scale (short version) had more robust psychometric statistics and content validity. (Taylor, Deb, & Unwin, 2011)

Current Symptoms Scale

The Current Symptoms Scale (Barkley & Murphy, 1998) is an 18-item selfreport scale with both a patient version and an informant version. It contains the 18 items from the diagnostic criteria in DSM-IV. Validity has been demonstrated through past findings of significant group differences between ADHD and control adults (Barkley, Murphy, DuPaul, & Bush, 2002). An earlier DSM-III version of the scale correlated significantly with the same scale completed by a parent (r = .75) and by a spouse or intimate partner of the ADHD adult (r = .65; Murphy & Barkley, 1996a).

Adult ADHD Self-Report Scale–version 1.1 (ASRSv1.1)

The ASRS-v1.1 (Adler, Kessler, & Spencer, 2003) is an 18-item measure based on the DSM-IV-TR criteria for ADHD that produces three scale scores. Questions are designed to suit an adult rather than a child, and the language provides a context for symptoms that adults can relate to. Internal consistency estimates are high, and the ASRS-v1.1 has been shown to have high concurrent validity (Adler et al., 2006).

Adler et al conducted a study to validate the pilot Adult ADHD Self-Report Scale (pilot ASRS) versus standard clinician ratings on the ADHD Rating Scale (ADHD RS). Sixty adult ADHD patients took the self-administered ADHD RS and then raters administered the standard ADHD RS. Internal consistency was high for both patient and rater-administered versions. The intra-class correlation coefficients (ICCs) between scales for total scores was also high, as were ICCs for subset symptom scores. There was acceptable agreement for individual items and significant kappa coefficients for all items. The pilot Adult ADHD Self-Report Scale symptom checklist was thus a reliable and valid scale for evaluating ADHD for adults and showed a high internal consistency and high concurrent validity with the rater-administered ADHD RS. (Adler et al., 2006)

Retrospective Assessments

Retrospective assessments collect information to help make a retroactive diagnosis of ADHD.

Wender Utah Rating Scale (WURS)

The WURS (Ward, Wender, & Reimherr, 1993) is based on items from the monograph Minimal Brain Dysfunction in Children (Wender, 1971), which is more detailed than the symptoms listed in the DSM or ICD-10. McCann and colleagues examined the factor structure and discriminant validity of the WURS in adults seeking evaluation for attention-deficit/hyperactivity disorder (ADHD). Three factors (Dysthymia, Oppositional/Defiant Behavior, and School Problems) accounted for 59.4% of the variance. In a stepwise discriminant function analysis, age and childhood school problems emerged as significant variables. The classification procedure correctly classified 64.5% of patients. Among those who did not have ADHD, only 57.5% were correctly classified compared with 72.1% among those with ADHD. The WURS thus appears to be sensitive in detecting ADHD, but it misclassified approximately half of those who do not have ADHD. (McCann, Scheele, Ward, & Roy-Byrne, 2000)

Non-Self Report Assessments

Brown Attention-Deficit Disorder Rating Scale for Adults (Brown ADD-RS)

The Brown ADD-RS (Brown, 1996; Brown & Gammon, 1991) assesses symptoms of ADHD in adults. It was developed before the DSM-IV concept of ADHD was published and focuses more on symptoms of inattention rather than hyperactivity and impulsivity. The scale shows high internal consistency (α = .96) and satisfactory validity (M. Weiss, Hechtman, & Weiss, 1999).

ADHD Investigator Symptom Rating Scale (AISRS)

To measure treatment response, the Adult ADHD Investigator Symptom Rating Scale (AISRS) was developed to better capture symptoms of ADHD in adult patients. The AISRS uses a semistructured interview methodology with suggested prompts for each item to improve interrater reliability. (Spencer et al., 2010) The authors analyzed psychometric properties of the AISRS total and AISRS subscales and compared them to the investigator rated version of the CAARS and the Clinical Global Impression-ADHD-Severity Scale using data from a placebo-controlled 6-month clinical trial of once-daily atomoxetine. Results showed that the AISRS and its subscales were robust, valid efficacy measures of ADHD symptoms in adult patients. Its anchored items and semistructured interview are mentioned as advancements over existing scales. (Spencer et al., 2010)

Neuropsychological Testing

Attention-deficit hyperactivity disorder (ADHD) is a behaviorally defined diagnosis. Despite the fact that neuropsychological tests have typically been used successfully to investigate the functional neuroanatomy of ADHD in neuroimaging research paradigms, these tests have been of surprisingly limited utility in the clinical diagnosis of the disorder. (Koziol & Stevens, 2012) Still, if used discriminatingly and with an understanding for their place in an assessment, neuropsychological testing can play a significant role in the assessment of ADHD. However, one needs to keep in mind that there is no single test or battery of tests that has adequate predictive validity or specificity to make a reliable diagnosis of ADHD. Although there seem to be differences between adults with ADHD and control participants on measures of cognitive functioning, these measures probably have limited predictive value in distinguishing ADHD from other psychiatric or neurological conditions that are associated with similar cognitive impairments (Wadsworth & Harper, 2007).

In adult ADHD, neuropsychological testing is most beneficial when the results are used to support conclusions based on history, rating scales, and analysis of current functioning. Cognitive assessments can be useful in that they can improve the validity of an ADHD assessment and be used in assessing the efficacy of pharmacological and/or psychological interventions (Epstein et al., 2003). Also, many researchers agree that a neuropsychological assessment will be most sensitive to ADHD when the assessment incorporates multiple, overlapping procedures measuring a broad array of attentional and executive functions (Alexander & Stuss, 2000; Cohen, Malloy, & Jenkins, 1998; Woods et al., 2002).

Important functional domains of neuropsychological tests are:

  • verbal ability
  • figural problem solving
  • abstract problem solving
  • executive function
  • fluency
  • simple attention
  • sustained attention
  • focused attention
  • verbal memory
  • figural memory

Woods and his colleagues (2002) reviewed the role of neuropsychological evaluation in the diagnosis of adults with ADHD. In their review of 35 studies, the authors found that the majority of the studies demonstrated significant discrepancies between adults with ADHD and normal control participants on at least one measure of executive function (i.e., the ability to assess a task situation, plan a strategy to meet the needs of the situation, implement the plan, make adjustments, and successfully complete the task; Riccio et al., 2005) or attention. Moreover, Woods et al. found that the most prominent and reliable executive function and attention measures that differentiated adults with ADHD were Stroop tasks (Stroop, 1935) and continuous performance tests (CPTs). (The Stroop phenomenon demonstrates that it is difficult to name the ink color of a color word if there is a mismatch between ink color and word. For example, the word GREEN printed in red ink. The CPT measures a person’s sustained and selective attention.)

Neuropsychological tests generally have a poor ability to discriminate between patients diagnosed with ADHD and patients not diagnosed with ADHD. Pettersson and colleagues investigated in their study the discriminative validity of neuropsychological tests and diagnostic assessment instruments in diagnosing adult ADHD in a clinical psychiatric population of 108 patients, 60 were diagnosed with ADHD. The Diagnostic Interview for ADHD in adults (DIVA 2.0) and Adult ADHD Self-Report Scale (ASRS) v.1.1 together with eight neuropsychological tests were investigated. All instruments showed poor discriminative ability except for the DIVA, which showed a relatively good ability to discriminate between the groups (sensitivity = 90.0; specificity = 72.9). A logistic regression analysis model with the DIVA and measures of inattention, impulsivity, and activity from continuous performance tests (CPTs) showed a sensitivity of 90.0 and a specificity of 83.3. This means that while the ability to discriminate between patients with and without ADHD is poor, variables from CPT tests can contribute to increasing the specificity by 10% if used in combination with the DIVA. (Pettersson, Söderström, & Nilsson, 2018)

Schoechlin and colleagues conducted a meta-analysis integrating 24 empirical studies reporting results of at least one of 50 standard neuropsychological tests comparing adult ADHD patients with controls. The 50 tests were categorized into the following 10 functional domains: verbal ability, figural problem solving, abstract problem solving, executive function, fluency, simple attention, sustained attention, focused attention, verbal memory, figural memory. For each domain a pooled effect size d′ was calculated. Complex attention variables and verbal memory discriminated best between ADHD patients and controls. Effect sizes for these domains were homogeneous and of moderate size (d′ between 0.5 and 0.6). In contrast to results reported in children, executive functions were not generally reduced in adult ADHD patients. (Schoechlin & Engel, 2005) Woods et al. (2002), on the other hand, concluded that although a general profile of attentional and executive function impairment is evident in adults with ADHD, expansive impairments in these domains (i.e., impairments on all attention and executive function tasks) is not common. Their review demonstrated inconsistencies in specific instruments across studies, indicating that adults with ADHD may not perform poorly on all attentional measures all the time. This finding is not surprising given the fact that adults with ADHD often demonstrate sporadic or inconsistent attention, which can be difficult to identify given the structure provided by the one-on-one testing environment (Barkley, 1998).

One popular family of measures for the assessment of attention and executive control is the continuous performance test (CPT). A review of the available research on CPTs reveals that they are quite sensitive to CNS dysfunction. This is both a strength and a limitation of CPTs in that multiple disorders can result in impaired performance on a CPT. The high sensitivity of CPTs is further complicated by the multiple variations of CPTs available, some of which may be more sensitive or demonstrate better specificity to ADHD in adults than others. If CPTs are to be used clinically, further research will be needed to answer the questions raised by this review. (Riccio & Reynolds, 2006).

Several theoretical models suggest that the core deficit of ADHD is a deficiency in response inhibition. While neuropsychological deficits in response inhibition are well documented in ADHD children, research on these deficits in adult ADHD populations is minimal. In a study by Epstein and colleagues, twenty-five adult ADHD patients, 15 anxiety-disordered adult patients, and 30 normal adults completed three neuropsychological tests of response inhibition: the Continuous Performance Test, Posner Visual Orienting Test, and the Stop Signal Task. ADHD adults demonstrated response inhibition performance deficits when compared to both normal adults and anxiety disordered adults only on the Continuous Performance Test. A similar pattern of differences was not observed on the other two neuropsychological tests. Differing results between tasks may be due to differences in test reliability, task parameters, or the targeted area of brain functioning assessed by each test. (Epstein, Johnson, Varia, & Conners, 2001)

Neurobiological Parameters

Abibullaev and colleagues proposed a decision support system in diagnosing ADHD through brain electroencephalographic signals. (Abibullaev & An, 2012) Lenartowicz and Loos concluded that while EEG cannot currently be used as a diagnostic tool, vast developments in analytical and technological tools in its domain anticipate future progress in its utility in the clinical setting. (Lenartowicz & Loo, 2014) However, the overall assessment still requires a clinical decision, which may depend on many factors, including the individual attitude towards the diagnosis held by the therapist.


Malingering is an important issue in ADHD diagnosis and is defined as the conscious fabrication or exaggeration of physical or psychological symptoms in the pursuit of a recognizable goal. A diagnosis of ADHD can provide an individual with several benefits, including stimulant medication, disability benefits, tax benefits, and academic accommodations, and such benefits may motivate adults undergoing diagnostic evaluations for ADHD to exaggerate symptomatology on self-report measures and tests of neurocognitive functioning. Musso and colleagues identified and summarize nineteen peer-reviewed, empirical studies published between 2002 and 2011 that investigated malingered ADHD in college students. Few of the measures examined proved useful for detecting malingered ADHD. Most self-report questionnaires were not sensitive to malingering. While there is some variability in the usefulness of neuropsychological test failure, profiles between malingerers and individuals with ADHD were too similar to confidently detect malingered ADHD. Failure of three or more symptom validity tests proved most useful at detecting malingered ADHD. The authors concluded that there is substantial need for measures designed specifically for detecting malingered ADHD simulators are able to produce plausible profiles on most tools used to diagnose ADHD. (Musso & Gouvier, 2014)

Detection of faking can prove difficult with adults in particular, as clinicians often do not have access to a parent or sibling who can attest to prior history of ADHD symptoms or the resources to follow up do not exist. Moreover, adults often lack developmental documentation such as report cards, teacher evaluations, or prior psychological testing reports.

Quinn (2003) examined the issue of malingering by comparing the susceptibility of a self-report ADHD rating scale and a CPT to faking in an undergraduate sample of individuals with and without a diagnosis of ADHD. Results indicated that the CPT showed greater sensitivity to malingering than did the self-report scale and that a CPT can successfully discriminate malingerers from those with a valid diagnosis of ADHD. Given the potential benefits associated with an ADHD diagnosis, clinicians should include a symptom validity measure in their assessment battery. At present, however, there is no demonstrated best practice for this.

Suhr and colleagues utilized archival data from young adults referred for concerns about ADHD, divided into three groups: (1) those who failed a measure of noncredible performance (the Word Memory Test; WMT), (2) those who met diagnostic criteria for ADHD, and (3) controls with psychological symptoms but no ADHD. Results showed a 31% failure rate on the WMT. Those who failed the WMT showed clinical levels of self-reported ADHD symptoms and impaired neuropsychological performance. Neither self-report measures nor neuropsychological tests could distinguish ADHD from psychological controls, with the exception of self-reported current hyperactive/impulsive symptoms and Stroop interference. (Suhr, Hammers, Dobbinsbuckland, Zimak, & Hughes, 2008) These results underscore the effect of noncredible performance on both self-report and cognitive measures in ADHD.

It is difficult to tell how much a greater focus on the communication dynamics in a clinical interview can improve the problems around malingering. However, communication in its diverse synchronous forms is probably much more difficult to consciously influence and ‘fake’ than a simple task. However, a greater focus on communication patterns and dynamics also requires the skills and experience in the clinician to work with them.

Differential Diagnosis

Diagnosing ADHD in adults requires careful consideration of differential diagnoses, as it can be difficult to differentiate ADHD from a number of other psychiatric conditions (Pary et al., 2002), including major depression, bipolar disorder, generalized anxiety, obsessive–compulsive disorder (OCD), substance abuse or dependence, personality disorders (borderline and antisocial), and learning disabilities (Searight, Burke, & Rottnek, 2000). For example, differential diagnosis of ADHD from mood and conduct disorders may be difficult because of common features such a mood swings, inability to concentrate, memory impairments, restlessness, and irritability (Adler, 2004). Differential diagnosis of learning disabilities can also prove difficult because of the interrelated functional aspects of the disorders that have the common outcome of poor academic functioning (Adler, 2004; Jackson & Farrugia, 1997).


High rates of comorbidities are also seen in adults with ADHD, with the majority having at least one additional psychiatric disorder. ADHD is associated with a high percentage of comorbid psychiatric disorders in every lifespan. In adulthood between 65–89% of all patients with ADHD suffer from one or more additional psychiatric disorders, above all mood and anxiety disorders, substance use disorders and personality disorders, which complicates the clinical picture in terms of diagnostics, treatment and outcome issues. (Sobanski, 2006) Outcome studies have demonstrated that individuals diagnosed with ADHD in childhood are at risk for developing comorbid conditions, some of which are likely secondary to ADHD-related frustration and failure.

The most frequent comorbid psychopathologies include mood and anxiety disorders, substance use disorders, and personality disorders. (Katzman, Bilkey, Chokka, Fallu, & Klassen, 2017) Biederman and colleagues (1993) found a relatively high incidence of lifetime diagnoses of anxiety disorders (43% to 52%), major depressive disorder (31%), ODD (29%), CD (20%), antisocial personality disorder (12%), and alcohol and drug dependencies (27% and 18%, respectively) in their sample of clinic-referred adults with ADHD. There are strong familial links and neurobiological similarities between ADHD and the various associated psychiatric comorbidities. Comparable rates of comorbidities have been found in men and women with ADHD, with the exception of men having higher rates of antisocial personality disorder. (Millstein et al., 1997)

With respect to ADHD subtypes in adults, Millstein and colleagues found higher rates of ODD, bipolar disorder, and substance use disorders in patients with the combined type of ADHD than in those with other subtypes and higher rates of ODD, OCD, and PTSD in patients with the hyperactive type than in those with the inattentive type.  In their study, Sprafkin and colleagues found that all three subtypes reported more severe comorbid symptoms than did a control group, with the combined group obtaining the highest ratings of comorbid symptom severity. The authors found that the ADHD symptom subtypes in adults are associated with distinct clinical correlates and conclude that the diversity of self-reported psychopathology in adults who meet symptom criteria for ADHD highlights the importance of conducting broad-based evaluations. (Sprafkin, Gadow, Weiss, Schneider, & Nolan, 2007)

Psychosocial Functioning

In addition to comorbid psychiatric disorders, adults with ADHD often complain of psychosocial difficulties, which can manifest in a significantly higher rate of separation and divorce and lower socioeconomic status, poorer past and current global functioning estimates, and higher occurrence of prior academic problems relative to the control group.

Murphy and Barkley (1996a) documented high rates of educational, employment, and marital problems in adults with ADHD. Multiple marriages were more common in the adult ADHD group, and significantly more adults with ADHD had performed poorly, quit, or been fired from a job and had a history of poorer educational performance and more frequent school disciplinary actions against them than did adults without ADHD. Low self-concept and low self-esteem are common secondary characteristics of adults with ADHD, often resulting from problematic educational experiences and interpersonal difficulties (Jackson & Farrugia, 1997). Adults with ADHD often have strong feelings of incompetence, insecurity, and ineffectiveness, and many of these individuals live with a chronic sense of underachievement and frustration (Murphy, 1995).


Variations in communication processes and patterns, both internally and externally, play an important role in the etiology and the symptomatology of ADHD. Unfortunately, there is not enough focus on them in diagnosis and treatment. The author has proposed a theoretical approach and several practical approaches elsewhere (Haverkampf, 2010b, 2017e, 2017d, 2018b) Since the symptoms of ADHD are consequences of maladaptive internal communication and processing mechanisms of meaningful information, while at the same time there are maladaptive external communication patterns with the world, which lead to the observed difficulties in the personal and professional life of the patient, a greater focus on communication is important.

The use of DSM-IV criteria for ADHD in adults has been criticized. Barkley (1998) suggests that applying current ADHD criteria to adults is not developmentally sensitive. The DSM-IV criteria for ADHD were designed for and selected based on studies with children (Riccio et al., 2005), and validation studies of ADHD criteria in adults have not been conducted (Belendiuk, Clarke, Chronis, & Raggi, 2007). It has thus been suggested that the symptom lists in DSM-IV may be inappropriately worded for adults and that diagnostic thresholds may be too stringent or restrictive when applied to adults (Heiligenstein, Conyers, Berns, & Smith, 1998). The level of impairment caused by ADHD symptoms may also be different between adults and children, and symptoms will likely affect more domains in adults. However, when looked at from a communication perspective, and when focusing on the basic of ADHD, such as the attention deficit, it seems possible to view ADHD as a condition where external and internal communication, including the receptiveness for and decoding of information, is altered in predictable patterns. (Haverkampf, 2017f)

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at or on the websites and


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Body Work and Exercise for Anxiety Panic Attacks Depression and OCD


Body Work and Exercise for Anxiety, Panic Attacks, Depression and OCD

Christian Jonathan Haverkampf, M.D.

Working with the body is often neglected in major schools of psychotherapy, such as psychodynamic psychotherapy and CBT. Depression and anxiety disorders are some of the most prevalent psychiatric disorders with close to one in five of adults exhibiting symptoms. Exercise has been shown to reduce symptoms associated with these disorders, has the potential to increase the effectiveness of psychopharmacology and to reduce depenndance on it in specific cases. The balance seems to be important between too little and excessive exercise.

Keywords: body work, exercise, treatment, anxiety, panic attacks, depression, OCD, obsessive-compulsive disorder, Communication-Focused Therapy, CFT, psychotherapy, psychiatry


Introduction. 4

Reconnection. 4

Communication. 4

Information Processing. 4

Integrative Therapy. 5

Exercise and Mental Health. 5

Depression and Anxiety. 5

Age. 6

Neurophysiology. 6

Hippocampal Volume. 6

Endocannabinoids. 6

Adrenocorticotropic Hormone (ACTH) 6

Serotonin. 7

Depression. 7

Body Image. 7

Body Image as a Problem.. 7

Obesity. 9

Breast Cancer. 9

Exercise as an Adjunct to Medication. 10

Techniques. 10

Basic Body Awareness Therapy (BBAT) 10

Pilates. 11

Body Psychotherapy (BPT) 11

Tai Chi 11

Yoga. 11

Exercise Dose. 12

Exercise and Anxiety. 12

Anxiety Sensitivity. 13

Body Dysmorphic Disorder: OCD.. 13

Hypochondriasis. 14

Risks. 15

Prevention. 15

Conclusion. 15

References. 17


Much of the information the brain processes is received from and through the body. Since anxiety, depression and OCD are disturbances in the communication and processing of information, it makes theoretical and practical sense to involve the body in the therapeutic process.

While studies support the use of exercise as a treatment for depression, healthcare professionals irregularly suggest and rarely prescribe it. In their depression treatment guidelines, the American Psychiatric Association (APA) states that exercise may be of value but does not consider it as a first-line treatment. The National Guideline Clearinghouse states in a consensus-based recommendation that exercise is recommended as an adjunctive treatment to antidepressants or psychotherapy.

Chronic major depressive disorder and dysthymia are associated with a high burden and substantial care costs. New and more effective treatments are required. Besides case series and small uncontrolled studies, recent well-controlled studies suggest that exercise training may be clinically effective, at least in major depression and panic disorder. (Ströhle, 2009)


Information comes in through the body. Types of body work and exercise which increase the sense of the body appear to be helpful in various psychiatric conditions. It helps to lessen the focus on a particular bodily function or organ and opens the inflow of information from more points in the body. This can help lower the partial disconnect which is usually present in conditions, such as anxiety, depression, panic attacks, OCD and more.


The body is a communication device, receiving information from the environment and allowing one to send messages, whether verbal or non-verbal. (Haverkampf, 2018) Communication is also the process which brings about change (Haverkampf, 2010a) and takes a preeminent place in communication-focused therapy (CFT) (Haverkampf, 2017a), which has been developed by the author, and plays a role in all psychotherapies.

Information Processing

The body also uses information that is communicated to it. As the nervous system innervates most parts of the body, there is a fast and ubiquitous connectedness throughout the body. While much information is relayed in the central nervous system (CNS) and then send out again, there are relatively autonomous neural networks distributed throughout the body. From a communication viewpoint one needs to look at them as doing something similar to the brain, though on a simpler level. Information is received, processed and new information is sent out again.

Integrative Therapy

The work with the mind and the work with the body in various shapes and form should be seen as two ways to work on communication systems inside the person. The objective is to make communication work better for the patient. This may require a new perspective on how the mind and the body interact, but communication is how things get done inside the body and with the rest of the world.

Exercise and Mental Health

Early large population studies examined the relationship between exercise behavior and mental health . The relation between self-reported physical activity and depressive symptom was analyzed for 1,900 healthy subjects aged 25–77 years in the Epidemiologic Follow-up Study (1982–1984) to the first National Health and Nutrition Examination Survey (NHANES I) and found that physical inactivity may be a risk factor for depressive symptoms.

Weyer found the odds ratio for depression to be significantly higher (OR 3.15) for the physically inactive compared to regular exercisers in a sample of 1,536 individual 15 years of age and older.

Subsequently, physical activity has been shown to be associated with decreased symptoms of depression and anxiety in numerous studies. For example, in a nationally representative sample of adults ages 15–54 in the United States (n = 8,098), regular physical activity was associated with a significantly decreased prevalence of current major depression and anxiety disorders.

Depression and Anxiety

There is a general belief that physical activity and exercise have positive effects on mood and anxiety and a great number of studies describe an association of physical activity and general well-being, mood and anxiety. (Ströhle, 2009) In a study of 19,288 individuals, De Moor found that regular exercise was associated with lower levels of depression, anxiety, and neuroticism.

Cooney and colleagues conducted a search of the Cochrane Depression, Anxiety and Neurosis Review Group’s Controlled Trials Register up to 2013, www.controlled‐, and the WHO International Clinical Trials Registry Platform and any potentially eligible trials not already included are listed as ‘awaiting classification.’ Exercise appeared moderately more effective than a control intervention for reducing symptoms of depression, but analysis of methodologically robust trials only showed a smaller effect in favor of exercise. When compared to psychological or pharmacological therapies, exercise appeared to be no more effective, though this conclusion was based on a few small trials. (Cooney et al., 2013)

Habitual exercise correlates to a heightened level of mental health and wellbeing and reduced feelings of anxiety regardless of the gender of the individual. Relative increases in maximal cardiorespiratory fitness and habitual physical activity appear to be associated with lower depressive symptoms and greater emotional well-being. Ohta noted that 30 minutes or more of walking or cycling while commuting to work might be associated with an increased perception of mental health in men.


The age of the individual may affect the relationship between physical activity and mental health. Exercise has a very small but statistically insignificant effect on reducing anxiety in adolescents. In contrast, Fox found that a population of European adults over the age of 70 had perceived levels of health and quality of life that were positively correlated to higher levels of physical activity.

While regular physical activity appears to be related to mental well-being, physical inactivity appears to be associated with the development of psychological disorders. Some cross-sectional and prospective-longitudinal clinical and epidemiological studies have shown a direct relationship between physical inactivity and symptoms of depression and anxiety.


Physical activity and exercise have been shown to induce widespread neurobiological adaptations. Imaging studies have demonstrated structural changes associated with early-onset depression in the hippocampus, amygdala, striatum, and frontal cortex; areas that are all extensively interconnected. Most consistently associated with depression are the findings of volume loss in the hippocampal formation. Increased levels of hippocampal brain-derived neurotrophic factor (BDNF) levels are associated with decreased anxiety. Exercise is associated with the increased synthesis and release of both neurotransmitters and neurotrophic factors, and these increases may be associated with neurogenesis, angiogenesis and neuroplasticity (Portugal et al., 2013).

Hippocampal Volume

As noted above, imaging studies have shown that depressed patients have decreased hippocampal volume. Brain neurogenesis is increased by antidepressant medications. Ernst and colleagues hypothesize that exercise similarly decreases depressive symptoms by increasing brain neurogenesis. They outline four possible molecular mechanisms for this increased neurogenesis, all of which both promote hippocampal neurogenesis and increase with exercise: B-endorphins, vascular endothelial growth factor, brain-derived neurotrophic factor, and serotonin.


Other possible mechanisms for exercise’s ability to improve mood include the association with exercise and increased levels of endocannabinoids, which are associated with analgesia, anxiolysis, and a sense of well-being.

Adrenocorticotropic Hormone (ACTH)

Changes in the hypothalamo-pituitary adrenal axis, including increased adrenocorticotropic hormone (ACTH) and decreased cortisol production, are associated with exercise and thought to be part of the mechanism of its positive effects on mood.


A randmoised prospective study by Wipfli and colleagues showed that the exercise group had lower levels of depression than the stretching‐control group after the intervention. The exercise group also showed a larger percentage decrease in serotonin than the stretching‐control group. This reduction in blood serotonin after exercise is similar to the effects of selective serotonin reuptake inhibitors. Additionally, percent change in serotonin was found to partially mediate the relationship between exercise and depression. (Wipfli, Landers, Nagoshi, & Ringenbach, 2011)


Multiple studies exist that suggest that exercise is an effective treatment for depression. A Cochrane meta-analysis of 25 randomized controlled trials comparing exercise and placebo or a control intervention found that the exercise groups had a significant improvement in depressive symptoms when compared to the placebo or control group. Only three trials with sufficient allocation concealment, intention to treat analysis, and blinded outcome assessment were found. When these three trials were analyzed together, the effect size was not significant.

There is empirical evidence that exercise compares favourably to antidepressant medications as a first-line treatment for mild to moderate depression. Blumenthal and colleagues conducted a randomized controlled trial in which they assigned 156 adults over age 50 to either aerobic exercise, sertraline, or both. After four months, all three groups had a statistically significant improvement in their depressive symptoms with no statistically significant difference between the groups. The medication group did have a faster response to treatment in the first four weeks, however. However, in a more recent study, the remission rates were also very similar (45-47%), while the rate in the placebo group was moderately, yet not statistically significantly, lower (31%).

Body Image

Exercise improves self-concept in depressed patients, possibly leading to decreased depressive symptoms. Bodywork is related to body image. Bodywork allows us to become more aware of our bodies. It is not necessarily the aim that one builds muscles or achieves a body ideal, which changes as soon as the new magazine ad replaces the old one. But working on and with anything increases our awareness for it. This also applies to the body. By working with the body, we learn about the body. Out of the interaction with the body we get new meaningful information and vice versa. Our bodies are powerful information processing entities, and the information we put into it can bring about significant changes. Exercising is a form of interacting with the body and having the body interact with the world, which leads to a range of changes.

Body Image as a Problem

With a healthy sense of self and a positive body image to go with it, the psyche and the body can work together well and lead to an experience of happiness and contentment. Unfortunately, body image disturbance is an increasing problem in Western societies and is associated with several adverse mental health outcomes, including anorexia, bulimia, body dysmorphia, and depression. (Pimenta, Sánchez-Villegas, Bes-Rastrollo, Lpez, & Martínez-González, 2009)

Body image is, of course, a subjective perception, something that is built from information from the outside (such as a visual image from a mirror) and the inside (perceived needs, values, aspirations, expectations). Body image thus also depends on what we believe is essential and what we think we need, value and should aspire to. It depends on how we communicate and interact with ourselves and other people. (Haverkampf, 2010a, 2017a)

How one sees one’s body affects how one shapes one’s body in the future. It also influences how one feels about the body and, as a consequence, about oneself. Pimenta and colleagues studied the association between body image disturbance and the incidence of depression in 10,286 participants from a dynamic prospective cohort of Spanish university graduates, who were followed-up for four years on average (the SUN study). The difference between BMI and body size perception was considered as a proxy of body image disturbance. Men who underestimated their body size were much more likely to be overweight and obese, whereas women who overestimated their body size were much more likely to be underweight. (Pimenta et al., 2009) However, the authors found no association between body image disturbance and subsequent depression.

Different population may place different emphases on different body attributes. Body fat may, for example, play a greater role in one population than in another, which is probably influenced to a large extent by socialization and communication with others. A study that looked at muscle dissatisfaction, body fat, and height dissatisfaction as predictors of signs of psychological distress, such as depression, eating restraint, eating concerns, and social sensitivity) in a community sample of 228 gay men found that body fat dissatisfaction was predictive of all four distress signs (controlling for muscle dissatisfaction). Conversely, muscle dissatisfaction was only associated with social sensitivity, while height dissatisfaction failed to significantly predict any of the criterion variables for distress. (Blashill, 2010) Another study found that women were more likely to engage in indoor tanning and perceived greater susceptibility to photoaging than men. Body image and depression were found to be associated with tanning behaviors and attitudes. (Gillen & Markey, 2012) Since preferred skin tone, and the behaviors to achieve it, has changed significantly throughout the ages, from very light in past centuries to suntanned in the 1970s and 1980s, social trends must play a significant role. Identifying how one takes in outside preferences and makes them one’s own is an important step in identifying more closely the own needs, values and aspirations, which has a direct effect on quality of life and mental health (Haverkampf, 2010b, 2017a).

Mood plays a large role in how one perceives one’s body. If one sees things more negatively overall, this can also affect one’s view of the own body. Joiner and colleagues examined the relationship between body dissatisfaction, depression, and bulimia in 119 female participants and found that depressed symptoms, but not whether the individual was bulimic, were associated with body dissatisfaction. (Joiner, Wonderlich, Metalsky, & Schmidt, 1995) It is thus important to keep in mind that aside from the effect of variations of the body on mood, the latter does have a significant effect on how we perceive the former. A significant aspect of how depression reduces the activity radius and the quality of life is through a distorted perception of the body.


There is a relatively close link between obesity and depression, although it is unclear what is the cause and what the effect. Depression may cause obesity, for example through changing eating patterns or reduced physical activity. But it is also possible that obesity may cause depression through an even more negatively perceived body image, which is a result from an interaction between the obesity and experienced social norms and interactions. The author has discussed possible etiologic factors from a communication perspective elsewhere (Haverkampf, 2017b). In any case, it is easy to see how a vicious cycle can form at the intersection between the psychological and the physical. Breaking that cycle requires awareness for an individual’s internal and external communication.

That internal or external communication dynamics may play a significant role could explain why being ‘overweight’, but not the extremes of being underweight or severely overweight, is most highly correlated with depression. De Wit and colleagues showed in their study a significant U-shaped trend in the association between BMI and depression. (De Wit, Van Straten, Van Herten, Penninx, & Cuijpers, 2009) Externally, the social context seems to play a role. Xie and colleagues investigated in a prospective study the associations between overweight and depressive symptoms in Asian and Hispanic adolescents. Significant mediation effect was found only in Asian girls and girls with high acculturation. Overweight significantly predicted higher body image dissatisfaction, which in turn was significantly related to depressive symptoms. (Xie et al., 2010)

On the other hand, there is data which shows an independence from social factors and current comorbidities. Zhao and colleagues examined the associations of depression and anxiety with BMI after taking into consideration obesity-related comorbidities and other psychosocial or lifestyle factors. They analyzed the data collected from 177 047 adults in the US. Within each gender, the prevalence of the three psychiatric disorders was significantly higher in both men and women who were underweight (BMI<18.5), in women who were overweight (BMI:25–<30) or obese (BMI⩾30), and in men who were severely obese (BMI⩾40) than in those with a normal BMI. Compared with men with a normal BMI, severely obese men were significantly more likely to have current depression or lifetime diagnosed depression and anxiety. Underweight men were also significantly more likely to have lifetime diagnosed depression. Overweight or obese women were significantly more likely than women with a normal BMI to have all three psychiatric disorders. (Zhao et al., 2009)

Breast Cancer

A condition that threatens the body’s integrity also tends to have a psychological effect. If the condition represents a serious threat, fear and anxiety are normal reactions to it. In one study with female survivors of breast cancer of all ages, 56% of the participants had scores that would correlate with potential depression (Begovic-Juhant, Chmielewski, Iwuagwu, & Chapman, 2012). The majority of women felt less attractive and less feminine. Low body image, attractiveness, and femininity positively correlated with depression and negatively with overall quality of life. (Begovic-Juhant et al., 2012) However, this may also provide an approach for ameliorating the depression through work on body image and the self-perception of attractiveness and femininity. Much of this could involve work with communication (Haverkampf, 2017a).

The body and the mind are inseparable. If the integrity of one is in danger, that will reflect of the sense of wholeness of the other. Lasry and colleagues investigated the psychological and social adjustment following total and partial mastectomy. Total mastectomy patients showed higher levels of depression and less satisfaction with body image. Partial mastectomy patients did not display any measurable increase in fear of recurrence. Patients undergoing radiation therapy showed a surprising rise in depressive symptoms, which could be related to an underestimated anxiety they experience. (Lasry et al., 1987)

Exercise as an Adjunct to Medication

Exercise has also been shown to improve depressive symptoms when added to medication. There seems to be an added benefit beyond the direct effect of the antidepressant. In one study, exercise significantly improved symptoms when added to an antidepressant in a group of older patients with depression that had not responded to 6 weeks of antidepressant medication alone. Unlike its benefit as an adjunct to antidepressant medications, exercise in addition to cognitive therapy was found not to be more beneficial than either one by itself. (Ströhle, 2009)


Many types of bodywork exist, and several are generally assumed to maintain and improve overall health and raise the quality of life. Important is as already mentioned above, aside from the physical exercise, the greater awareness and the better more meaningful information about the body and how it interacts with the psyche and the outside world. However, there is still far less knowledge of movement-based treatments focusing on body awareness than medication or psychotherapeutic approaches.

While more research is needed on the type of exercise needed for depression treatment, available research indicates that the type of exercise may not be as important as having the physical activity reach a sufficient intensity. For example, both running and weightlifting were found to significantly decrease depressive symptoms with no significant difference found between these two forms of physical activity and the decrease in symptoms.

Basic Body Awareness Therapy (BBAT)

Danielsson and Rosberg explored the experiences of basic body awareness therapy (BBAT) in 15 persons diagnosed with major depression who participated in the treatment in a randomized clinical trial. The participants’ experiences were essentially grasped as a process of

  • (Danielsson & Rosberg, 2015)

Five constituents of this meaning were described (Danielsson & Rosberg, 2015):

The authors conclude that the process of enhanced perceptual openness challenges the numbness experienced in depression, which can provide hope for change, but it is connected to hard work and can be emotionally difficult to bear. (Danielsson & Rosberg, 2015)


Mokhtari and colleagues investigated the efficiency of 12-week Pilates exercises on depression and balance associated with falling in thirty elderly participants. The Pilates exercises decreased depression and improved the balance related to falling in participants. (Mokhtari, Nezakatalhossaini, & Esfarjani, 2013)

Body Psychotherapy (BPT)

Body Psychotherapy (BPT) may be an effective treatment option for patients with chronic depression. Rohricht and colleagues studied the effectiveness of BPT in patients with chronic depression. Patients with chronic depressive syndromes and a total score of ≥20 on the Hamilton Rating Scale for Depression (HAMD) were randomly allocated to either immediate BPT or a waiting group which received BPT 12 weeks later. Thirty-one patients were included and twenty-one received the intervention. At the end of treatment patients in the immediate BPT group had significantly lower depressive symptom scores than the waiting group (mean difference 8.7). (Rohricht, Papadopoulos, & Priebe, 2013)

Mindfulness-Based Cognitive Therapy (MBCT) pursues the development of a heightened awareness of one’s body, and its effectiveness has been shown in several empirical studies. Research has focused on the interactions between bodily, cognitive, and emotional processes. Michalak and colleagues argue that considering embodied processes might be a useful perspective for research on the etiology of depression and for mechanisms of action in MBCT. (Michalak, Burg, & Heidenreich, 2012)

Tai Chi

Tai Chi has also been explored in its effectiveness against mental health conditions. It has soft movements, slower speeds, and is relatively easy to learn. The posture of high or low and the amount of exercise can be different according to individual physical fitness. It can meet the needs of different ages and physical fitness. Data from a small study with a single-case design suggests that the intervention had the strongest effect on the participant who presented with hyperactivity and heightened anxiety. (Baron & Faubert, 2005)


Field and colleagues compared the effects of yoga (physical activity) versus social support (verbal activity) on prenatal and postpartum depression. Ninety-two prenatally depressed women were randomly assigned to a yoga or a social support control group at 22 weeks gestation. The yoga group participated in a 20-min group session (only physical poses) once per week for 12 weeks. The social support group (a leaderless discussion group) met on the same schedule. At the end of the first and last sessions the yoga group reported less depression, anxiety, anger, back and leg pain as compared to the social support group. At the end of the last session the yoga group and the support group did not differ. They both had lower depression, anxiety, and anger scores and improved relationship scores. In addition, cortisol levels decreased for both groups following each session. Estriol and progesterone levels decreased after the last session. At the postpartum follow-up assessment depression and anxiety levels were lower for both groups. (Field, Diego, Delgado, & Medina, 2013)

Exercise Dose

A dose-response effect with exercise in the treatment for depression has been noted. In one study, high-intensity weight training was more effective than low-intensity weight training in treating depression. Low-intensity weight training and general practitioner care were found to have nearly the same improvement in depression that is consistent with the widely accepted number of the 30% placebo effect in depression treatment. With aerobic exercise, intensity equaling the energy expenditure in public health recommendations was more effective than a program of guided movements of low intensity that had a reduction in depressive symptoms equal to the placebo group.

Aerobic exercise at a dose consistent with public health recommendations is an effective treatment for MDD of mild to moderate severity. Dunn and colleagues studied whether exercise is an efficient treatment for mild to moderate major depressive disorder (MDD), and the dose-response relation of exercise and reduction in depressive symptoms. Participants were randomized to one of four aerobic exercise treatment groups that varied total energy expenditure and frequency or to exercise placebo control. A 17.5-kcal/kg/week dose is consistent with public health recommendations for physical activity. The main effect of energy expenditure in reducing Hamilton Rating Scale for Depression (HRSD17) scores at 12 weeks was significant. Adjusted mean HRSD17 scores at 12 weeks were reduced 47% from baseline for the 17.5-kcal/kg/week dose, compared with 30% for a lower dose and 29% for control. There was no main effect of exercise frequency at 12 weeks. (Dunn, Trivedi, Kampert, Clark, & Chambliss, 2005)

Exercise and Anxiety

Compared to the wide range of research on the positive effects of exercise on depression, anxiety disorders have been less frequently studied. In general, aerobic exercise has been shown to be an effective and cost-efficient treatment alternative for a variety of anxiety disorders. Several studies have indicated that aerobic exercise may be as effective in reducing generalized anxiety as cognitive behavioral therapy.

In general, exercise does appear to be effective in reducing symptoms associated with anxiety. Furthermore, symptoms improve following both an acute episode of physical activity as well as following a program of routine exercise.

In treating anxiety, exercise has been shown to alleviate anxious feelings. While useful in treatment, exercise does not seem to reduce anxiety to the level achieved by psychopharmaceuticals. In a study of patients suffering from moderate to severe panic disorder, both a 10-week protocol of regular aerobic exercise and clomipramine were associated with significant improvement of symptoms compared to placebo. In comparison with exercise, clomipramine improved anxiety symptoms more effectively and significantly earlier.

In another study, the effects of a Feldenkrais® Awareness Through Movement program and relaxation procedures were assessed on a volunteer sample of 54 undergraduate physiotherapy students over a 2-week period. Analysis of variance showed that anxiety scores for all groups varied significantly over time and, specifically, that participants reported lower scores at the completion of the fourth intervention. Further, compared to the control group, females in the Feldenkrais® and relaxation groups reported significantly lower anxiety scores on completion as compared to the beginning of the fourth session, and this reduction was maintained one day later. (Kolt & McConville, 2000)

Anxiety Sensitivity

Exercising at 70%–90% of maximum heart rate for 20 minutes three times a week seems to reduce anxiety sensitivity significantly (Carek, Laibstain, & Carek, 2011). Self-reported fears of anxiety sensations, fears of respiratory and cardiovascular symptoms, publicly observable anxiety symptoms, and cognitive dyscontrol decrease following a prescribed exercise program (Carek et al., 2011). In a study by Cox and colleagues, the most substantial reduction in state anxiety occurred 90 minutes following 20 minutes of aerobic exercise at 80% of maximal oxygen uptake (Cox, Thomas, Hinton, & Donahue, 2004).

Body Dysmorphic Disorder: OCD

The relationship between obsessive–compulsive disorder (OCD) and body dysmorphic disorder (BDD) is unclear. BDD has been proposed to be an OCD‐spectrum disorder or even a type of OCD. There is a growing literature on the concept of an obsessive–compulsive spectrum of disorders. (Lochner & Stein, 2006)

Body dysmorphic disorder (BDD) is a distressing and impairing preoccupation with an imagined or slight defect in appearance, with depression as its most frequent comorbid condition. (Nierenberg et al., 2002)

BDD is frequently comorbid with major depression, is associated with an earlier age of onset of depression and longer duration of depressive episodes, and is found more frequently with atypical than non-atypical depression. Nierenberg and colleagues evaluated the rate of BDD in a cohort of consecutive outpatients with typical and atypical major depressive disorder in 350 outpatient participants. Twenty-eight (8.0%) subjects had a lifetime history of BDD and 23 (6.6%) had current BDD. Those with comorbid lifetime BDD had an earlier age of onset of depression and longer duration of the current episode, but not a greater number of depressive episodes or greater severity of depression. Subjects with and without BDD were similar with respect to age, gender, and marital status. There was a higher rate of lifetime and current BDD in subjects with atypical depression than in those with non-atypical depression. Subjects with BDD also had higher rates of social phobia, any eating disorder, and any somatoform disorder but not OCD. They also had higher rates of avoidant, histrionic, and dependent personality disorders. (Nierenberg et al., 2002)

OCD and BDD do not significantly differ on many variables but did have some clinically important differences. In one study, the comorbid BDD/OCD group evidenced greater morbidity than subjects with OCD or BDD in a number of domains, but differences between the comorbid BDD/OCD group and the BDD group were no longer significant after controlling for BDD severity. However, differences between the comorbid BDD/OCD group and the OCD group remained significant after controlling for OCD severity.

Lochner and Stein conducted a computerized literature search (MEDLINE: 1964–2005) to collect studies addressing different dimensions on which the OCSDs lie. Their cluster analysis found that in OCD there were 3 clusters of OCD spectrum symptoms:

  • “Reward deficiency” (including trichotillomania, pathological gambling, hypersexual disorder and Tourette’s disorder),
  • “Impulsivity” (including compulsive shopping, kleptomania, eating disorders, self-injury and intermittent explosive disorder), and
  • “Somatic” (including body dysmorphic disorder and hypochondriasis).

It is unlikely that OC symptoms and disorders fall on any single phenomenological dimension; instead, multiple different constructs may be required to map this nosological space. Although there is evidence for the validity of some of the relevant dimensions, additional work is required to delineate more fully the endophenotypes that underlie OC symptoms and disorders. (Lochner & Stein, 2006)

It has been argued that body-focused repetitive behavior disorders (e.g., trichotillomania and skin-picking disorder) should be included within the obsessive-compulsive and related disorders category, as this is how most clinicians see these behaviors, and as this may optimize clinical utility. The descriptions of these disorders should largely mirror those in DSM-5, given the evidence from recent field surveys. (Stein & Bouwer, 1997)


The symptoms of HC overlap to an extent with certain anxiety disorders, such as panic disorder and OCD. The results of a study using discriminant function analysis indicated that whereas individuals with hypochondriasis experience panic attacks, obsessions, and compulsions, these symptoms are markedly less pronounced than among those with panic disorder and OCD. Conversely, overlaps were found in terms of cognitive biases, with hypochondriasis patients demonstrating elevated levels of intolerance of uncertainty, body vigilance, and fear of cardiovascular symptoms. (Deacon & Abramowitz, 2008)


While the Center for Disease Control and Prevention and the American College of Sports Medicine recommend that individuals should engage in 30 minutes or more of moderate-intensity physical activity on most (preferably) all days of the week, physical activity and exercise have risks that need to be considered. The most common risk of physical activity in adults is musculoskeletal injury. The risk of injury increases with obesity, volume of exercise, and participation in vigorous exercise such as competitive sports.

Furthermore, vigorous physical activity acutely increases the risk of sudden cardiac death and myocardial infarction among individuals with both diagnosed and occult heart disease.


Reduced incidence rates of depression and (some) anxiety disorders in exercising subjects raise the question whether exercise may be used in the prevention of some mental disorders. A review of studies showed a bidirectional relationship between physical activity, exercise and adolescent mental health (Pascoe & Parker, 2019). The results suggested that physical activity and exercise programs designed to increase the level of activity in young people should be implemented to be attractive and achievable to young people that may have poor psychological health (Pascoe & Parker, 2019). Another study found that participating in diverse leisure activities and longer exercise time decreases older adults’ risk of having depression. Additionally, the results confirmed that depression is positively correlated with chronic diseases (Lee, Yu, Wu, & Pan, 2018). On the other hand, data from the Netherlands Mental Health Survey and Incidence Study did not find evidence for a dose–response relationship between exercise levels and mental health. Among those with mental disorder at baseline, exercise participants were more likely to recover from their illness compared to their counterparts who did not take exercise, but the authors pointed out that it remains uncertain whether this association truly reflects a causal effect of exercise (Ten Have, de Graaf, & Monshouwer, 2011). In a 2010 meta-review, an ssociation between physical activity and mental health in young people was evident, but research designs were described as often weak and effects small to moderate. Evidence showed small but consistent associations between sedentary screen time and poorer mental health (Biddle & Asare, 2011). In another study involving 42 undergraduates, vigorous exercise had mental health benefits beyond moderate physical activity, was associated with less stress, pain, insomnia and depression, more favorable objective sleep patterns, and fewer mental health problems if the individual was exposed to high stress (Gerber et al., 2014).


Depression and anxiety disorders are some of the most prevalent neurological disorders with close to one in five of adults demonstrating symptoms. Exercise has been shown to reduce symptoms associated with these disorders and has the potential to lessen the dependability on psychopharmacology. Physicians should recommend that adults participate in at least 30 minutes of accumulated moderate-intensity physical activity (for example, walking fast) on most days of the week. (Phillips et al., 2007) The balance seems to be important. The term ‘exercise addition’ has been coined for another extreme, in which an individual experiences a need to engage in excessive exercise, has the potential to have adverse effects on both physical and mental health (Berczik et al., 2012).

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at or on the websites and


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Anxiety and Panic Attacks


Anxiety and Panic Attacks

Christian Jonathan Haverkampf, M.D.

Abstract – Anxieties can cause incredible suffering, especially in combination with panic attacks, which are usually a short-lived but more intense form of anxiety. At the foundation is often a subconscious, or sometimes partially conscious, feeling that something in life is ‘out of sync’. Anxiety is often triggered by interpersonal difficulties, such as relationship breakups or human problems at the work place. The less one has a good sense of oneself, one’s values, interests and needs, the more difficult interactions and communication with others can become, the lower is one’s resilience in conflicts and situations of divergent interests. All this can induce and maintain anxiety. While a predisposition for anxiety has been shown on the molecular biological and the epidemiological level, it usually is triggered and maintained by conflicts on the inside or the outside. Psychotherapy has been shown to be very effective in treating anxiety disorder and panic attacks.

Keywords: anxiety, panic attacks, psychotherapy

Table of Contents

Anxiety Disorders. 3

Biology. 4

Panic Attack. 4

Invisibility. 5

Lack of Communication. 5

Loss of Control 5

The Need for Control 5

A Signal of Change. 6

Fear of Imminent Death: Somatic (Body) Reaction. 6

Certainty and Security. 6

Meaningful Relationships. 7

Values and Interests. 8

Inner Conflicts. 8

Self-Talk. 9

Three Steps. 9

Happiness. 10

References. 11

Anxiety Disorders

Anxiety is an unpleasant feeling that is often accompanied by tension, nervousness and a restlessness to escape from it. It is a dread of uncertainty about the immediate future, but can also be about the more distant one. Communication Anxiety is an unpleasant feeling that is often accompanied by tension, nervousness and restlessness to escape from it. It is a dread of uncertainty about the immediate future, but can also be about the more distant one. Communication plays, as in most mental health conditions, a vital role (Haverkampf, 2010b). The more connected one feels with others and oneself in a meaningful way, the lower the levels of anxiety usually are (Haverkampf, 2017c) As communication reduces uncertainty, better and more meaningful interactions with oneself and others regularly reduce anxiety.Anxiety is an unpleasant feeling that is often accompanied by tension, nervousness and a restlessness to escape from it. It is a dread of uncertainty about the immediate future, but can also be about the more distant one. Communication plays, as in most mental heal

Anxiety disorders are a group of mental disorders characterised by feelings of anxiety and fear. (APA, 2013) It is a worry about the uncertainty about the nature and occurrence of future events and fear is a reaction to a specified current event. These feelings may cause physical symptoms, such as a fast heart rate and shakiness. There are a number of anxiety disorders:

generalised anxiety disorder

specific phobia

social anxiety disorder,

separation anxiety disorder,


panic disorder, and

selective mutism.

An individual may be diagnosed with more than one anxiety disorder. It is important to remember that in psychiatry diagnoses are mostly bundle of symptoms dating back to a time when little was known about the underlying causes, the etilogy of a condition. Over time, the diagnostic systems will change as our understanding of these underlying causes develops further, biologically and psychologically (Haverkampf, 2018b). For now it is important to note that all forms of anxiety have certain common communication and information constellation patterns. Anxiety is often a signal that something is ‘out of sync’.

The epigenetic factors of anxiety are usually placed within the realms of


Psychology, and

Social systems / Economics,

but it takes all three too varying degress to result in anxiety.


Anxiety is a behavioural state, which occurs in response to signals of danger. On the physiological level these signals initiate activation of the hypothalamus-pituitary-adrenal (HPA) axis (Boyce & Ellis, 2005) and secretion of adrenal steroids called stress hormones, which are present in almost every vertebrate cell (Korte, 2001) This leads to increased heart rate, deeper breathing, vigilance, decrease in feeding, and exploration of environment (Cannon, 1916). The genes that code for stress hormones are highly conserved across diverse species: primates, rodents, reptiles, and amphibians (Lovejoy & Balment, 1999; Lovejoy & Jahan, 2006). Neuroevolutionary studies have shown that anxiety is an adaptive response that has been conserved during evolution (Nesse, 1998; Stein & Bouwer, 1997).

Individuals can have a genetic predisposition towards anxiety, which means they are more likely to suffer from an anxiety than someone who does not have this predisposition given the same amount of stress or other internal psychological or external factors. The amygdala, for example, is believed to play a key role in assigning emotional significance to specific sensory input, and conditions such as anxiety, autism, stress, and phobias are thought to be linked to its abnormal function. Growing evidence has also implicated the amygdala in mediation of the stress-dampening properties of alcohol. There have been reports that decreased phosphorylation of cAMP responsive element–binding protein (CREB) resulted in decreased neuropeptide Y (NPY) expression in the central amygdala of alcohol-preferring rats, causing high anxiety-like behaviour (Wand, 2005). Alcohol intake by these animals was shown to increase PKA-dependent CREB phosphorylation and thereby NPY expression, subsequently ameliorating anxiety-like behaviour. Thus, a CREB-dependent mechanism may underlie high anxiety-like and excessive alcohol-drinking behaviour.

Panic Attack

The first panic attack can occur as from nowhere and the sudden sense of imminent death or literally going crazy usually comes as an enormous and sudden shock. In many cases, it has five stages:

An ominous feeling of an imminent panic attack. A heightened sense of self-consciousness with beginning hyperventilation and other symptoms.

  • The sense that there is no way to avert the full-blown panic attack.
  • The panic attack with hyperventilation, heart palpitations, the sense of imminent doom and/or death.
  • Alternations in the intensity of the panic attack, leading to a decline after about ten minutes.
  • A post-panic phase in which there is a sense of exhaustion and sometimes elation that it is over.

Since the first panic attack often occurs in adolescence or young adulthood, the individual might not know what a panic attack is. In older people, panic attacks often lead to visits to the hospital emergency admission.


A feature of many anxieties and panic attacks is that they go largely unnoticed by the environment. Anxieties and panic attacks can lead to the inability to leave the house and interfere with almost every sphere of life, professional, social, and one’s relationships. When anxiety reaches into all areas of life and no longer seems specific to certain situations and locations, we call it ‘generalised’. It is then the pure form of a disturbing feeling that no longer is attached to specific object, but ‘floats freely’.

Loneliness has been demonstrated to be strongly associated with anxiety over social skills, for both male and female undergraduates and for a variety of social relationships. Both factors were related significantly but independently to loneliness, with anxiety having a larger effect size. (Solano & Koester, 1989) Communication as a basic information process plays a strong role in anxiety. (Haverkampf, 2012, 2017b)

Lack of Communication

When people identify and talk about their emotions, they usually become more manageable to the individual. This also applies to anxiety. The more one can talk about the anxiety and the underlying emotions, the less the anxiety will feel uncertain and unpredictable, which helps break through the vicious cycle of feeling anxious about feeling anxious. Any form of communication can potentially break through the vicious cycle. Psychotherapy, however, can deliver results faster and more reliably, because of the focus of the interaction and the training of the therapist.

Loss of Control

Anxiety and Panic Attacks are often a result of a perceived loss of control in an area one feels is relevant to oneself, emotionally and otherwise. Often patients mention the sense of loss of control. This may be linked to emotions from past experiences which have not been resolved or current stress situations which have led to feelings of entrapment in a hopeless situation with out a way out. At the core is the sense that one is not strong enough to bring about a change, which is often a result of losing the sense of efficacy in the world. Since communication is how humans interact with the world, the loss of control is ultimately due to the faith in the own abilities to communicate with oneself and the world. (Haverkampf, 2010c, 2010a, 2017a, 2018a)

The Need for Control

The more one perceives being in a situation where one cannot pursue the own needs, values and aspirations, the higher is usually the sense of loss of control. If there is also a perceived lack of strength and ability to bring about a change, the loss of control will only be increased. Frequently, when there is an underlying depression or unresolved negative past experiences, the own sense of efficacy will be lowered, which can then lead to an aversion of change and a persistent feeling of being trapped.

On the other side, a greater sense of stable factors in oneself and the world can lower anxiety. Such factors may include a good and stable sense of self, basic values, fundamental needs and wants, several personality traits, character attributes, one’s memory of facts and thoughts, a sense for one’s body, and a number of other factors. Once one learns to explore and reflect on oneself and the world around, the need for control lessens because one sees more regularity and structure and learns to experience excitement rather than anxiety when looking at oneself and the world.

A Signal of Change

Since anxiety is a sign that something is ‘out of sync’, it also signals a necessity for change. This does not necessarily require a change in job or relationship partner, but often it does mean that a modification of existing relationships or situations can be beneficial. When things seem to be out of sync, the world becomes less certain and predictable. Anxiety is not a fear of something specific, but of uncertainty itself. It springs from a realisation that something is out of sync, and usually this something refers to interpersonal relationships. People may be fearful of objects, but the latter are unlikely to cause anxiety.

Anticipatory processes are a general feature of the mind that includes responses to both real and imagined (neurotic) appraisals of a situation. (Wong, 1998) This has originally been described by Freud as signal anxiety, whose general concept has been confirmed in research. From a communication perspective, anything that helps in making the information of emotional conflicts available to consciousness is valuable. This can help the individual to reduce the emotional conflicts, primarily through communicating with the environment and with oneself.

Fear of Imminent Death: Somatic (Body) Reaction

Panic attacks often trigger thoughts of an imminent death, such as not being able to breathe anymore or a heart attack. They frequently go along with bodily ‘fear’ reactions, such as heart palpitations and dizziness. In general, there is a general sense of a loss of control over one’s body and even one’s mind, which further worsens the panic attack. Often panic attacks start in adolescence and young adulthood and frequently they are triggered by relationship events and social situations. But if they remain untreated, they can spread out and become ‘generalised’. They can reach a point where they even occur when someone is at home lying in back or after waking up at night. In the extreme, this can lead to a situation in which a patient is not only house but also bed bound.

Certainty and Security

Under the surface of the symptoms of anxiety and panic attacks there often a perceived deficit of certainty and security in one’s life. As babies and small children learn to rely on their interactions with others, especially primary caretakers, to meet their needs, they build up a sense of safety regarding the world around them and a secure sense of self. As we figure out the ‘rules of daily life’ as children we learn to be reasonably in the world. Things might still be unpredictable at times, but in a caring and supportive environment, unpredicted events, whether good or bad, are seen as a fact of life that one might not be able to control, but that one cope with. In an environment where individuals are less able to deal with such events, a greater sense of uncertainty and a greater susceptibility to anxiety develops, especially if there are also biological factors present. It ultimately comes down not to the actual level of control one has over external and internal events, such as the functions of the own body, but the perceived need for it. Yielding control can be quite effective in regaining control over life in a more general sense.

Sanderson and co-workers tested in a study the notion that a sense of control can mitigate anxiety and panic attacks caused by the inhalation of 5.5% carbon dioxide (CO2)—enriched air. (Sanderson, Rapee, & Barlow, 1989) Twenty patients with panic disorder inhaled a mixture of 5.5% CO2-enriched air for 15 minutes. All patients were instructed that illumination of a light directly in front of them would signal that they could decrease the amount of CO2 that they were receiving, if desired, by turning a dial attached to their chair. For ten patients, the light was illuminated during the entire administration of CO2. For the remaining ten patients, the light was never illuminated. In fact, all patients experienced the full CO2 mixture, and the dial was ineffective. When compared with patients who believed they had control, patients who believed they could not control the CO2 administration (1) reported a greater number of DSM-III—revised panic attack symptoms, (2) rated the symptoms as more intense, (3) reported greater subjective anxiety, (4) reported a greater number of catastrophic cognitions, (5) reported a greater resemblance of the overall inhalation experience to a naturally occurring panic attack, and (6) were significantly more likely to report panic attacks. (Sanderson et al., 1989) Thus it seems that the subjective amount of control a patient has over the level of anxiety influences the experienced anxiety. Clinically, it is often observed that if a patient carries a relatively fast acting anxiolytic in their pockets, the additional sense of control can reduce the occurrence of panic attacks. It is often the anxiety about becoming anxious or suffering a panic attack which is the most debilitating feature of more pronounced anxiety and panic attacks.

Society has developed several ways to deal with anxiety and reduce uncertainty. Many human endeavours aim to provide a greater sense of safety. Laws and scientific progress deal with both, uncertainty in people and uncertainty in the natural world. However, in generalised anxiety and panic attacks, it is less a certainty in the outside world than in the inside world which individuals with anxiety strive for, and it is here that psychotherapy often takes its starting point.

Meaningful Relationships

A message is meaningful if it has a degree of novelty and can bring about a change in the person receiving the message. Relationships are meaningful if there is mutual understanding and empathy, but also if there is an exchange of information that benefits both over the long-run. For someone suffering from anxiety it may not be easy to communicate to an extent that could help against the anxiety, which can prolong the latter. Reducing perceived dangers from participating in interactions with others can be achieved by shifting the focus away from the own person, making other people’s comments not about the own person and realising it is OK to say ‘no’. This can be quite easily resolved through the communication work in the therapeutic session by developing awareness for these patterns, reflecting on them and working out modifications or replacing them with other patterns in a playful and experimental way.

Meaningful relationships with other and with oneself help to counteract anxiety because the individual feels a higher degree of efficacy in the world and with respect to oneself. Meaningful communication reconnects the individual with others, but it also aids in self-regulation and gives the individual a greater sense of being effective in taking care of oneself through the interactions with others.

Values and Interests

The other important element is finding not only the strength in oneself but also the direction to proceed in the life. Often there are many paths that can be taken, which confuses people and causes anxiety. Without a sense of one’s trues values, interests and aspirations it is more difficult to make the relevant decisions in life that lead to greater happiness. If one’s sense for one’s own values and fundamental interests and aspirations is compromised because of losses of connection with the rational and emotional self, stress, anxiety and burnout can ensue. It is like running in place without getting anywhere, while having a strong desire to get somewhere.

True values, part biology, part social learning from other human beings, means a fundamental belief that acting according to these values and interests and attaining one’s aspiration will really mean happiness in the long run. In anxiety, these values and fundamental interests are out of sync with our lives.

Inner Conflicts

Anxiety is caused by inner conflicts, which in the cognitive behavioural therapy tradition are assumed to be conscious or ‘near-conscious’, while the psychodynamic or psychoanalytic psychotherapy traditions see most of it in the domain of the unconscious. This largely explains the differences in treatment times between the two approaches, but on a theoretical level both can complement each other quite well. Fundamentally the causes are difficulties in communicating one’s underlying needs and wishes in a way that subjectively strengthens rather than weakens a relationship out of a fear of further loss. This also makes the internal conflicts persist. Our communication with the people in our lives has an impact on how we talk to ourselves, because they provide crucial feedback to us. When our social interactions become meaningless, our sense of shaping our world in a way that makes us feel secure and happy suffers.

Effective mental functioning requires that cognition be protected from emotional conflict due to interference by task-irrelevant emotionally salient stimuli. The neural mechanisms by which the brain detects and resolves emotional conflict are still largely unknown, however. Using functional magnetic resonance imaging (fMRI), Etkin et al found that activity in the amygdala and dorsomedial and dorsolateral prefrontal cortices reflects the amount of emotional conflict. By contrast, the resolution of emotional conflict is associated with activation of the rostral anterior cingulate cortex. Activation of the rostral cingulate is was accompanied by a simultaneous and correlated reduction of amygdalar activity. These data suggested that emotional conflict is resolved through top-down inhibition of amygdalar activity by the rostral cingulate cortex. (Etkin, Egner, Peraza, Kandel, & Hirsch, 2006). Interestingly, the amygdala also plays a significant role in the triggering and maintenance of anxiety.

Resolving emotional conflicts is thus an important technique to lower anxiety. Often, one may not be aware of these emotional conflicts. Particularly in stress or burnout situations, the focus is on survival in a job, a relationship or everyday life rather than on self-exploration and connecting emotionally with oneself. The therapeutic interaction can be helpful to provide the space and the sense of safety to explore and reconnect emotionally. While at first this can increase the anxiety level, within weeks of consistent work the anxiety levels often drop dramatically, even before concrete external adjustments can be made in life.


When I refer to ‘talking to oneself’ I do not mean literally talking to oneself in the street but bouncing back and forth thoughts in one’s head, observing one’s thought process and reflecting on it. This requires the exchange of highly complex information in even more complex webs of networks of nerve cells in the brain. Since our brain is a highly complex network of ever smaller networks of nerve cells it allows the brain to process information in parallel. This is the reason why we can ‘listen’ to our own thoughts. Brain cells are in contact with other brain cells and they can alter the properties of their own connections depending on the information they transmit. Medication can alter certain types of transmissions in this system, but if we want to be more specific, we have to expose ourselves to meaningful information which the brain can use to refigure itself. This is essentially what psychotherapy does. As many empirical studies have shown, psychotherapy can bring about changes in connectivity and activation of the brain, which in turn can have a lasting effect on certain conditions, such as anxieties and panic attacks.

Three Steps

The first step is to become aware of situations that trigger anxieties and panic attacks, such as relationship problems or work-related stress. But these problems might not always be obvious, and they might not even explain the anxiety. Problems in a relationship or shyness in social situations are normally not the ultimate explanation for anxiety or panic attacks. We need to analyse in the specific case why losing a relationship causes such threatening fears as anxieties or panic attacks suggest. Sometimes it is worthwhile taking a look into one’s past and reconstruct how an individual dealt with his or her environment as a child or adolescent and how the environment dealt with the individual. At other times, it may be important to ‘dissect’ the thought patterns in the here and now and to try to find out what they could mean. “If I leave the house I might have to figure out what I really want to do in life. “If this relationship breaks up I might have to figure out what I need and what I want, who I am, who I want to be with …” and so on. This step is about better understanding one’s needs, values and aspirations, and thus oneself.

The second step is to determine if the current approach, such as avoidance or negation, is the best strategy. It always never is. But this does not mean that one has to radically alter one’s current lifestyle or social life, though in special cases it might. The actual life we have starts in our head, so it is first and foremost about determining the questions that matter to oneself and how to approach them. This is actually easier than most people think, because it is not so much about having certain answers but about learning how to think and communicate in novel ways. Change usually means widening one’s mental repertoire, not narrowing it. The more effective tools are in our toolbox and the more meaningful information we have access to, the better will be our answers and decisions.

The third step is to act according to this novel information. This might sound like a tall order in the face of fears, anxieties and panic attacks, but once someone reaches this stage, the hurdles are often diminished or gone altogether. The fears usually disappear during the first and the second step. The reason is that we are usually more afraid of an uncertain ill-defined event than a certain defined event. When you are facing a threatening event, the uncertainty about an unlikely ill-defined outcome can be more painful than the certainty about a certain well-defined event. The certainty of death does not disturb people nearly as much as not knowing how they will die.


The goal is not absolute certainty in life but the attainment of happiness. Anxiety does not necessarily mean a shift in the balance between happiness and writing a meaningful story for one’s life, rather, it often is a wake-up call for us to re-evaluate who we are and what we really want in life to make us happier.

Most people want to lead lives which feel true to themselves for the simple reason that they believe it will make them happy. The only certainty that really helps against anxiety is the certainty that one follows one’s own path. To help a patient reach this path and follow it with confidence is an important objective of psychotherapy and counselling.

Dr. Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He also has advanced degrees in management and law. The author can be reached by email at or on the websites and


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This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

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The Fear of Living (1)


The Fear of Living

Christian Jonathan Haverkampf, M.D.

Fear of death is widespread, but the fear of living can often be more impairing in daily life. Many mental health symptoms derive from an anxiousness, fear or apprehension about living in line with one’s needs, values and aspirations. Not engaging with life can lead to an unfilled life and several mental health issues. Engaging with life means communicating with others and oneself effectively.

Keywords: fear of living, communication, psychotherapy

Table of Contents

Introduction. 5

Control and Perspective. 6

Communication Fears and Barriers. 6

Understanding Fear. 7

Overgeneralization. 8

Fear and cognitive abilities. 8

Learning. 9

Anxiety. 9

Social Networks. 9

Connectedness, Social Networking Sites (SNSs) and the Fear of Missing Out (FOMO) 10

Extinction. 10

Flexibility. 10

Memory. 11

Learning. 11

Empathy and Fear. 11

Stress. 11

Fear and Society. 12

You and I 12

Example: Initiating Communication with a Romantic Interest. 13

The Fear of Being Single, Scarcity and ‘Settling for Less’ 13

Proactive Behaviours in Men. 13

Fear of Rejection. 14

Early Communication. 15

Attachment. 15

The Power of Connectedness. 16

Self-Statements. 16

Technology and Communication. 17

Information about Oneself 18

Anxiety vs Behaviours. 20

Misattribution. 20

Fearing the Fear. 21

Fear of Change. 21

Reasonable vs Unreasonable Fears. 21

Neurobiology. 21

The Fear Network. 22

Serotonin. 22

Oxytocin. 23

The Amygdala. 23

Fear without the Amygdala?. 23

Fast Pathways. 24

The Microbiome. 24

Inferior Frontal Gyrus. 24

Learning. 24

Reversal 25

Neuronal coordination. 25

Memory. 26

The Thalamus. 26

Fear vs Anxiety: Information. 27

Extinction. 27

Change. 28

The Cortical Neural Network. 28

Anxiety. 29

Biological Approaches. 29

Memory. 29

C-Cycloserine. 29

MDMA. 30

Other Approaches. 30

Change. 30

Change from Within. 30

Change Without. 31

Psychological Approaches. 31

CBT: Fear of Flying. 31

Virtual Exposure. 31

Fear of Flying (FOF) 32

Systematic Desentization. 32

Expressive Therapy. 32

Cognitive Processing Therapy (CPT) 32

Thoughts and Emotions. 32

Meaningfulness. 33

Communication and Fear. 33

Patterns and Communication Structures. 34

Questions. 34

Building the Motivation to Overcome One’s Fears. 34

Information Overload. 34

Relevance. 35

Selecting Information. 35

The Right Question. 35

Values and Basic Interests. 35

Generalisation. 36

General Questions. 36

Communication to Counter Fear. 36

References. 37


Many are aware of the fear of death, but the fear of living can often be more impairing in daily life. Fear can be an adaptive emotion that helps defend against potential danger. However, the overgeneralization of fear to harmless stimuli or situations is a burden to daily life and characteristic of posttraumatic stress disorder and other anxiety disorders. (Dunsmoor & Paz, 2015)

Many mental health symptoms to derive from an anxiousness, fear or apprehension about living in line with one’s needs, values and aspirations. Life can be complicated and scary, but not engaging with it can lead to an unfilled life and various mental health issues. One of the pillars of life is the exchange of information, whether this occurs in a single cell organism or the human body. The communication between cells and within cells ensures survival. Once it ceases, death results. Communication also occurs among living organisms, including people. Engaging with life means communicating with others and oneself effectively.

The first important step is to identify what is the aim of a fear one is experiencing. In many cases, this may be life itself or just allowing oneself to be happy. Facing one’s fears means acting. They are a hindrance to interactions with oneself and the world, and overcoming them can increase happiness, satisfaction and contentment in the long run. Unhelpful fears are those that do not offer protection and interfere with life. The fear of interacting and connecting with oneself and others can be the most life impairing one.

Emotions are usually valuable signals, but internal events unrelated to the current situation can trigger fear. Emotional messages, such as fear, are at the most basic information that is assembled and communicated internally. (Haverkampf, 2018a) Foa and Kozak contended that emotions are represented by information structures in memory, and anxiety occurs when an information structure that serves as a program to escape or avoid danger is activated. (Foa & Kozak, 1986) Fear of communication, the flow of information, is probably the widest-reaching and most debilitating fear because any new information to which the brain is exposed can activate it.

The information flows leading to the emergence of fear follow the basic rules of communication, while there are certain structures in the brain which play a more pronounced role in fear. The amygdala has many efferent projections and represents a central fear system involved in both the expression and the acquisition of conditioned and unconditioned fear. (Davis, 1997) Lesions of the amygdala block innate or conditioned fear, as well as various measures of attention, and local infusions of drugs into the amygdala have anxiolytic effects in several behavioural tests.  From a biological standpoint, fear is a very important emotion. It helps you respond appropriately to threatening situations that could harm you. This response is generated by stimulation of the amygdala, followed by the hypothalamus. This is why some people with brain damage affecting their amygdala do not always respond appropriately to dangerous scenarios. When the amygdala stimulates the hypothalamus, it initiates the fight-or-flight response. The hypothalamus sends signals to the adrenal glands to produce hormones, such as adrenaline and cortisol.

Control and Perspective

Having a sense of control makes people feel more secure in life. However, the amount of influence one has is a matter of perspective. Fear and anger have opposite effects on risk perception. Whereas fearful people express pessimistic risk estimates and risk-averse choices, angry people show optimistic risk estimates and risk-seeking choices. Appraisals of certainty and control seem to moderate and (in the case of control) mediate the emotion effects. (Lerner & Keltner, 2001) This does not mean going through life taking senseless risks and being angry, but to be open to and keep an eye on the options life has to offer. Following the own path feels at least more in control and less fearful than just running around in circles.

Important in overcoming fear is to assess the level of control that a given situation requires. Often, fear is a result of an increased perceived need for control to stay ‘safe’. Feeling less in control usually happens when the internal compass of needs, values and aspirations gets lost. One can recover it by thinking of what one needs to feel happy and content. In communication-focused therapy, one way to address this is to look at the primary parameters, the needs, values and aspirations of the individual. (Haverkampf, 2018f) Quite often, patients find out that they were searching for that basic sense of security in something external, such as relationships or material goods, that were not the highest priorities on their needs and value lists. So, rather than feeling safer, they often felt less safe when acquiring them.

Communication Fears and Barriers

People build barriers when they are afraid. The problem with this is that information can reduce fears, and any restrictions on the free flow of meaningful information will make it even harder to lessen fears, leading into a vicious cycle. Connectedness with oneself and with others reduces anxiety, but it may require changing unhelpful and counterproductive communication patterns which interfere with effective communication within oneself and with others (Haverkampf, 2018b, 2019a)

Internal communication, the one we have with ourselves, and external communication, the one we have with others, are closely linked, and often reflections of each other. In the area of dating communicatioon, for example, results of one study showed that relatively shy emerging adults had more internalizing problems (e.g., anxious, depressed, low self-perceptions in multiple domains), engaged in fewer externalizing behaviours (e.g., less frequent drinking), and experienced poorer relationship quality with parents, best friends, and romantic partners than did their non-shy peers. (Nelson et al., 2008)

Understanding Fear

When faced with threat, the survival of an organism is contingent upon the selection of appropriate active or passive behavioural responses. Freezing is an evolutionarily conserved passive fear response, for example. The central amygdala (CEA) is a forebrain structure vital for the acquisition and expression of conditioned fear responses, and the role of specific neuronal sub-populations of the CEA in freezing behaviour is well-established. Fadok and colleagues showed that active and passive fear responses are mediated by distinct and mutually inhibitory CEA neurons. Cells expressing corticotropin-releasing factor mediate conditioned flight, and activation of somatostatin-positive neurons initiates passive freezing behaviour. (Fadok et al., 2017) The selection of appropriate behavioural responses to threat seems to be based on competitive interactions between inhibitory signals on each other from these cell groups.

Since our reality is built from the information in our brain, an emotion can be as real as a rock. A fear of life can perfuse everything that we associate with life, including the things that may be important or of special value to us. Taking the first step to go out there and actively participate in life, whether in work or in one’s personal life, can inspire fear. Quite often apprehensiveness with connectedness in one realm can spill into the other one, and vice versa. While fears can be quite specific, such as a fear of insects, a fear of a more colourful and enjoyable life can modify everyday behaviours and thoughts considerably.

Understanding the fear signals and the information they contain provide important insight, which  can bring about change that reduces the fear. An emotion is an ‘e-motion’ because it is supposed to move something, because it needs to bring about change. Identifying the information behind, or underlying, an emotion required identifying and reflecting on the emotion, but in communication oriented therapies, for example, it can become a useful habit. (Haverkampf, 2010c, 2017d, 2017b, 2018c) The effect of fears and anxiety, and whether they can lead to positive adjustments and changes, depends on how one reads them, how one extracts and distils the signals contained in them. Often, the fear of being fearful prevents the resolution of fear. In this situation a focus on changes in internal and external communication patterns can lead to the needed information to resolve the fear in a better way than merely confronting an emotion. The author has described many techniques in this regard elsewhere (Haverkampf, 2017a, 2018c).


A fear of living is different from simply a generalised anxiety disorder because of its all-pervasiveness, affecting also one’s perspective and approach to life, often without even being aware of it. The overgeneralization of fear is maladaptive and can be observed also in conditions such as PTSD. A generalisation of fear can happen quite quickly and within few steps. Asok and colleagues examined how male and female mice generalize contextual fear at 3 weeks after conditioning. The test order of training and generalization contexts appeared to be critical determinants of the generalization and context discrimination. (This was particularly true for female mice, while tactile elements that were present during fear conditioning were more salient for male mice.) (Asok et al., 2019)

Fear and cognitive abilities

Fear of physical injury includes matters that are perceived by human beings that depend on reality testing, abstraction ability, and capacity for self-preservation. (Blackman, 2018). Treating people who are afraid of physical injury involves helping them to understand the realities of life and to acknowledge their reality perceptions of danger. In cases where the reality of the danger is miniscule or non-existent but reality testing is adequate and abstraction ability good, insight-directed work can help people understand the contributions to their fears of physical injury from various stages of development where they experienced difficulty.


It may sometimes be hard to understand why horrible man-made atrocities and natural disasters happen in the world. As a first step, we may have to accept that they do, which can be helpful in trying to prevent them. When someone has experienced trauma, often the fear of communicating with oneself and others increases. Overall, engaging with and in life becomes more difficult. One usually withdraws from the world but dissociates from oneself at the same time. The end result can be a feeling of numbness and disconnectedness from oneself and others. It also shakes the sense of security in the world and within oneself because rules that underlie the predictability and normalcy of everyday life have been shattered and broken.  Soldiers who witnessed atrocities in combat or rape victims are brought to and beyond the edge of normal human experience, perpetrated by other human beings where the basic parameters of what it means to be human seemingly no longer apply.

It is now generally believed that PTSD is due at least in part to a learning process in which formerly neutral stimuli are paired with extremely aversive events. This may be something as mundane as a spoon, if this was the last thing one used before the Tsunami hit the bar, or in a rape situation the pattern on a carpet. This is a classic example of Pavlovian fear conditioning, particularly if it happens repeatedly. Even though it may seem that the fear is focused on specific objects or situations, it is important to remember that trauma by its very definition affects the overall sense of feeling safe within the world and oneself. Reshaping communication-patterns, new meaningful information and a greater connectedness with oneself and others are all helpful in overcoming trauma (Haverkampf, 2016)


Learning by conditioning is a key ability of animals and humans for acquiring novel behaviour necessary for survival in a changing environment. Aberrant conditioning has been considered a crucial factor in the aetiology and maintenance of various types of fear. We learn throughout our entire life, which brings about change, which can cause anxiety. Once we realize how close anxiety and excitement lie together, it can help to establish a deeper feeling and connection with life. While fear can be helpful in the moment, we need to overcome int over time when we face a similar situation again. Below a sea of anxiety there is really the bright light of a love for life and connectedness with the universe.


Anxiety begets more fears. The learning of fear seems to be facilitated in patients suffering from anxiety. In a meta-study by Duits and colleagues, results demonstrated increased fear responses to conditioned safety cues in anxiety patients compared to controls during acquisition. In contrast, during extinction, patients show stronger fear responses to the safety cues and a trend toward increased differentiation between the safety and danger cues compared to controls. (Duits et al., 2015) A fear of life is thus greater when there is a background anxiety. But as mentioned above, it depends on how the feeling of anxiety is interpreted. If the feeling of anxiety is interpreted as excitement in the sense of investigating how the world works, fear in general will be lower (Haverkampf, 2017g, 2018e).

Social Networks

Our social network are the outcomes of our communication patterns and interactions with other people. Social networking sites are especially attractive for adolescents, but it has also been shown that these users can suffer from negative psychological consequences when using these sites excessively. Particularly, the fear of missing out has becomes a major problem. Since information about the outside world and the inside world is processed in the same brain in often the same centres, it is easy to understand that virtual networks can seem very real. While it is still possible to use the virtual nature of social networks to ease into dating, it may be the case that over time the virtual world becomes the new real world.

At the same time, it is important to remember that the need to communicate is a basic biological requirement of life, and that the fear of missing out is connected with this basic need. The main problem is that if meaningful sources of information cannot be identified effectively, the person may look to plug into communication networks, including social networks, merely for the sake of connecting, rather than really benefiting from it. As mentioned before, fear can be reduced by meaningful information (Haverkampf, 2018e), but that requires the skills and insight to identify sources of meaningful information.

Connectedness, Social Networking Sites (SNSs) and the Fear of Missing Out (FOMO)

In an online survey of over a thousand social media users between 16 and 18 years old, it was found that both the fear of missing out and social networking intensity mediate the link between psychopathology and negative consequences of using social networking sites via mobile devices, but by different mechanisms. Additionally, for girls, feeling depressed seemed to trigger higher SNS involvement, while for boys, anxiety triggered higher SNS involvement. (Oberst, Wegmann, Stodt, Brand, & Chamarro, 2017) In another study by Blackwell and colleagues that investigated whether extraversion, neuroticism, attachment style, and fear of missing out were predictors of social media use and addiction, 207 participants completed a brief survey measuring levels of extraversion, neuroticism, attachment styles, and FOMO. Younger age, neuroticism, and fear of missing out predicted social media use. However, only fear of missing out predicted social media addiction. Attachment anxiety and avoidance predicted social media addiction, but this relationship was no longer significant after the addition of FOMO. (Blackwell, Leaman, Tramposch, Osborne, & Liss, 2017) In a study by Elhai and colleagues, smartphone use was most correlated with anxiety, need for touch and FOMO. Problematic smartphone use was associated with FOMO, depression (inversely), anxiety, and need for touch. Frequency of use was associated with need for touch, and (inversely) with depressive symptoms. Interestingly, emotional suppression also mediated the association between problematic smartphone use and anxiety. (Elhai, Levine, Dvorak, & Hall, 2016) This is another example for the tight link between external and internal connectedness (Haverkampf, 2010a).


The goal of any therapeutic approach to fear, or to managing fear in life generally, is to manage fear. While this should not mean extinguishing all fear, as this is an important informational signal for survival, but to be able to reduce or extinguish the fear which is interfering with life in unhelpful ways. In fear extinction, the positive experience of an omitted aversive event drives the reduction of fear responses and the formation of long-term extinction memories. Dopamine emerges as key neurobiological mediator of these related processes. (Kalisch, Gerlicher, & Duvarci, 2019) Exposure therapy is a form of cognitive intervention that specifically changes the expectancy of harm. (Hofmann, 2008)

Extinction is possible even without exposure to the feared situation or location in real life. A number of studies have shown that exposure to virtual stimuli works as well. Investigators have, for example, shown that VRT was successful in reducing the fear of the public speaking. (North, North, & Coble, 2015) In other words, the information is again what is important and the way in which it is communicated.


Fear can be highly adaptive in promoting survival, yet it can also be detrimental when it persists long after a threat has passed. Flexibility of the fear response may be most advantageous during adolescence when animals are prone to explore novel, potentially threatening environments. Two opposing adolescent fear-related behaviours—diminished extinction of cued fear and suppressed expression of contextual fear—may serve this purpose, but the neural basis underlying these changes is unknown.


Memory is a store of information available for retrieval by the individual. As meaningful information can reduce fear, the ability to store it, can have a lasting effect of reducing or mitigating fear. Fear memory is formed in the hippocampus (contextual conditioning and inhibitory avoidance), in the basolateral amygdala (inhibitory avoidance), and in the lateral amygdala (conditioning to a tone).

The circuitry involves, in addition, the pre- and infralimbic ventromedial prefrontal cortex, the central amygdala subnuclei, and the dentate gyrus. Fear learning models, notably inhibitory avoidance, have also been very useful for the analysis of the biochemical mechanisms of memory consolidation as a whole. These studies have capitalized on in vitro observations on long-term potentiation and other kinds of plasticity. The effect of a very large number of drugs on fear learning has been intensively studied, often as a prelude to the investigation of effects on anxiety.


Fear memory was thoroughly investigated mostly using two classical conditioning procedures (contextual fear conditioning and fear conditioning to a tone) and one instrumental procedure (one-trial inhibitory avoidance).

Empathy and Fear

The relationship between empathy, a connective signal, and fear, a potentially disconnective signal, is interesting. Olsson and colleagues investigated how social (vicarious) fear learning is affected by empathic appraisals by asking participants to either enhance or decrease their empathic responses to another individual (the demonstrator), who received electric shocks paired with a predictive conditioned stimulus. A third group of participants received no appraisal instructions and responded naturally to the demonstrator. During a later test, participants who had enhanced their empathy evinced the strongest vicarious fear learning as measured by skin conductance responses to the conditioned stimulus in the absence of the demonstrator. Moreover, this effect was augmented in observers high in trait empathy. Their results suggest that a demonstrator’s expression can serve as a “social” unconditioned stimulus (US), similar to a personally experienced US in Pavlovian fear conditioning, and that learning from a social US depends on both empathic appraisals and the observers’ stable traits. (Olsson et al., 2016)


Stress has a critical role in the development and expression of many psychiatric disorders and is a defining feature of posttraumatic stress disorder (PTSD). Stress also limits the efficacy of behavioural therapies aimed at limiting pathological fear, such as exposure therapy. Here we examine emerging evidence that stress impairs recovery from trauma by impairing fear extinction, a form of learning thought to underlie the suppression of trauma-related fear memories. We describe the major structural and functional abnormalities in brain regions that are particularly vulnerable to stress, including the amygdala, prefrontal cortex, and hippocampus, which may underlie stress-induced impairments in extinction. We also discuss some of the stress-induced neurochemical and molecular alterations in these brain regions that are associated with extinction deficits, and the potential for targeting these changes to prevent or reverse impaired extinction. A better understanding of the neurobiological basis of stress effects on extinction promises to yield novel approaches to improving therapeutic outcomes for PTSD and other anxiety and trauma-related disorders. (Maren & Holmes, 2016)

Fear and Society

Society is built on communication links, which are not entirely flexible. Since fear and anxiety are both lower the more meaningful information there is, their level depends on how messages are formed and can be transmitted within a community. More rapid and efficient communication networks can make more meaningful information from more sources more easily and quickly available, but their effectiveness in the end depends on how information streams are selected and the individual’s ability to choose information sources most efficiently and beneficially. Messages of fear can reduce openness and put a narrower focus on the sources and the content of these messages. Tannenbaum and colleagues have studied fear appeals in a comprehensive meta-analysis investigating their effectiveness for influencing attitudes, intentions, and behaviours. Results showed that fear appeals were effective at positively influencing attitude, intentions, and behaviours, that there were very few circumstances under which they were not effective, and that there were no identified circumstances under which they backfired and lead to undesirable outcomes. (Tannenbaum et al., 2015) Group messages can even give rise to irrational or illogical fears, which then have the potential to become entrenched. Research results imply that there is a fear of the feminine in men, which prevents them from infringing on prescribed gender boundaries. This may also take the form of the use of psychological defences to distance from thoughts and behaviours perceived as not masculine. (Kierski & Blazina, 2009)

You and I

Shyness is a form of social anxiety that has been characterized as anxious preoccupation with the self in the presence of others. Some researchers argue that a necessary precondition for experiencing the state emotion of shyness is public self-consciousness—that is, awareness of the self as a social object. Although the importance of self-processes in the experience of shyness has been generally recognized, the role of the self has not been fully explicated in this regard. This chapter reviews previous researches on shyness as well as some recent data with particular emphasis on the discrepancy between self and other perception of social behaviour. An overview of the concept of shyness is presented and its emergence in the psychological literature as a descriptive and theoretical construct is discussed. The research is analysed which focuses on shyness including the rate of its occurrence, internal, and behavioural correlates. The data linking dispositional shyness to limited and problematic social networks is also reviewed in the chapter. (Jones & Briggs, 1984)

Perspective is important, because one cannot read another person’s thoughts. One often decodes information from oneself and from other’s differently, which depends on the assumptions one makes about how another person processes information (Haverkampf, 2018a).  In one study, participants who indicated that they were more likely than a potential partner to be inhibited from making an initiative by a fear of rejection, attributed a potential partner’s inaction to a lack of interest in developing a relationship with them. Individuals spontaneously perceive a potential partner’s inaction as reflective of disinterest more so than they perceive their own inaction in these terms. Participants’ divergent perceptions of their own vs their potential partner’s underlying feelings stemmed from the biased interpretation of inaction. (Vorauer & Ratner, 1996)

Example: Initiating Communication with a Romantic Interest

Making romantic connections is a very basic, yet powerful need. Evolutionary requirements for the survival of the species come into play, which may explain why the mating process involves communication nuances on so many levels. It is biologically serious business, and fears in this domain can impact significantly on the quality of the life of the individual. On the other hand, there is hardly any domain of communication which has as much to do with how one communicates with oneself, self-image, confidence, self-esteem, and one’s place in the world overall. Mating communication thus serves as a good example to investigate the fear of living in general.

The Fear of Being Single, Scarcity and ‘Settling for Less’

Spielmann and colleagues in a cross-sectional study found that those with stronger fear of being single reported greater longing for their ex‐partners. The fear of being single seemed to increase after a breakup, regardless of who initiated the breakup. Longing for an ex‐partner and attempts to renew the relationship were greater on days with stronger fear of being single. The fear of being single increased longing and renewal attempts over time, but longing and renewal attempts did not influence fear of being single. (Spielmann, MacDonald, Joel, & Impett, 2016)

In another study by the same authors, the fear of being single predicted (Spielmann et al., 2013)

  • settling for less in ongoing relationships

interest in less responsive and less attractive dating targets being less selective in expressing romantic interest but did not predict the other’s romantic interest.

Proactive Behaviours in Men

In a study by Kraeger and colleagues on American online dating data, the authors found that men and women tend to send messages to the most socially desirable alters in the dating market regardless of their own desirability levels. They also found that male initiators connect with more desirable partners than men who wait to be contacted, but female initiators connect with equally desirable partners as women who wait to be contacted. Female‐initiated contacts are also more than twice as likely as male‐initiated contacts to result in a connection, but women send four times fewer messages than men. (Kreager, Cavanagh, Yen, & Yu, 2014)

Fear of Rejection

Fisman and colleagues studied dating behavior using data from a Speed Dating experiment where we generate random matching of subjects and create random variation in the number of potential partners. Our design allows us to directly observe individual decisions rather than just final matches. Women put greater weight on the intelligence and the race of partner, while men respond more to physical attractiveness. Moreover, men do not value women’s intelligence or ambition when it exceeds their own. Also, we find that women exhibit a preference for men who grew up in affluent neighborhoods. Finally, male selectivity is invariant to group size, while female selectivity is strongly increasing in group size. (Fisman, Iyengar, Kamenica, & Simonson, 2006)

Using technology to eliminate a fear of rejection offers a powerful incentive for a powerful emotion. One invention, for example, uses the knowledge one has with certain people or companies of interest, and discloses a member’s intention to advance relation to the other only when the other also wants to advance it, and only when certain criteria or expectations predefined by the members are met. (“US20090006120A1 – Social and/or Business Relations Icebreaker: the use of communication hardware and/or software to safely communicate desires to further advance relations without the fear of being rejected and/or unnecessarily revealing information and/or intentions. – Google Patents,” n.d.)

It is also important to consider that rejection may have an important role to play. In a study using online dating data, couple similarities were more likely to result from relationship termination, i.e. nonreciprocity, than initial homophilous preferences. (Kreager et al., 2014)

Online dating sites try to lower the fear of rejection by collecting and comparing data to lessen the risk of rejection. In one case, the computer program takes advantage of existing contact lists such as those on social networking sites, instant messaging programs, or cell phones. It allows the user to characterize each contact on the basis of the user’s level of interest in that contact as a date. The program keeps these rankings secret until two users indicate an interest in each other that surpasses a certain threshold. The users are then notified of the mutual interest. (“US9934297B2 – Method of facilitating contact between mutually interested people – Google Patents,” n.d.) This may help lesten the risk of rejection, but by not exposing individuals to rejection, it may actually worsen it when it happens. On the other hand, computer-assisted matchmaking makes it possible to screen more information in a smaller amount of time. So, thereby it may enhance the engagement with the romantic aspect of life, even though it may lower the risk of rejection.

Perceiving Reality

Fears can distort how we perceive reality. They change how information is decoded and translated into meaning or how one perceives the communication process. Work on communication patterns in interpersonal and internal contexts in CFT can reverse this distortion (Haverkampf, 2017a). Vorauer and colleagues demonstrated in their studies that fears of rejection prompt individuals to exhibit a signal amplification bias, whereby they perceive that their overtures communicate more romantic interest to potential partners than is actually the case. The link between rejection anxieties and the bias was evident regardless of whether feats of rejection were assessed in terms of chronic attachment anxiety or were induced by reflection on a previous rejection experience. Mediation analyses suggested that the bias stems in part from an expected-augmenting process, whereby persons with strong fears of rejection incorrectly assume that the recipient of their overtures will take their inhibitions into account when interpreting their behavior. Implications for understanding the link between attachment anxiety and loneliness and for designing social skills interventions are discussed. (Vorauer, Cameron, Holmes, & Pearce, 2003)

Human emotions serve adaptive functions. A study by Teich and colleagues proposed that mating anxiety helps solve the adaptive problem of the costliness of being rejected by a potential mate. To accomplish this, the mating anxiety mechanism was hypothesized to estimate the likelihood of rejection by a potential mate by calculating the discrepancy between their respective levels of desirability (Mate Value Discrepancy) in terms of social attractiveness and social / financial resources. Hierarchical Linear Modeling was used to test the predictions about mate value discrepancy (MVD) and likelihood of rejection (LR) on Anxiety. MVD had a highly significant effect on Anxiety and on LR. LR had a significant effect on Anxiety as predicted, but did not mediate the effect of MVD on Anxiety. A gender differences in anxiety were found in the effect of profile status/resources on anxiety, but not for other profile or participant characteristics as expected. men having greater anxiety than women. (Telch et al., n.d.)

Early Communication

This study examined the relationship between perceived dysfunctional family-of-origin rules and intimacy in single young adult dating relationships. A sample of 754 single, Caucasian-American young adults completed measures of perceived dysfunctional family-of-origin rules and emotional, intellectual, and sexual intimacy in dating relationships. When controlling for the effects of gender and age, results showed that perceived dysfunctional family-of-origin rules had a negative impact on the perceived expression and experience of these three kinds of intimacy in dating relationships. Implications for relationship therapy are discussed. (Larson, Peterson, Heath, & Birch, 2000)


Attachment anxiety predicts dating outcomes that goes beyond other factors, including attractiveness. In a study by McClure and colleagues, anxious participants at speed-dating were motivated by loneliness. They were unpopular and unselective; they missed fewer opportunities but made more failed attempts. Anxious men made fewer matches than non-anxious men, whereas anxious women were buffered by having a response bias toward saying “yes” to potential partners. (McClure, Lydon, Baccus, & Baldwin, 2010)

Electronic intrusion (EI) is the use of social media to intrude into the privacy of a dating partner, monitor a partner’s whereabouts and activities, and pressure a partner for constant contact. A survey study of 703 high school girls and boys by Reed and colleagues found that higher levels of attachment anxiety were associated with more frequent perpetration of EI for both girls and boys. Therefore, especially for anxiously attached teens, social media may create a “cycle of anxiety” in which social media serve as both a trigger for relationship anxiety and a tool for partner surveillance in an attempt to alleviate anxiety. (Reed, Tolman, Ward, & Safyer, 2016)

This prospective study (N = 90) investigated the early formation of romantic relationships within an attachment‐theoretical framework. Specifically, it tested whether general attachment to romantic partners was predictive of single individuals’ progressing from not dating to dating and from not dating or casual dating to a committed and exclusive relationship when simultaneously considering desire for starting a committed relationship, prior dating involvement, and self‐perceived physical attractiveness. Attachment avoidance, but not anxiety, was predictive of not entering into committed dating relationships even with rival predictors included. The transition from not dating to casual or committed dating was mainly predicted by prior dating success with some support for a potential additional role of the desire to form a committed relationship. (Schindler, Fagundes, & Murdock, 2010)

The Power of Connectedness

The effect of communication connectedness goes beyond any immediate direct effects. La Greca and colleagues found in their study found that adolescents with fewer other-sex friends and those with less positive and more negative interactions with their best friends reported high levels of dating anxiety. They concluded that adolescents’ social relationships have the potential to support or interfere with the development of successful romantic relationships. (La Greca & Mackey, 2007) In a study by Himadi and colleagues, low-daters showed greatermdifficulties in same-sex friendship interactions and were less well-adjusted on the Eysenck Personality Inventory (EPI) than more relaxed frequent daters. However, these differences were not observed in women. (Himadi, Arkowitz, Hinton, & Perl, 1980)


Results in a study by Glass and colleagues indicated that participants trained in cognitive self-statement modification showed significantly better performance in role-play situations for which they were not trained, made significantly more phone calls, and made a significantly better impression on the women than subjects in other groups. These effects were generally maintained at follow-up, and the cognitive self-statement groups’ performance on the role-play measures improved from posttreatment to follow-up. (Glass, Gottman, & Shmurak, 1976) Women with breast cancer or a genetic susceptibility to developing this disease report a myriad of dating concerns. In a study by Shaw and colleagues, six areas of concern were identified: Feeling unattractive due to treatment side effects; perceiving limited dating partners available; determining how, when and what to disclose; fear of cancer recurrence and reduced life expectancy; apprehension about entering into a new sexual relationship; and dating urgency and not wanting to ‘waste time’ on partners without long-term potential. (Shaw, Sherman, & Fitness, 2015)

Technology and Communication

Anxiety associated with dating appears to occur for a variety of reasons, such as (a) the desire to establish heterosocial relationships; (b) the social importance and status associated with dating; (c) the fact that dating is a social skill that emerges relatively late in development (Hansen, Christopher, & Nangle, 1992)

Technology can help overcome inhibitions, particularly in men. A survey of the users of an online computer-mediated matchmaking service by Scharlott and Christ found that (Scharlott & Christ, 1995)

  • Men generally contacted women more than vice versa, but a substantial minority of the women contacted a great number of men.
  • Users who scored higher on a shyness scale were much more likely than less shy users to say they were using the system to find romance or sex
  • Women who rated their own appearance as average were less likely to be contacted by men than those who rated their appearance as above average
  • There was no significant difference between appearance groups concerning the likelihood of starting a romantic or sexual relationship.
  • Intrinsic aspects of the computer-mediated matchmaking system helped some users overcome relationship-initiation barriers rooted in sex role, shyness, and appearance inhibitions.

In a study by Gatter and Hodkinson, no differences were found in motivations, suggesting that people may use both Online Dating Agencies and Tinder for similar reasons. There were no differences in self-esteem or sociability between the groups. Users of both Tinder and Online Dating Agencies did not appear to differ from the general population. (Gatter & Hodkinson, 2016) However, in a study by Zlot and colleagues, users of Internet-dating applications showed higher scores on a sex addiction scale. (Zlot, Goldstein, Cohen, & Weinstein, 2018)

“People-nearby applications” (PNAs) are a form of ubiquitous computing that connect users based on their physical location data. One example is Grindr, a popular PNA that facilitates connections among gay and bisexual men. A factor analysis by Van De Wiele and Tong revealed six uses and gratifications: social inclusion, sex, friendship, entertainment, romantic relationships, and location-based search. (Van De Wiele & Tong, 2014)

Dinh and colleagues examined the mate preferences and communication patterns of male and female users of the online dating site eHarmony over the past decade to identify how attitudes and behaviors have changed over the past decade. (Dinh, Gildersleve, & Yasseri, 2018) Some of the findings were that

  • women are more selective and restrict their potential mating pool more than men do
  • smoking level, ethnicity, and drinking level were the most important match criteria for both men and women overall
  • income was the second least important criterion to women, religion being the least
  • women on average do consider income in a potential match more important than men do, but the importance of this trait has decreased significantly over time
  • women are still more restrictive overall in their preference for age than men are
  • In larger group sizes, male selectivity is unchanged (about one in two), while females become significantly more selective, choosing a little more than a third of their partners
  • physical attractiveness does not have a linear relationship with communication rate; communication rates may also be determined by expectations about who will respond
  • women’s communication rates seem to me more dependent on their looks than for men
  • an indication, at least, that individuals have an awareness, if weak, of their own desirability
  • correlations between attractiveness and selectivity
  • being younger and athletic and having more photos increases likelihood of receiving messages in online dating, as does being romantic and altruistic.

However, apart from some very general pointers, much may also depend on the dating platform. As people’s motives for joining a virtual mating space may be different, so will also be the chances of finding what one is looking for. Some sites are also making the sending of certain signals that one is interested more costly or restrict their number. This could help to create a more even playing field and reduce the problem that sending messages to a large number of people is a strategy for several men. In the case of Bumble, for example, only women can make the first move by sending the first message. This may solve some problems, but also turn away those who want the man to take the first step, whether male or female, and preselect a certain profile.

Information about Oneself

The experience of the self is equivalent to the experience of information flows within oneself and with the outside world (Haverkampf, 2012, 2017f). Feeling alive means perceiving more information flows. Information about the self is information about these information flows, which are unique to the individual but happen within the information flows in the world shared with others.

Social anxiety is linked to the communication of information about the self. Social anxiety appears to arise from people’s concerns about the impressions others are forming of them. Social anxiety occurs when people are motivated to create a desired impression on audiences but doubt they will do so (Schlenker & Leary, 1985). High social anxiety, in turn, is associated with qualitative and quantitative changes in how people communicate (Schlenker & Leary, 1985).

Attempting to create the desired impression, but low expectations of achieving this, produces negative affect, physical or psychological withdrawal from the situation, and self-preoccupation with one’s limitations. The heightened social anxiety impedes optimally effective self-monitoring and control. A protective self-presentational style, in which the focus is on avoiding blatant failures rather than achieving significant successes, is engaged. The result can include (Schlenker & Leary, 1985):

  • less interactions with others,
  • the avoidance of topics that might reveal one’s ignorance (e.g. factual matters),
  • minimal disclosure of information about the self,
  • cautious self-descriptions that are less positive and less likely to assert unique qualities that draw attention to the self, and
  • a passive yet pleasant interaction style that avoids disagreement (e.g. reflective listening, agreeing with others, smiling).

The consequence is a vicious cycle in which less engagement with life leads to even greater isolation. Once one begins to focus and connect with oneself, this cycle can be broken. Practically, this can be achieved by working on the communication patterns one uses with oneself and others. The authors has described several techniques and the theoretical underpinnings elsewhere (Haverkampf, 2017a, 2018d). Improved communication patterns support a more active participation in life and foster the feeling of greater self-efficacy, self-actualization, more fulfilment, satisfaction and a greater quality of life in general (Haverkampf, 2017e).


Usually, one uses the information one has about oneself to conjecture how one appears to others. Projection is when we use our own thoughts to estimate what others are thinking, when we see others as copies of ourselves without realising it. The problem is that when we are critical of ourselves we will think others are critical of us or when we feel incompetent we think that others see us as incompetent. If we constantly feel a need to evaluate or control ourselves, we feel that others are constantly evaluating us as well, even in areas that may not be visible to another. It has been argued from a self-presentational view that the fear of being socially evaluated is pivotal to dispositional shyness.  In a study by Asendorpf, compared with the group lower in shyness, the shy subjects (Asendorpf, 1987)

  • recalled more fear of social evaluation (including fear of positive evaluation) but did not more often report other kinds of fear,
  • had more negatively biased thoughts about the impression made on their partner but not more impression-related thoughts in general, and
  • showed more negatively biased reactions to the positive feedback of their partner.

Findings further suggested that evaluative situations also arouse fears of having to evaluate others. (Asendorpf, 1987) The problem with a constant need for evaluation is that we cannot measure something that is still unfolding, one’s journey in life. Something that may not make sense yet could be a blessing later on. The only thing we can do is live life in alignment with the basic parameters, the needs, values and aspirations, which should spring from well-informed insight (Haverkampf, 2018f).  This approach is particularly helpful when one experiences anxiety and fears, and the author has described several techniques from a CFT perspective (Haverkampf, 2017c)

Socially anxious or shy individuals may use their anxiety symptoms as a strategy to control attributions made about their performances in social-evaluative settings. In a study by Snyder and colleagues the results supported the following for males but not for females  (Snyder, Smith, Augelli, & Ingram, 1985):

  • trait-socially anxious or shy Ss would report more symptoms of social anxiety in an evaluative setting in which anxiety or shyness could serve as an excuse for poor performance than would Ss in (a) an evaluative setting in which shyness was precluded as an excuse or (b) a nonevaluative setting
  • this self-protective pattern of symptom reporting would not occur for Ss who were not trait-socially anxious because these Ss would not commonly use such symptoms as a self-handicapping strategy

Anxiety vs Behaviours

From a communication perspective, it is important to remember that it is ultimately about meaningful information. Since information flows on the inside inform us of moods and anxiety, for example, communication patterns in the external world have also as an aim to gain or to give information. There are important conceptual distinctions between of reticence, shyness, communication apprehension, and unwillingness to communicate and other constructs. Some of these terms refer to subjective, affective responses, and comprise specific instances of the umbrella construct of social anxiety. Others refer to patterns of overt, social‐communicative behaviours. (LEARY, 1983) But all of them affect how information is being communicated and whether a message ultimately arrives as intended.

In any pursuit in life, not just dating, better ways of communicating and working with information are frequently key in being successful. Work on communication patterns in Communication-Focussed Therapy (CFT) helps to make communication with oneself and the world more effective (Haverkampf, 2010b, 2017a, 2019b)


Schachter and Singer postulated in the 1960s that physical arousal played a primary role in emotions. The arousal was hypothesized to be the same for a wide variety of emotions, so physical arousal alone could not be responsible for emotional responses. The arousal must be identified to feel a specific emotion. An experimental design based upon an explication of Schachter’s theory of emotion demonstrated that fear reduction through induced misattribution of the physiological concomitants of fear could be accomplished. A test situation was utilized in which reduced fear would be reflected by test subjects’ willingness to work on a puzzle which would gain them monetary reward while leaving unsolved a puzzle which could allow them to avoid impending electrical shock. (Ross, Rodin, & Zimbardo, 1969)

Fearing the Fear

Fear can inhibit communication, which happens to be the instrument to resolve it. The reason for this may be to conserve resources for more automatic problems of fight or flight. In today’s world, however, more complex ways of reacting to fear are required, and new sources of information to be able to do so have to be tapped. An important strategy to counter fear is thus to communicate nonetheless. An adjustment and change in communication patterns can make this easier and less fear inducing. On the inside, more effective and gentler ways of connecting with oneself are helpful. Towards the outside, adjusting communication patterns, more questioning and reflecting, and more openness can make it easier to get the information one needs, while reducing the fear and anxiety.

In the case of kidney transplantation, prolongation of life involves not only adding time to the length of life, but it also involves the matter of the quality and worthwhileness of the life that is thus prolonged (Beard, 1969).

Fear of Change

Often, people are afraid of connecting with themselves and others because they fear the changes which can be brought on by the additional information, the impact it can have on their lives. In the case of anxiety and OCD, the ability to distinguish between a mere thought and reality is often reduced, which leads to more anxiety in a world which seems more uncertain and unpredictable. Breaking down fears is thus made easier when one is able to take a step back and identify the type and source of communicated messages, while also trying to determine the meaning in them relative to oneself.

Reasonable vs Unreasonable Fears

Our mind may tell us that a fear of tall buildings is unnecessary, but our emotions tell us otherwise. Some of these fears may be linked with experiences from one’s own past, others with innate programs in our brain. Emotions have an evolutionary function to guarantee our survival by providing simple signals to induce action or stop an action. However, the brain circuits leading to fear, for example, are partly hardwired for specific information. A fear of heights on top of a tall building makes sense, because tall buildings have only been around for a fraction of human history. In earlier times, standing close to a precipice on a tall cliff or mountain was indeed a dangerous affair.


Tremendous progress has been made in basic neuroscience in recent decades. One area that has been especially successful is research on how the brain detects and responds to threats. Such studies have demonstrated comparable patterns of brain-behaviour relationships underlying threat processing across a range of mammalian species, including humans. This would seem to be an ideal body of information for advancing our understanding of disorders in which altered threat processing is a key factor, namely, fear and anxiety disorders. But research on threat processing has not led to significant improvements in clinical practice. The authors propose that in order to take advantage of this progress for clinical gain, a conceptual reframing is needed. Key to this conceptual change is recognition of a distinction between circuits underlying two classes of responses elicited by threats:

  • behavioral responses and accompanying physiological changes in the brain and body and
  • conscious feeling states reflected in self-reports of fear and anxiety.

This distinction leads to a “two systems” view of fear and anxiety. The authors argue that failure to recognize and consistently emphasize this distinction has impeded progress in understanding fear and anxiety disorders and hindered attempts to develop more effective pharmaceutical and psychological treatments. The two-system view suggests a new way forward. (LeDoux & Pine, 2016) Fear conditioning and extinction learning in animals often serve as simple models of fear acquisition and exposure therapy of anxiety disorders in humans.

The Fear Network

Fear is mediated by a brain-wide distributed network involving long-range projection pathways and local connectivity. The disinhibitory microcircuit is a common motif in the basolateral amygdala (BLA), central amygdala and the prelimbic region of the medial prefrontal cortex, and is instrumental in fear acquisition and expression. (Tovote, Fadok, & Lüthi, 2015) Stress promotes a shift from a hippocampus-dependent, ‘cognitive’ memory system to a dorsal striatum-dependent, ‘habitual’ memory system, which also plays an important part in fear-related disorders. Importantly, glucocorticoids have similar effects on memory processes in both cognitive and habitual forms of memory. (de Quervain, Schwabe, & Roozendaal, 2017) There is overlap of neuronal circuits that mediate negative and positive valence in areas such as the VTA. Understanding the interplay between these circuits is of vital importance for understanding adaptive behavioural states. (Tovote et al., 2015)


Brain serotonin system dysfunction is implicated in exaggerated fear responses triggering various anxiety-, stress-, and trauma-related disorders. Waider and colleagues investigated the impact of constitutively inactivated serotonin synthesis on context-dependent fear learning and extinction using mice, which are completely devoid of serotonin synthesis in the  brain. The mice displayed accelerated fear memory formation and increased locomotor responses to foot shock. Furthermore, recall of context-dependent fear memory was increased. The behavioural responses were associated with increased c-Fos expression in the dorsal hippocampus. The hippocampus controls contextual representation of fear-related behavioural responses and c-fos expression indicates neuronal activity. It also showed resistance to foot shock-induced impairment of hippocampal long-term potentiation. (Waider et al., 2019)


Brain areas supporting the formation romantic attachment are those rich in oxytocin (OT) receptors (Acevedo et al., 2011), underscoring the potential role of OT in romantic bonding. (Schneiderman, Zagoory-Sharon, Leckman, & Feldman, 2012)  OT is a nonapeptide hormone associated with affiliative bonding in mammals (Insel et al., 1997) that is known to mediate social behaviour, pair-bonding, and parental attachment across a variety of species (Carter, 1998). Specifically, OT has been shown to play a critical role in the regulation of pair-bond formation in monogamous mammals (Ross and Young, 2009). It has been repeatedly shown that the Mating-induced release of OT reverses social fear in mice (Grossmann, Sommer, Menon, & Neumann, 2017)

The Amygdala

Conditions such as anxiety, autism, depression, post-traumatic stress disorder, and phobias are suspected of being linked to abnormal functioning of the amygdala, owing to damage, developmental problems, or neurotransmitter imbalance. The amygdala is a key brain region that is critically involved in the processing and expression of anxiety and fear-related signals. It is an almond-shape set of neurons located deep in the brain’s medial temporal lobe and forms part of the limbic system. The amygdala has been shown to play key roles in the processing of emotions. In humans and other animals, this subcortical brain structure is linked to both fear responses and pleasure. Its size is also positively correlated with aggressive behaviour across species. In humans, it is the most sexually-dimorphic brain structure, and shrinks by more than 30% in males upon castration.

Fear without the Amygdala?

The amygdala’s role appears to extend to both recognition and recall of fearful facial expressions. Bilateral amygdala damage in humans compromises the recognition of fear in facial expressions while leaving intact recognition of face identity (Adolphs et al., 1994). This impairment appears to result from an insensitivity to the intensity of fear expressed by faces. The amygdala seems to be required to link visual representations of facial expressions, on the one hand, with representations that constitute the concept of fear, on the other. Adolphs and colleagues reported of patient “S.M.” who lost her left and right amygdalae to disease. Initial testing suggested that S.M.’s most defining symptom was an inability to recognize fear in other people’s facial expressions. (R Adolphs, Tranel, Damasio, & Damasio, 1995; Barrett, 2018) Returning to the patient ten years later, Adolphs and colleagues showed that her impairment stems from an inability to make normal use of information from the eye region of faces when judging emotions, a defect they traced to a lack of spontaneous fixations on the eyes during free viewing of faces. Although the patient failed to look normally at the eye region in all facial expressions, her selective impairment in recognizing fear was explained by the investigators by the fact that the eyes are the most important feature for identifying this emotion. Her recognition of fearful faces became entirely normal when she was instructed explicitly to look at the eyes. (Ralph Adolphs et al., 2005)

Fast Pathways

A fast, subcortical and phylogenetically old pathway to the amygdala is thought to have evolved to enable rapid detection of threat, which could also explain nonconscious emotional responses. Mendez-Bertolo and colleagues recorded human intracranial electrophysiological data and found fast amygdala responses, beginning 74-ms post-stimulus onset, to fearful facial expressions, which had considerably shorter latency than fear responses that were observed in the visual cortex. They were limited to low spatial frequency components of fearful faces and were not evoked by photographs of arousing scenes. (Méndez-Bértolo et al., 2016)

The Microbiome

There are at least as many bacterial cells as human cells in the body, of which many are in the intestinal tract. They are commonly called the microbiome in their entirety. They seem to influence brain development, activity and behaviour. A growing number of preclinical and human studies have implicated the microbiome–gut–brain in regulating anxiety and stress-related responses. Hoban and colleagues demonstrated in their study that the presence of the host microbiome is crucial for the appropriate behavioural response during amygdala-dependent memory retention. (Hoban et al., 2018)

Inferior Frontal Gyrus

There appears to be a link between cerebral correlates of cognitive processing in the inferior frontal gyrus and emotional processing in the amygdalae – insulae – anterior cingulate cortex axis during symptom improvement across time in panic disorder with agoraphobia. In a randomized, controlled, multicentre clinical trial Kircher and colleagues studied medication-free patients with panic disorder with agoraphobia who were treated with 12 sessions of manualized CBT. Patients’ functional MRIs compared to those of control subjects revealed reduced activation for the conditioned response in the left inferior frontal gyrus. This activation reduction was correlated with reduction in agoraphobic symptoms. Patients compared to control subjects also demonstrated increased connectivity between the IFG and the amygdalae – insulae – anterior cingulate cortex axis across time. (Kircher et al., 2013)


The link between specific stimuli and fear responses is often learned. Input specificity is a fundamental property of long-term potentiation (LTP). (Maren, 2017) Kim and Cho showed that fear conditioning is mediated by synapse-specific LTP in the amygdala, allowing animals to discriminate stimuli that predict threat from those that do not. (Kim and Cho, 2017) In rats, brief electrical stimulation of the infralimbic cortex has been shown to reduce conditioned freezing during recall of extinction memory. This finding has been translated to humans with magnetic resonance imaging–navigated transcranial magnetic stimulation (TMS). (Raij et al., 2018)


Learning mechanisms can also explain how the link between specific stimuli and a fear response can be attenuated and eliminated. Learning-related changes of synaptic connections in the cortex seem to be at least partially reversed after unlearning. Lai and colleagues examined in their study the impact of auditory-cued fear conditioning and extinction on the remodelling of synaptic connections in the living mouse auditory cortex. They found that fear conditioning leads to cue-specific formation of new postsynaptic dendritic spines, whereas fear extinction preferentially eliminates these new spines in a cue-specific manner. (Lai, Adler, & Gan, 2018)

Neuronal coordination

Coordination dynamics provides a unifying framework for understanding the neurophysiological mechanisms underlying the integration and segregation of cortical areas in large-scale networks. A goal of coordination dynamics is to identify the key variables of coordination (defined as a functional and/or task-dependent ordering among context-sensitive interacting components) and their dynamics (rules that govern the stability and change of coordination patterns), and the nonlinear coupling among components that gives rise to them. In the context of cognitive neuroscience, the aim of coordination dynamics is to understand the functional interactions within and between different areas of the brain in relation to cognitive task performance. (Bressler & Kelso, 2016)

Precise spike timing through the coordination and synchronization of neuronal assemblies is an efficient and flexible coding mechanism for sensory and cognitive processing. In cortical and subcortical areas, the formation of cell assemblies critically depends on neuronal oscillations, which can precisely control the timing of spiking activity. Fear behaviour relies on the activation of distributed structures, among which the dorsal medial prefrontal cortex (dmPFC) is known to be critical for fear memory expression.

The results of a study by Dejean and colleagues identified a novel phase-specific coding mechanism, which dynamically regulates the development of dmPFC assemblies to control the precise timing of fear responses. Fear behaviour relies on the activation of distributed structures, among which the dmPFC is known to be critical for fear memory expression. In the dmPFC, the phasic activation of neurons to threat-predicting cues, a spike-rate coding mechanism, correlates with conditioned fear responses and supports the discrimination between aversive and neutral stimuli. However, this mechanism does not account for freezing observed outside stimuli presentations, and the contribution of a general spike-time coding mechanism for freezing in the dmPFC remains to be established. They used a combination of single-unit and local field potential recordings along with optogenetic manipulations to show that, in the dmPFC, expression of conditioned fear is causally related to the organization of neurons into functional assemblies. During fear behaviour, the development of 4 Hz oscillations coincides with the activation of assemblies nested in the ascending phase of the oscillation. The selective optogenetic inhibition of dmPFC neurons during the ascending or descending phases of this oscillation blocks and promotes conditioned fear responses, respectively. (Dejean et al., 2016)


Strong aversive memories lie at the core of several fear-related disorders. Therefore, the memory-modulating properties of glucocorticoids have become of considerable translational interest. (de Quervain et al., 2017) Evidence indicates that the effects of glucocorticoids on both the consolidation and the retrieval of memory depend on interactions with the endocannabinoid system, which may open novel therapeutic avenues. (de Quervain et al., 2017) The evidence that genetic and epigenetic variations in the glucocorticoid system are related to traumatic memory, as well as to post-traumatic stress disorder (PTSD) risk and treatment, adds to the understanding of individual risk and resilience factors for PTSD. (de Quervain et al., 2017) Collections of cells called engrams are thought to represent memories. Although there has been progress in identifying and manipulating single engrams, little is known about how multiple engrams interact to influence memory. In lateral amygdala (LA), neurons with increased excitability during training outcompete their neighbours for allocation to an engram. Rashid and colleagues examined whether competition based on neuronal excitability also governs the interaction between engrams. Mice received two distinct fear conditioning events separated by different intervals. LA neuron excitability was optogenetically manipulated and revealed a transient competitive process that integrates memories for events occurring closely in time (coallocating overlapping populations of neurons to both engrams) and separates memories for events occurring at distal times (disallocating nonoverlapping populations to each engram). (Rashid et al., 2016)

The Thalamus

The prelimbic prefrontal cortex, which is necessary for fear retrieval sends dense projections to the paraventricular nucleus of the thalamus (PVT). Do-Monte and colleagues showed that the PVT may act as a crucial thalamic node recruited into cortico-amygdalar networks for retrieval and maintenance of long-term fear memories by demonstrating that the dorsal midline thalamus of rats is required for the retrieval of auditory conditioned fear at late (days), but not early (hours) time points after learning. (Do-Monte, Quiñones-Laracuente, & Quirk, 2015)

Shift in Retrieval Circuits

Do-Monte also showed that there may be a shift in the retrieval circuits along the time axis. The PVT showed increased c-Fos expression, indicating neuronal activity, only at late time points, indicating that the PVT is gradually recruited for fear retrieval. Retrieval at late time points activated prelimbic prefrontal cortex neurons projecting to the PVT and silencing of these projections impaired retrieval at late time points. In contrast, silencing of prelimbic prefrontal cortex inputs to the basolateral amygdala impaired retrieval at early time points. Retrieval at late time points also activated PVT neurons projecting to the central nucleus of the amygdala, and silencing these projections at late time points induced a persistent attenuation of fear. (Do-Monte et al., 2015)

Fear vs Anxiety: Information

A fear of living is really a combination of both, a concrete fear of a very broad concept and an anxiety associated with uncertainty and strong emotions. It is unclear to what extent a small dose of them can push or pull us forward on our journey. But it is quite clear that they can be huge obstacles in large doses. In order to better work with them, it is first of all important to distinguish a deep respect, excitement and appreciation for the miracle of life from fear and anxiety. As a second important step, one needs to be able to distinguish between fear and anxiety, since the target of a fear is much better defined and clearer than the general uncertainty that is associated with anxiety. From a CFT perspective, however, both manifest with well defined communication patterns (Haverkampf, 2017c, 2017g)

As mentioned previously, fear and anxiety are two distinguishable phenomenological entities. The amount of information available about the threat appears to be a critical deciding factor. Fear is elicited by a defined threat, while one feels anxious when the threat is uncertain or not clearly defined. The distinction is also reflected on a neuro-morphological level. Anxiety is usually associated with activation in ventromedial prefrontal cortex and hippocampus, while fear is correlated with activation in the periaqueductal grey. At the same time, the amygdala seems associated with both.

To test this, Rigoli and colleagues used functional MRIs to record participants’ brain activity while they performed a computer-based task which required to press a button to move an artificial agent to a target position while an artificial predator chased the agent. In the fear condition the predator was visible, while in the anxiety condition the predator was invisible. Ventromedial prefrontal cortex, hippocampus, and amygdala showed increased activity when the predator was invisible compared to visible, while the opposite effect was observed in periaqueductal grey. They also observed that participants with high but not low trait-anxiety showedhippocampal activation with invisible threat at an earlier time stage during the trial. (Rigoli, Ewbank, Dalgleish, & Calder, 2016)


A single session of exposure therapy can eliminate fears of objects or situations. Encoding of fear extinction involves many of the same brain areas that are involved in fear acquisition and expression; however, different circuits within the amygdala and prefrontal cortex are involved. Indeed, fear extinction circuits may in fact inhibit fear circuits to dampen fearful responding. (Tovote et al., 2015) The extinction of fear learning involves to an extent a reversal of the flow of information in the pre- and infralimbic ventromedial prefrontal cortex, the central amygdala subnuclei, and the dentate gyrus. and is used in the therapy of posttraumatic stress disorder and fear memories in general. (Izquierdo, Furini, & Myskiw, 2016)

If applied too life itself, exposure can include anything from meditation to going on a date. We expose ourselves to life if we constantly break down barriers and widen our horizon. This can also include information inside of us. For example, someone who is reflecting on a topic or investigating a feeling is also widening the information horizon, transmitting and receiving meaningful information, and thus engaging with life. As with many other fears, exposure to communication can reduce the anxieties and fears connected with life.

Exposure to various forms of communication, as long as they are not intrinsically harmful, can reduce the fears and anxieties associated with them. This also enlarges the activity radius and mental horizon an individual experiences in life. There are specific brain regios that seem to play an elevated role in fear and the effect of exposure in general. Hauner and colleagues studied changes in brain activity as a result of one successful two hour exposure treatment. Before treatment, fear eliciting images excited activity in a network of brain regions, including amygdala, insula, and cingulate cortex, relative to neutral images. Successful therapy dampened responsiveness in this fear-sensitive network while concomitantly heightening prefrontal involvement, which persisted even six months later, but without prefrontal engagement. Additionally, individual differences in the magnitude of visual cortex activations recorded shortly after therapy predicted therapeutic outcomes six months later. (Hauner, Mineka, Voss, & Paller, 2012)


Throughout development, an important process is to arrive at a point where the amount of fear signalled in daily life is at the correct measure where it sustains survival without interfering too much in life. Flexibility of the fear response may be most advantageous during adolescence when living beings in general are prone to explore novel, potentially threatening environments.

Two opposing adolescent fear-related behaviours—diminished extinction of cued fear and suppressed expression of contextual fear—may serve this purpose. Using microprisms to image prefrontal cortical spine maturation across development in mice, Pattwell and colleagues identified a dynamic blasolateral amygdala – hippocampus – medial prefrontal cortex circuit reorganization associated with behavioural shifts. (Pattwell et al., 2016) The same circuit also seems to play a role in social defeat and some of its consequences. (Qi et al., 2018)

The Cortical Neural Network

Emotional states of consciousness, or what are typically called emotional feelings, are traditionally viewed as being innately programmed in subcortical areas of the brain and are often treated as different from cognitive states of consciousness, such as those related to the perception of external stimuli. Ledoux and Brown argued that conscious experiences, regardless of their content, arise from one system in the brain. In this view, what differs in emotional and non-emotional states are the kinds of inputs that are processed by a general cortical network of cognition, a network essential for conscious experiences. Although subcortical circuits are not directly responsible for conscious feelings, they provide nonconscious inputs that coalesce with other kinds of neural signals in the cognitive assembly of conscious emotional experiences. (LeDoux & Brown, 2017) When subjective state words are used to describe behaviours, or brain circuits that control them nonconsciously, the behaviours and circuits take on properties of the subjective state. Subjective state words should be limited to the description of inner experiences, and avoided when referring to circuits underlying nonsubjectively controlled behaviors. (LeDoux, 2017)


Anxiety is an emotion characterized by an unpleasant state of inner turmoil. It is the subjectively unpleasant feelings of dread over anticipated events, such as the feeling of imminent death.  Anxiety is, as mentioned, not the same as fear, which is a response to a real or perceived immediate threat, whereas anxiety involves the expectation of future threat. Anxiety is a feeling of uneasiness and worry, usually generalized and unfocused as an overreaction to a situation that is only subjectively seen as menacing.

As with fear and fear extinction, a brain-wide neuronal network underlies anxiety, with identified local microcircuits within the bed nucleus of the stria terminalis, the lateral septum, the ventral tegmental area (VTA) and the basolateral amygdala. Importantly, there is potential overlap between fear and anxiety circuits. (Tovote et al., 2015)

Biological Approaches

While psychotherapy should be the first line of treatment when it comes to unhelpful fears, there are biological tools that may be of use in more extreme cases of fear. Psychotherapy and medication both work on the information receiving and processing system in the brain.


Glucocorticoids affect distinct memory processes that can synergistically contribute to a reduction of fear-related symptoms, for example, by both reducing aversive-memory retrieval and enhancing the consolidation of fear-extinction memory (de Quervain et al., 2017). Clinical trials have provided the first evidence that glucocorticoid-based pharmacotherapies aimed at attenuating aversive memories might be helpful in the treatment of fear-related disorders. In particular, the strategy to enhance extinction processes by combining exposure-based psychotherapy with timed glucocorticoid administration seems to be a promising approach to treat fear-related disorders. (de Quervain et al., 2017)


D-cycloserine is a molecule that binds to the NMDA receptor and improves its efficiency. Because D-cycloserine facilitates extinction in rats, Davis and colleagues investigated whether D-cycloserine might facilitate the loss of fear in human patients. It indeed seemed to help reduce fear of heights substantially after seven or eight sessions. (Davis, 2010) The ability of D-cycloserine to improve psychotherapy been replicated in other studies in obsessive- compulsive disorder, social phobia, and panic disorder.


MDMA used as an adjunct during psychotherapy sessions has demonstrated effectiveness and acceptable safety in reducing PTSD symptoms in Phase 2 trials, with durable remission of PTSD diagnosis in more than two thirds of participants. MDMA enhances release of monoamines (serotonin, norepinephrine, dopamine), hormones (oxytocin, cortisol), and other downstream signalling molecules (BDNF) to dynamically modulate emotional memory circuits. By reducing activation in the amygdala and insula, and increasing connectivity between the amygdala and hippocampus, MDMA may allow for reprocessing of traumatic memories and emotional engagement with therapeutic processes. (Feduccia & Mithoefer, 2018)

Other Approaches

Transcranial magnetic stimulation (TMS) is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression, for example. During a repetitive TMS session, an electromagnetic coil is placed against the scalp near the forehead, which is thought to activate regions of the brain that have decreased activity in depression. Liston showed that transcranial magnetic stimulation targeting a human homolog of a rodent fear regulation circuit enhanced extinction learning in healthy human subjects. (Liston, 2018)


The brain processes information, and fortunately we can consciously select information and teach our brain new ways of dealing with information. But this requires taking a close look at our basic values and fundamental interests, which ultimately drive any change. If you feel that something is important to you, you are more likely to spend energy on figuring out a way to effect a change. Knowing why doing something is valuable and important to oneself is an important force in doing something even if one is fearful (as long as there is no real threat of harm from the activity).

Change from Within

In many cases, however, feeling pressure to go through with a feared activity can be counterproductive. As the need to take the elevator, for example, increases, the fear increases as well. The problem is that the activity is seen as a ‘need’ dictated by the outside world. Overcoming a fear should come from an internal need, the fulfilment of a basic value or fundamental interest.

Greater insight into the own needs, values and aspirations can thus be very helpful in confronting the own fears. This explorative process in itself can already be helpful in confronting the fears. It is facilitated through a better internal communication (Haverkampf, 2010c), a better emotional and cognitive communication, which can be trained in a communication-oriented therapy. (Haverkampf, 2010b, 2017a) An easier access to this emotional information can also provide more stability and trust in oneself, which helps whenever fears, whether internal or external, need to be confronted.

Change Without

Changing communication patterns within leads to changes in communication patterns without. This is how better boundaries can be drawn to the outside world, which also makes the world appear safer and more secure. The ability to stand up for one’s needs, values and aspirations and to say ‘No’ as well as ‘Yes’ requires a good connection on the inside, which then makes it possible to work on one’s communication patterns with the world. Better and more effective external communication patterns can make it easier to deal with everyday problems and other people who may hold different opinions.

Good external communication patterns are those which facilitate understanding on both sides, and understanding can reduce fears and anxiety, as thus feeling understood. Meaningful communication can reduce fears and anxiety because it can bring about changes in the communication partners and adjustments in as situation which benefit everyone. However, it can only accomplish this if the internal communication is also working on both sides.

Psychological Approaches

CBT: Fear of Flying

The Fear of flying (FOF) can be a serious problem for individuals who develop this condition and for military and civilian organizations that operate aircraft. People with fear of flying experience intense, persistent fear or anxiety when they consider flying, as well as during flying. They will avoid flying if they can, and the fear, anxiety, and avoidance cause significant distress and impair their ability to function. Take-off, bad weather, and turbulence appear to be the most anxiety provoking aspects of flying. The most extreme manifestations can include panic attacks or vomiting at the mere sight or mention of an aircraft or air travel. Around 60% of people with fear of flying report having some other anxiety disorder.

Krijn and colleagues compared the effectiveness of bibliotherapy (BIB) without therapist contact, individualized virtual reality exposure therapy (VRE) and CBT. Treatment with VRE or CBT was more effective than BIB. Both VRE and CBT showed a decline in FOF on the two main outcome measures. There was no statistically significant difference between those two therapies. However, effect sizes were lower for VRE (small to moderate) than for CBT (moderate). CBT followed by group cognitive-behavioural training showed the largest decrease in subjective anxiety. (Krijn et al., n.d.)

Virtual Exposure

Virtual Reality (VR) is a technological interface that allows users to experience computer-generated environments within a controlled setting. This technology has been increasingly used in the context of mental health treatment and within clinical research.  VR aims to parallel reality and create a world that is both immersive and interactive. Users fully experience VR when they believe that the paradigm accurately simulates the real-world experience that it attempts to recreate. The sense of presence, or “being there” in VR, is facilitated through the use of technology such as head-mounted displays, gesture-sensing gloves, synthesized sounds, and vibrotactile platforms, which allow for the stimulation of multiple senses and active exploration of the virtual environment. Furthermore, some VR paradigms are programmed to react to the actions of the user. This dynamic interaction enables the participant to engage with the VR environment in a more naturalistic and intuitive way. VR’s precise control of sensory cues, particularly for auditory, tactile, and olfactory systems, increases the sense of realism and memory of the virtual environment. (Maples-Keller, Bunnell, Kim, & Rothbaum, 2017)

Fear of Flying (FOF)

In a study by Rothbaum and colleagues, patients with FOF (N = 49) were randomly assigned to virtual reality exposure therapy, standard exposure therapy, or a wait-list control. Treatment consisted of 8 sessions over 6 weeks, with 4 sessions of anxiety management training followed by either exposure to a virtual airplane or exposure to an actual airplane at the airport. The results indicated that virtual reality exposure and standard exposure were both superior to the control group, with no differences between the two approaches. The gains observed in treatment were maintained at a 6-month follow up. (Rothbaum, Hodges, Smith, Lee, & Price, 2000)

Systematic Desentization

Systematic desensitization has become one of the most effective new therapeutic methods. There are clinical series and laboratory experiments demonstrating its success in alleviating fear and anxiety. Both stimulus and response control elements may contribute to the success of desensitization and similar fear modification treatments. (Lang, 2017)

Expressive Therapy

Fagen reported cases and analyses of terminal-cancer pediatric patients that display a variety of music therapy techniques to show how “grief work” is part of a larger therapeutic process. Fagan concluded that the creative life of the child must not be dismissed as secondary in times of illness, that it must share equal importance with other intellectual and physical needs. (Fagen, 1982)

Cognitive Processing Therapy (CPT)

Cognitive processing therapy (CPT) is based on an information processing theory of PTSD and includes education, exposure, and cognitive components. Its effectiveness was shown in smaller sample sizes. (Resick & Schnicke, 1992)

Thoughts and Emotions

The thoughts and emotions we perceive arise in an interconnected system of areas with nerve cells (neurons). Both are types of information, which can lead to change in the individual, whether resulting in changes in state, behaviours or thinking, if the messages are meaningful, that is if they lead to new meaningful information within the context of existing information, whether in memory or anywhere else in the nervous system.

Thoughts and emotions are thus messages representing sets of information being shuttled between different locations in the brain. The sense of this movement of information gives rise to the sense of self, which is not just a metacognitive ability, but the actual awareness of all those information flows. The greatest fear may be the fear that these information flows stop suddenly, which would resemble the death of the self. However, since the information flows continue throughout life, it is a fear of losing the awareness of them.

The emotions in conjunction with the ability to reflect about them help to identify the thoughts, actions, behaviours and situations which make a person feel better. Especially when confronting fears, whether on the inside or on the outside, this information can be helpful. Emotions are not as accessible to rationality because we are not conscious of the large amount of information that goes into them, a process that happens largely in our subconscious, but thinking about situations in the past and connecting emotionally can help to make it easier to identify them.


It is only worth facing one’s fears where an action makes sense in the context of one’s values and aspirations. This means using one’s thoughts and feelings to find those things which make one happy and are enjoyable, as well as being in sync with one’s values. This is a first important step in breaking down fears and developing the motivation and initiative to overcome them.

Meaningfulness is a practical concept. If something is meaningful, it can bring about a change in an individual. For example, if something triggers a feeling in a person, it is meaningful, particularly if it changes the affective state of the person. Whether something triggers a new though, a sadness, anger or happiness, it is meaningful. How a message fits into and corresponds with the information already in the nervous system, and other parts of the body, determines whether it is meaningful. If information about a situation, for example, corresponds with a past situation in memory, which is associated with other information and a feeling of sadness, both these thoughts and the sadness can be triggered. But something more happens, than the retrieval of information. The information about the new situation and the existing information have to be reconciled, which is essentially a creative act, leading to new information. There could, for example, be a new insight into oneself or the world, cognitively, emotionally or otherwise. Meaningfulness thus leads to innovation, which is of particular importance when it comes to facing fears, within and without. Anxiety in itself is not an emotion, but underlying it are usually emotions which need to be addressed to resolve the anxiety or panic attacks.

Communication and Fear

How we communicate with others has an influence of the fears we are experiencing. Meaningful helpful communication can reduce fears, if delivered with empathy and understanding, while negative communication or a lack of communication can increase fears. When we face those fears, communicating with someone else or others can be helpful in overcoming the fears.

Patterns and Communication Structures

Whether something is a fear or not depends on how one communicates with oneself and others. It is usually helpful to recognize the emotion of fear, but to see in it the question which it is. When one encounters a tiger in the wild, the fear really presses the question on one, what to do, whether to freeze or run away. Once the question has been answered, fear may also provide the increase in energy to initiate the action, such as running away. In other words, the purpose of the emotion is to get a new communication process going which often involves the non-emotional mind in the form of asking a question.


Many people who experience fears and anxieties have picked up on the need for answers, but they skip the crucial step of asking the right question. However, without an awareness of the question looking for an answer is futile, which usually increases the sense of helplessness and hopelessness. An employee who experiences anxiety and the workplace and begins to dread everything about it, and as a consequence is heading straight into a burnout, cannot change anything until the question is asked what needs to be changed. In essence, the fear or possible change and the uncertainty which comes with it lets him or her experience anxiety fears, anxiety or even emotional numbness and disconnect, which would end in the moment the question about change is asked. The mind would immediately focus on constructing a new future rather than on the helplessness and hopelessness of the situation.

Questions are so powerful because they change the communication patterns one has with oneself and with others. While they are a communication entity in themselves with message and meaning, the information they contain leads to a change in the information flows in oneself or in others, as long as they possess meaning to the recipient.

Building the Motivation to Overcome One’s Fears

Reconnecting with ourselves should allow us to identify our value and aspirations which can be very effective in building the motivation to overcome fears and even to reduce them. Doing something we feel strongly about might not reduce the nervousness we feel, but it can lower the amount of fear or even transform it into excitement. It is easier to overcome one’s fears if one knows why this is beneficial to oneself and others.

Information Overload

In the complex world we live in our brains can get overloaded with information, a situation that in itself can cause fears. So, an important first step is to untangle the web of complexity by picking out the information that is important to us. Being selective requires knowing what one wants and what one is looking for. This is why getting in touch with one’s values can be so important. They tell us what is important to us and what we should be looking for. Openness is important to find new interests, make better decisions, formulate new plans and aspire to even greater things, but if we do things that are not in sync with our core sense of ourselves as person and our basic values[1], there will be little happiness in these activities.


Humans often spend too much resources on information that is not relevant to them or where they cannot change anything. If you cannot change an issue, there is not much sense in wasting mental or physical resources on it. In such a situation, it is more important to deal with your emotions, be they fears, sadness or anger. One way is to find a way to communicate them in a meaningful way. Communicating an emotion helps to resolve it. This could be in the form of talking about it, writing about it, or even making a movie about it.

Selecting Information

The way we select, process and manage information is important in alleviating fears. You may be anxious of something or of a situation, but maybe one reason is that you do not have enough information about it. We live in a world where information is very readily available, so informing oneself is often not that difficult. And if you do not find answers to a question you have, consider if you are asking the right question, one that is helpful to you.

The Right Question

Often, we ask questions that do not really provide us direction or useful answers, so we get lost in ruminations and endless spirals of meaningless thought cascades. Try to split up a question and see if you might not get at least partial answers to the component that is relevant, while leaving the irrelevant part unanswered.

Values and Basic Interests

Any information is helpful if it helps one live according to one’s values and basic interests. Life is going along a path. You cannot know the entire path until you have lived your life, but your values provide a good compass and they help dispel fear whenever it pops up along the way.


Quite often fears generalize in what is called a ‘generalised anxiety’. This can lead to a general fear of life itself. Here it is important to determine which emotions and specific fears are underlying the generalised anxiety.

You may identify something that triggered the anxiety, but the reasons for it can go back a long time. Dealing with some of the underlying issues may require identifying your values and interests. You want to cut down on thoughts and fears that are irrelevant to you and focus constructively on the issue that are relevant to you by finding helpful information.

General Questions

Generalised anxiety occurs often when people feel they have to fix something or find answers or make decisions, when they do not know where to look for them, or even where to start. Take a step back, see the situations for what it is with its relevant and irrelevant components, and measure your options against what you truly need and want. Much in life is noise and irrelevant to one’s path.

Communication to Counter Fear

It helps to be in contact with someone else to make the fears manageable. Facing fears with another may make it easier to deal with your fears and anxieties because you know you do not have to face them alone. When you talk to your neighbour on an airplane, for example, you might not even notice the take-off, and the brief interaction with the stranger reduces the emotional pressure on the inside.

Dr Jonathan Haverkampf, M.D. (Vienna) MLA (Harvard) LL.M. (ULaw) trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over two hundred articles.

Jonathan can be reached by email at or via the websites and


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[1] One’s sense of self, one’s personality and one’s values usually change little over one’s life span, except for exposure to extreme, and especially traumatic, experiences.

ADHD and Medication (3)


ADHD and Medication

Christian Jonathan Haverkampf, M.D.

Attention deficit hyperactivity disorder (ADHD) has become treatable with medication and psychotherapeutic approaches that have become available recently. This article provides a brief overview of some aspects of the medication used for ADHD.

The most widely used group of medication for ADHD comprises the stimulants. Stimulants such as methylphenidate and amphetamine are currently the most common treatment for ADHD. The substance used should fit the particular individual and the particular condition and situation.

Open and transparent communication between clinician and patient is of paramount importance in the case of ADHD for a successful treatment outcome.

Keywords: ADHD, attention deficit hyperactivity disorder, medication, psychiatry

Table of Contents

Keywords: ADHD, attention deficit hyperactivity disorder, medication, psychiatry. 1

Introduction. 5

The Prefrontal Cortex. 5

Substance Abuse. 6

Psychotherapy. 6

Social 6

Diagnosis of ADHD.. 7

Different Types of ADHD.. 7

EEG.. 8

Diagnosis of ADHD in Children. 8

Stability over Time. 9

Adult ADHD.. 10

Baseline assessment. 11

Medication. 11

Long-Term Effect. 12

Anxiety. 12

Tics. 12

Emotional Lability. 13

Smoking. 13

Medication Groups. 13

Methylphenidate. 13

Atomoxetine. 14

Extended Release. 14

Sex. 14

Medication for Children. 14

Consider offering. 15

Medication for Adults. 15

Consider offering. 15

ADHD Type and Medication. 16

Subtype. 16

Sleep. 16

Anxiety. 16

Genotype. 17

Dose Titration. 17

Abuse. 18

Coexisting Conditions. 18

Caution. 18

Psychosis. 19

Bipolar Disorder. 19

Aggression. 20

Seizures. 20

Priapism.. 20

Peripheral Vasculopathy, Including Raynaud’s Phenomenon. 20

Visual Disturbance. 20

Drug Dependence. 20

Pregnancy. 21

Monitoring. 21

Behavior. 21

Height. 21

Weight. 22

Cardiovascular System.. 22

Children and Adolescents. 23

Adults. 23

Tics. 23

Sexual Dysfunction. 23

Seizures. 23

Sleep. 24

Compliance. 24

Psychotherapy. 24

References. 25


The use of medications to treat attention deficit hyperactivity disorder (ADHD) has increased. Using a common protocol and data from thirteen countries and one SAR, Raman and colleagues show increases over time but large variations in ADHD medication use in multiple regions across the world. (Raman et al., 2018)

While medication is effective, one needs to keep in mind that most mental health conditions, and particularly ADHD, is caused and maintained not only by neurobiology, but also by psychological, environmental and social patterns. Most patients would thus benefit from a combined approach. Safren and colleagues, for example, studied cognitive-behavioral therapy (CBT) for adults with attention-deficit hyperactivity disorder (ADHD) who have been stabilized on medications but still show clinically significant symptoms. The data showed that CBT for adults with ADHD with residual symptoms can be a feasible, acceptable, and potentially efficacious next-step treatment approach. (Safren et al., 2005)

The most widely used class of medication for ADHD is the group of stimulants, including methylphenidate and other substances. A stimulant is a drug that stimulates the central nervous system, increasing arousal, attention and endurance. For years, it was assumed that stimulants had paradoxical calming effects in ADHD patients, whereas stimulating ‘normal’ individuals and producing locomotor activation in rats. It is now known that low doses of stimulants focus attention and improve executive function in both normal and ADHD subjects. Stimulants are frequently used to treat attention deficit-hyperactivity disorder. Because the medications can be addictive, patients with a history of drug abuse are typically monitored closely or treated with a non-stimulant. It is argued that the risk of addiction in patients diagnosed with ADHD is much lower. On the other hand, well-monitored stimulant treatment may even reduce the risk for alcohol and substance use in adolescent ADHD. (Hammerness, Petty, Faraone, & Biederman, 2017)

The Prefrontal Cortex

At low doses that improve prefrontal cortex-dependent cognitive function and that are devoid of locomotor-activating effects, methylphenidate substantially increases norepinephrine and dopamine efflux within the prefrontal cortex. In contrast, outside the prefrontal cortex these doses of methylphenidate have minimal impact on norepinephrine and dopamine efflux. (Berridge et al., 2006) The prefrontal cortex regulates behavior and attention using representational knowledge, and imaging and neuropsychological studies have shown that the prefrontal cortex is weaker in subjects with ADHD. This cortical area is very sensitive to levels of catecholamines: moderate levels engage postsynaptic α2A-adrenoceptors and D1 receptors and improve prefrontal regulation of behavior and attention, while high levels impair prefrontal function via α1-adrenoceptors and excessive D1 receptor stimulation. Administering low doses of methylphenidate to rats improves the working memory and attentional functions of the prefrontal cortex, while high doses impair working memory and produce a perseverative pattern of errors similar to that seen in patients. The low dose improvement is blocked by either an α2-adrenoceptor or Dl receptor antagonist, suggesting that both norepinephrine and dopamine contribute to the beneficial actions of stimulant medications. (Arnsten, 2006)

Substance Abuse

Chang and colleagues found no indication of increased risks of substance abuse among individuals prescribed stimulant ADHD medication; if anything, the data suggested a long‐term protective effect on substance abuse. (Chang et al., 2014) However, one should still be vigilant towards stimulant misuse and diversion in ADHD patients.

Careful therapeutic monitoring can reduce medical misuse and diversion of controlled medication among adolescents. They appear to be more prevalent among adolescents who misuse their controlled drugs. In a survey study by McCabe and colleagues, misusers were more likely than non-misusers to divert their controlled medications and to abuse other substances. The odds of a positive screening result for drug abuse were substantially higher among medical misusers compared with medical users who used their controlled medications appropriately. The odds of drug abuse did not differ between medical users who used their controlled medications appropriately and nonusers. Most adolescents who used controlled medications took their medications appropriately. (McCabe et al., 2011) In a literature review by Torgersen and colleagues, psychopharmacotherapy did not seem to affect substance use disorder. (Torgersen, Gjervan, & Rasmussen, 2008)

It is is also important to keep in mind the risk of not medicating ADHD. Empirical data indicates that ADHD is a significant risk factor for the development of SUDs and cigarette smoking in both sexes. (Wilens et al., 2011) One would also need to include the risk of self-medication with illegal drugs due to problems that can be caused or maintained by ADHD, such as unemployment or relationship difficulties (Haverkampf, 2017a).


Psychotherapy is often very valuable in combination with medication to alleviate the impairments of ADHD. The author has described communication-focused therapy for ADHD elsewhere. (Haverkampf, 2010, 2017d, 2018b) Unfortunately, while the efficacy of stimulants in reducing ADHD symptoms for adults is well documented in meta-analyses, there is a concerning lack of meta-analysis about other treatment interventions (Moriyama, Polanczyk, Terzi, Faria, & Rohde, 2013). Apart from reports using behavioral therapies, there are also several studies on the successful use of psychodynamic techniques


The social and environmental aspects are often underestimated in the case of ADHD. Pfiffner and colleagues evaluated in their study the efficacy of the Child Life and Attention Skills (CLAS) program, a behavioral psychosocial treatment integrated across home and school, for youth with attention-deficit/hyperactivity disorder-inattentive type (ADHD-I). CLAS resulted in greater improvements in teacher-reported inattention, organizational skills, social skills, and global functioning relative to both PFT and TAU at posttreatment. Parents of children in CLAS reported greater improvement in organizational skills than PFT and greater improvements on all outcomes relative to TAU at posttreatment. Differences between CLAS and TAU were maintained at follow-up for most parent-reported measures but were not significant for teacher-reported outcomes. Direct involvement of teachers and children in CLAS appears to amplify effects at school and home and underscores the importance of coordinating parent, teacher, and child treatment components for cross-setting effects on symptoms and impairment associated with ADHD-I. (Pfiffner et al., 2014)

There are also several psychological models that have been helpful in the treatment of adults. Solanto and colleagues assessed the effectiveness of a new manualized group Meta-Cognitive Therapy (MCT) for adults with ADHD that extends the principles and practices of cognitive-behavioral therapy to the development of executive self-management skills in thirty patients. General linear modeling revealed a robust significant posttreatment decline on the CAARS DSM-IV Inattentive symptom scale as well as improvement on the Brown ADD Scales. The findings indicated that participants in the MCT program showed marked improvement with respect to core ADHD symptoms of inattention, as well as executive functioning skills, suggesting that this program has promise as a treatment for meta-cognitive deficits in adults with ADHD. (Solanto, Marks, Mitchell, Wasserstein, & Kofman, 2008)

Charach and colleagues in a review of the literature between 1980 and 2010. The available evidence suggested that underlying prevalence of ADHD varies less than rates of diagnosis and treatment. Patterns of diagnosis and treatment appeared to be associated with such factors as locale, time period, and patient or provider characteristics. The strength of evidence for parent behavior training as the first-line intervention for improved behavior among preschoolers at risk for ADHD was high, while the strength of evidence for methylphenidate for improved behavior among preschoolers was low. Evidence regarding long-term outcomes following interventions for ADHD was sparse among persons of all ages, and therefore inconclusive, with one exception. Primary school–age children, mostly boys with ADHD combined type, showed improvements in symptomatic behavior maintained for 12 to 14 months using pharmacological agents, specifically methylphenidate medication management or atomoxetine. (A Charach et al., 2011)

Diagnosis of ADHD

The clinical interview is the most important pillar in the process of diagnosing ADHD. Reflecting on the interaction with the patients and observing the communication patterns used is very helpful in the diagnosis and in the treatment of ADHD.

There is also the overall problem in the case of ADHD that, while the diagnostic criteria in the diagnostic manuals are quite clear, it may sometimes be diagnosed based on the individual heuristic criteria the therapist has developed over time. Since attention deficit can occur in several disorders and is not as pathognomonic as, for example, feeling depressed or anxious for depression and anxiety, respectively, it takes more complex algorithms to formulate a diagnosis. However, there still seem to be problems, which, however, are not uncommon in psychiatric diagnosis. The accuracy itself even seems to depend on the diagnosis. For some diagnoses, especially psychotic categories, administrative data were generally predictive of true diagnosis. For others, such as anxiety disorders, the data were less satisfactory. (Davis, Sudlow, & Hotopf, 2016)

Different Types of ADHD

ADHD is to a certain degree heterogeneous which can have a n efefct of how well a particular treatment modality or even a specific treatment works. Unfortunately, there are not many clear parameters that can help to optimize treatment. However, in speical circumstances there may be information available that can be helpful in designing a treatment plan.

  1. ADHD, Predominantly Inattentive Presentation (ADHD-I)

Patients have difficulty paying attention. They are easily distracted but do not have significant symptoms of impulsivity or hyperactivity. This is sometimes called attention-deficit disorder (or ADD).

  • ADHD, Predominantly Hyperactive-Impulsive Presentation (ADHD-H)

Patients who have this type of ADHD have symptoms of hyperactivity and feel the need to move constantly. They also struggle with impulse control. Inattention is not a significant issue. This type is seen most often in very young children.

  • ADHD, Combined Presentation (ADHD-C)

Patients with this type of ADHD show significant problems with both hyperactivity/impulsivity and inattention. Children may gradually have less trouble with hyperactivity/impulsivity as they get into their teen years.

In a study by Mullins and colleagues, children with ADHD varied more in the size and direction of their time reproduction errors than control children. Those with ADHD-C demonstrated more intraindividual variability than did those with ADHD-I in the size of their errors. The data provided support for a relationship between sustained attention and time reproduction.(Mullins, Bellgrove, Gill, & Robertson, 2005)


Arns and colleagues demonstrated in their study that the EEG phenotypes as described by Johnstone, Gunkelman & Lunt are identifiable EEG patterns with good inter-rater reliability. Furthermore, it was also demonstrated that these EEG phenotypes occurred in both ADHD subjects as well as healthy control subjects. The Frontal Slow and Slowed Alpha Peak Frequency and the Low Voltage EEG phenotype discriminated ADHD subjects best from controls (however the difference was not significant). The Frontal Slow group responded to a stimulant with a clinically relevant decreased number of false negative errors on the CPT. The Frontal Slow and Slowed Alpha Peak Frequency phenotypes have different etiologies as evidenced by the treatment response to stimulants. In previous research Slowed Alpha Peak Frequency has most likely erroneously shown up as a frontal theta sub-group. Furthermore, the divergence from normal of the frequency bands pertaining to the various phenotypes is greater in the clinical group than in the controls. Investigating EEG phenotypes provides a promising new way to approach EEG data, explaining much of the variance in EEGs and thereby potentially leading to more specific prospective treatment outcomes. (ARNS, GUNKELMAN, BRETELER, & SPRONK, 2008)

Diagnosis of ADHD in Children

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood and can profoundly affect the academic achievement, well-being, and social interactions of children; the American Academy of Pediatrics first published clinical recommendations for the diagnosis and evaluation of ADHD in children in 2000; recommendations for treatment followed in 2001. (American Academy of Pediatrics, 2000)

Bruchmüller and colleagues sent a case vignette to 1,000 child psychologists, psychiatrists, and social workers and asked them to give a diagnosis. The results were that in the non-ADHD vignettes, 16.7% of therapists diagnosed ADHD. In the boy version of these vignettes, therapists diagnosed ADHD around 2 times more than they did with the girl vignettes. Their study suggested that there may be an overdiagnosis of ADHD and that the patient’s gender influences diagnosis considerably. (Bruchmüller, Margraf, & Schneider, 2012) It is unclear whether the problem is that therapists do not adhere enough to diagnostic manuals and diagnostic criteria, or if there are other factors, such as issues with the diagnostic criteria or diagnostic algorithms. Another explanation could be that a significant amount of information gets lost in the interaction with the patient. Especially, if the time allowed for the meeting is very limited, there is the risk of both over- and underdiagnosis where maybe several other issues are involved, such as trauma, anxiety or depression, for example.

This guideline has been developed to advise on the treatment and management of attention deficit hyperactivity disorder (ADHD). The guideline recommendations have been developed by a multidisciplinary team of healthcare professionals, service users and carers, and guideline methodologists after careful consideration of the best available evidence. It is intended that the guideline will be useful to clinicians and service commissioners in providing and planning high-quality care for people with ADHD while also emphasizing the importance of the experience of care for them and their carers (see Appendix 1 for more details on the scope of the guideline). Although the evidence base is rapidly expanding, there are a number of major gaps; future revisions of this guideline will incorporate new scientific evidence as it develops. The guideline makes a number of research recommendations specifically to address gaps in the evidence base. In the meantime, it is hoped that the guideline will assist clinicians, people with ADHD and their carers by identifying the merits of particular treatment approaches where the evidence from research and clinical experience exists. ((UK, 2018)

While the disorder continues to be viewed as one of inattention and/or hyperactive-impulsive behavior, theories of ADHD are beginning to focus more on poor inhibition and deficient executive functioning (self-regulation) as being central to the disorder. Clinicians should be aware of these problems and the adjustments that need to be made to them when dealing with special populations that were not represented in the field trials used to develop these criteria. (Barkley, 2003)

Kadesjo and Gillberg examined patterns of comorbid/associated diagnoses and associated problems in a population sample of children with and without DSM-III-R attention-deficit hyperactivity disorder (ADHD). Half (N = 409) of a mainstream school population of Swedish 7-year-olds were clinically examined, and parents and teachers were interviewed and completed questionnaires. The children were followed up 2–4 years later. Eighty-seven per cent of children meeting full criteria for ADHD (N = 15) had one or more—and 67% at least two—comorbid diagnoses. The most common comorbidities were oppositional defiant disorder and developmental coordination disorder. Children with subthreshold ADHD (N = 42) also had very high rates of comorbid diagnoses (71% and 36%), whereas those without ADHD (N = 352) had much lower rates (17% and 3%). The rate of associated school adjustment, learning, and behavior problems at follow-up was very high in the ADHD groups. We concluded that pure ADHD is rare even in a general population sample. Thus, studies reporting on ADHD cases without comorbidity probably refer to highly atypical samples. By and large, such studies cannot inform rational clinical decisions. (Kadesjö & Gillberg, 2001)

Stability over Time

Children rarely remain in the HT classification over time; rather, they sometimes desist from ADHD but mostly shift to CT in later years.  In a study on a sample of 118 4- to 6-year-olds who met DSM-IV criteria for ADHD, Lahey and colleagues showed that the number of children who met criteria for ADHD declined over time, but most persisted. Children who met criteria for the combined subtype (CT, n = 83) met criteria for ADHD in more subsequent assessments than children in the predominantly hyperactive-impulsive subtype (HT, n = 23). Thirty-one (37%) of 83 CT children and 6 (50%) of 12 children in the predominantly inattentive subtype (IT) met criteria for a different subtype at least twice in the next 6 assessments. Children of the HT subtype were even more likely to shift to a different subtype over time, with HT children who persisted in ADHD mostly shifting to CT in later assessments. The subtypes exhibited consistently different mean levels of hyperactive-impulsive symptoms during years 2 through 8 that corresponded with their initial subtype classifications, but initial subtype differences in inattention symptoms diminished in later years. Conclusions  In younger children, the CT and IT may be stable enough to segregate groups for research, but they seem too unstable for use in the clinical assessment of individual children. (Lahey, Pelham, Loney, Lee, & Willcutt, 2005) The authors suggested a continuous hyperactivity-impulsivity rating model in the diagnosis.

Adult ADHD

The diagnosis of attention-deficit hyperactivity disorder (ADHD) in adults is a complex procedure which should include retrospective assessment of childhood ADHD symptoms either by patient recall or third party information, diagnostic criteria according to DSM-IV, current adult ADHD psychopathology including symptom severity and pervasiveness, functional impairment, quality of life and comorbidity. The author has discussed the diagnosis of adult ADHD in greater depth elsewhere. (Haverkampf, 2018c)

A valid and reliable assessment should be comprehensive and include the use of symptom rating scales, a clinical interview, neuropsychological testing, and the corroboration of patient reports. Specific diagnostic criteria that are more sensitive and specific to adult functioning are needed. In treatment, pharmacological interventions have the most empirical support, with the stimulants methylphenidate and amphetamine and the antidepressants desipramine and atomoxetine having the highest efficacy rates. Scientific research on psychosocial treatments is lacking, with preliminary evidence supporting the combination of cognitive behavioral therapy and medication. (Davidson, 2008)

The Wender-Utah Rating Scale (WURS) and the Childhood Symptoms Scale by Barkley and Murphy try to make a retrospective assessment of childhood ADHD symptoms. The Connors Adult ADHD Rating Scales (CAARS), the Current Symptoms Scales by Barkley and Murphy (CSS), the Adult Self Report Scale (ASRS) by Adler et al. and Kessler et al. or the Attention Deficit Hyperactivity Disorder—Self Report Scale (ADHD-SR by Rösler et al.) are self-report rating scales focusing mainly on the DSM-IV criteria. The CAARS and the CSS have other report forms too. The Brown ADD Rating Scale (Brown ADD-RS) and the Attention Deficit Hyperactivity Disorder-Other Report Scale (ADHD-OR by Rösler et al.) are instruments for use by clinicians or significant others. Both self-rating scales and observer report scales quantify the ADHD symptoms by use of a Likert scale mostly ranging from 0 to 3. This makes the instruments useful to follow the course of the disease quantitatively. Comprehensive diagnostic interviews not only evaluate diagnostic criteria, but also assess different psychopathological syndrome scores, functional disability measures, indices of pervasiveness and information about comorbid disorders. The most comprehensive procedures are the Brown ADD Diagnostic Form and the Adult Interview (AI) by Barkley and Murphy. An instrument of particular interest is the Wender Reimherr Interview (WRI) which follows a diagnostic algorithm different from DSM-IV. The interview contains only items delineated from adult psychopathology and not derived from symptoms originally designed for use in children. (Rösler et al., 2006)

Baseline assessment

Before starting medication for ADHD, people with ADHD should have a full assessment, possibly through their GP, which should include also:

  • a review to confirm they continue to meet the criteria for ADHD and need treatment
  • a review of mental health and social circumstances, including:
    • presence of coexisting mental health and neurodevelopmental conditions
    • current educational or employment circumstances
    • risk assessment for substance misuse and drug diversion

care needs There should also be a review of physical health, including also:

  • a medical history, taking into account conditions that may be contraindications for specific medicines
  • current medication
  • height and weight (measured and recorded against the normal range for age, height and sex)
  • baseline pulse and blood pressure (measured with an appropriately sized cuff and compared with the normal range for age)
  • a cardiovascular assessment
  • an electrocardiogram (ECG) if the treatment may affect the QT interval.

One should refer for a cardiology opinion before starting medication for ADHD in cases including also:

  • history of congenital heart disease or previous cardiac surgery
  • history of sudden death in a first-degree relative under 40 years suggesting a cardiac disease
  • shortness of breath on exertion compared with peers
  • fainting on exertion or in response to fright or noise
  • palpitations that are rapid, regular and start and stop suddenly (fleeting occasional bumps are usually ectopic and do not need investigation)
  • chest pain suggesting cardiac origin
  • signs of heart failure
  • a murmur heard on cardiac examination
  • blood pressure that is classified as hypertensive for adults


Stimulants are the classic medication which is used in the treatment of ADHD. If it is used correctly and for the correct indication, it can help patients have a significant improvement in their quality of life.

However, treatment success in the individual and treatment success on average in a large group can diverge significantly. A clinician’s skills in using the medication can play a significant role. In a large Canadian study, Currie and colleagues found little evidence of improvement in either the medium or the long run. Our results are silent on the effects on optimal use of medication for ADHD, but suggest that expanding medication in a community setting had little positive benefit. (Currie, Stabile, & Jones, 2014)

Long-Term Effect

While methylphenidate (MPH) often ameliorates attention-deficit/hyperactivity disorder (ADHD) behavioral dysfunction, it there is little evidence that methylphenidate (MPH) medication leads to long-term-term academic gains in ADHD. In a study by Hale and colleagues, children aged 6 to 16 with ADHD inattentive type (IT; n = 19) and combined type (n = 33)/hyperactive-impulsive type (n = 4) (CT) participated in double-blind placebo-controlled MPH trials with baseline and randomized placebo, low MPH dose, and high MPH dose conditions. Robust cognitive and behavioral MPH response was achieved for children with significant baseline executive working memory (EWM) / self-regulation (SR) impairment, yet response was poor for those with adequate EWM/SR baseline performance. Even for strong MPH responders, the best dose for neuropsychological functioning was typically lower than the best dose for behavior. (Hale et al., 2011)

There is overall little evidence to suggest that the type of treatment in the present affects the severity of ADHD in the future. A study by Molina and colleagues has shown that or intensity of 14 months of treatment for ADHD in childhood (at age 7.0–9.9 years) does not predict functioning 6 to 8 years later. Rather, early ADHD symptom trajectory regardless of treatment type is prognostic. This finding implies that children with behavioral and sociodemographic advantage, with the best response to any treatment, will have the best long-term prognosis. As a group, however, despite initial symptom improvement during treatment that is largely maintained after treatment, children with combined-type ADHD exhibit significant impairment in adolescence. (Molina et al., 2009)


Compared to parent and teacher reports of anxiety, child reported comorbid anxiety shows foremost the largest associations with the neurocognitive dysfunctions observed in children with ADHD. (Bloemsma et al., 2013) In another study, overall rates of individual anxiety disorders, as well as age of onset and severity of illness were not significantly different in the presence of comorbid ADHD. School functioning in children with anxiety disorders was negatively impacted by the presence of comorbid ADHD. Frequency of mental health treatment in children with anxiety disorders was significantly increased in the presence of comorbid ADHD. ADHD had a limited impact on the manifestation of anxiety disorder in children suggesting that ADHD and anxiety disorders are independently expressed. (Hammerness et al., 2010)


Findings in a study by Gadow and Nolan suggest that the co-occurrence of diagnosed ADHD, chronic multiple tick disorder and anxiety represents a particularly troublesome clinical phenotype, at least in the home setting. Comorbid anxiety disorder was not associated with a less favorable response to immediate release methylphenidate in children with ADHD and chronic multiple disorder, but replication with larger samples is warranted before firm conclusions can be drawn about potential group differences. (Gadow & Nolan, 2011)

Emotional Lability

Emotional lability, or sudden strong shifts in emotion, commonly occurs in youth with attention-deficit/hyperactivity disorder. Although these symptoms are impairing and disruptive, relatively little research has addressed their treatment, likely due to the difficulty of reliable and valid assessment. Promising signals for symptom improvement have come from recent studies using stimulants in adults, children and adolescents. Similarly, neuroimaging studies have begun to identify neurobiological mechanisms underlying stimulants’ impact on emotion regulation capacities. (Posner, Kass, & Hulvershorn, 2014)


Individuals suffering from ADHD have a significantly higher risk of cigarette smoking. Stimulant treatment of ADHD may reduce smoking risk. Schoenfelder and colleagues examined the relationship between stimulant treatment of ADHD and cigarette smoking in a meta-analysis. The study revealed a significant association between stimulant treatment and lower smoking rates. the effect was larger in samples with more severe psychopathology. Implications for further research, treatment of ADHD, and smoking prevention are discussed. (Schoenfelder, Faraone, & Kollins, 2014)

Medication Groups

Common stimulants include:

Methylphenidate (Methylphenidate®, Concerta®), a norepinephrine-dopamine reuptake inhibitor

Dextroamphetamine (Dexedrine®), the dextro-enantiomer of amphetamine

Dexmethylphenidate (Focalin®), the active dextro-enantiomer of methylphenidate

Lisdexamfetamine (Vyvanse®), a prodrug containing the dextro-enantiomer of amphetamine

There are also mixed amphetamine salts, such as Adderall®, a 3:1 mix of dextro/levo-enantiomers of amphetamine.

Atomoxetine (Strattera ®) is a norepinephrine (noradrenaline) reuptake inhibitor which is approved for the treatment of attention deficit hyperactivity disorder (ADHD).

There are also some antidepressants that have mild stimulant effects. Further information can be found in the author’s book An Overview of Psychiatric Medication (Haverkampf, 2018a)


Methylphenidate is indicated as an integral part of a total treatment program which typically includes other remedial measures (psychological, educational, social) for a stabilizing effect in children with a behavioral syndrome characterized by the following group of developmentally inappropriate symptoms:

  • moderate-to-severe distractibility
  • short attention span
  • hyperactivity
  • emotional lability, an
  • impulsivity.

The diagnosis of this syndrome should not be made with finality when these symptoms are only of comparatively recent origin. Non-localizing neurological signs, learning disability, and abnormal EEG may or may not be present, and a diagnosis of central nervous system dysfunction may or may not be warranted.


In pediatric patients with ADHD and comorbid symptoms of depression or anxiety, atomoxetine monotherapy appears to be effective for treating ADHD. (Kratochvil et al., 2005) In the study by Kratochvil and colleagues, anxiety and depressive symptoms also improved, but the absence of a placebo-only arm did not allow the investigators to conclude that these effects are specifically the result of treatment with atomoxetine. Combined atomoxetine and fluoxetine therapy were, however, well tolerated.

Extended Release

When prescribing stimulants for ADHD, one needs to consider modified-release once-daily preparations for the following reasons:

  • convenience
  • improving adherence
  • reducing stigma (because there is no need to take medication at school or in the workplace)
  • reducing problems of storing and administering controlled drugs at school
  • the risk of stimulant misuse and diversion with immediate-release preparations
  • their pharmacokinetic profiles.

Immediate-release preparations may be suitable if more flexible dosing regimens are needed, or during initial titration to determine correct dosing levels.


ADHD was once thought of as a predominantly male disorder. While this may be true for ADHD in childhood, extant research suggests that the number of women with ADHD may be nearly equal to that of men with the disorder (Faraone et al., 2000). There is accumulating research which clearly indicates subtle but important sex differences exist in the symptom profile, neuropathology and clinical course of ADHD. Compared to males with ADHD, females with ADHD are more prone to have difficulties with inattentive symptoms than hyperactive and impulsive symptoms, and females often receive a diagnosis of ADHD significantly later than do males (Gaub & Carlson, 1997; Gershon, 2002a, 2002b). Emerging evidence suggests differences exist in the neuropathology of ADHD, and there are hormonal factors which may play an important role in understanding ADHD in females. Although research demonstrates females with ADHD differ from males in important ways, little research exists that evaluates differences in treatment response. Given the subtle but important differences in presentation and developmental course of ADHD, it is essential that both clinical practice and research be informed by awareness of these differences in order to better identify and promote improved quality of care to girls and women with ADHD. (Nussbaum, 2012)

Medication for Children

Drug treatment is not indicated for all children with this syndrome. Stimulants are not intended for use in the child who exhibits symptoms secondary to environmental factors and/or primary psychiatric disorders, including psychosis. Appropriate educational placement is essential and psychosocial intervention is generally necessary. When remedial measures alone are insufficient, the decision to prescribe stimulant medication will depend upon the physician’s assessment of the chronicity and severity of the child’s symptoms.

Methylphenidate should not be used in children under 6 years, since safety and efficacy in this age group have not been established.

Consider offering

  1. Methylphenidate as the first line pharmacological treatment,
  2. Lisdexamfetamine for those who have had a 6‑week trial of methylphenidate at an adequate dose and not derived enough benefit in terms of reduced ADHD symptoms and associated impairment,
  3. Dexamfetamine for those whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile,
  4. Atomoxetine or Guanfacine if:
  5. they cannot tolerate methylphenidate or lisdexamfetamine or
  6. their symptoms have not responded to separate 6‑week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.

Medication for Adults

Consider offering

  1. Lisdexamfetamine or Methylphenidate as first-line pharmacological treatment,
  2. Lisdexamfetamine for those who have had a 6‑week trial of methylphenidate at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment,

Methylphenidate for those who have had a 6‑week trial of lisdexamfetamine at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment,

  • Dexamfetamine for those whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile,
  • Atomoxetine if:
  • they cannot tolerate lisdexamfetamine or methylphenidate or
  • their symptoms have not responded to separate 6‑week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.

Do not offer any of the following medication for ADHD without advice from a tertiary ADHD service:

  • guanfacine for adults
  • clonidine for children with ADHD and sleep disturbance, rages or tics
  • atypical antipsychotics in addition to stimulants for people with ADHD and coexisting pervasive aggression, rages or irritability
  • other medication than that listed above.

ADHD Type and Medication


In a study by Barbaresi and colleagues, there was no association between DSM-IV subtype and likelihood of a favorable response or of side effects. Dextroamphetamine and methylphenidate were equally likely to be associated with a favorable response, but dextroamphetamine was more likely to be associated with side effects. (Barbaresi et al., 2014)


Differences in sleep problems seem to be a function of ADHD subtype, comorbidity, and medication. In a study by Mayes and colleagues, children with ADHD-I alone had the fewest sleep problems and did not differ from controls. Children with ADHD-C had more sleep problems than controls and children with ADHD-I. Comorbid anxiety/depression increased sleep problems, whereas ODD did not. Daytime sleepiness was greatest in ADHD-I and was associated with sleeping more (not less) than normal. Medicated children had greater difficulty falling asleep than unmedicated children. (Mayes et al., 2008) Linear regression analyses by Corkum and colleagues showed that (1) dyssomnias were related to confounding factors (i.e., comorbid oppositional defiant disorder and stimulant medication) rather than ADHD; (2) parasomnias were similar in clinical and nonclinical children; and (3) the DSM-IV combined subtype of ADHD was associated with sleep-related involuntary movements. However, sleep-related involuntary movements were more highly associated with separation anxiety. (CORKUM, MOLDOFSKY, HOGG-JOHNSON, HUMPHRIES, & TANNOCK, 1999)


ADHD co-occurring with internalizing disorders (principally parent-reported anxiety disorders) absent any concurrent disruptive disorder, ADHD co-occurring with ODD/CD (oppositional defiant disorder / conduct disorder) but no anxiety (ADHD + ODD/CD), and ADHD with both anxiety and ODD/CD (ADHD + ANX + ODD/CD) may be sufficiently distinct to warrant classification as ADHD subtypes separate from ADHD without this phenomenology. Jensen and colleagues found evidence of main effects of internalizing and externalizing comorbid disorders. Moderate evidence of interactions of parent-reported anxiety and ODD/CD status were noted on response to treatment, indicating that children with ADHD and anxiety disorders (but no ODD/CD) were likely to respond equally well to behavioral and medication treatments. Children with ADHD-only or ADHD with ODD/CD (but without anxiety disorders) responded best to medication treatments (with or without behavioral treatments), while children with multiple comorbid disorders (anxiety and ODD/CD) responded optimally to combined (medication and behavioral) treatments. (JENSEN et al., 2001)


Stein and colleagues studied the relationship between DAT1 3′-untranslated region (3′-UTR) variable number tandem repeats (VNTR) genotypes and dose response to MPH. Children were genotyped for the DAT1 VNTR and evaluated on placebo and three dosage levels of OROS® MPH. Children who were homozygous for the less common, 9-repeat DAT1 3′-UTR genotype displayed a distinct dose–response curve from that of the other genotype groups, with an absence of typical linear improvement when the dose was increased from 18 mg to 36 and 54 mg. (Stein et al., 2005)

In a study by Epstein and colleagues, youths and adults with ADHD showed attenuated activity in fronto‐striatal regions. In addition, adults with ADHD appeared to activate non‐fronto‐striatal regions more than normals. A stimulant medication trial showed that among youths, stimulant medication increased activation in fronto‐striatal and cerebellar regions. In adults with ADHD, increases in activation were observed in the striatum and cerebellum, but not in prefrontal regions. Conclusions: This study extends findings of fronto‐striatal dysfunction to adults with ADHD and highlights the importance of frontostriatal and frontocerebellar circuitry in this disorder, providing evidence of an endophenotype for examining the genetics of ADHD. (Epstein et al., 2007)

Some medication which is licensed for use in childhood may have to be continued off license in adults if there are no better alternatives and the patient has benefitted from it significantly. Psychotherapy may have to be adjusted to external and internal changes that are part of growing up.

Dose Titration

The dose should be titrated against symptoms and adverse effects in line with guidelines until optimized. This means reduced symptoms, positive behavior changes, improvements in education, employment and relationships, with tolerable adverse effects.

During the titration phase, ADHD symptoms, impairment and adverse effects should be recorded at baseline and at each dose change on standard scales, in children also by parents and teachers, and progress reviewed regularly.

Dose titration should be slower and monitoring more frequent if another condition is present, such as

  • neurodevelopmental disorders (for example, autism spectrum disorder, tic disorders, learning disability)
  • mental health conditions (for example, anxiety disorders [including obsessive–compulsive disorder], schizophrenia or bipolar disorder, depression, personality disorder, eating disorder, post-traumatic stress disorder, substance misuse)
  • physical health conditions (for example, cardiac disease, epilepsy or acquired brain injury).
  • Think about using immediate- and modified-release preparations of stimulants to optimize effect (for example, a modified-release preparation of methylphenidate in the morning and an immediate-release preparation of methylphenidate at another time of the day to extend the duration of effect).
  • Addictions


One needs to be particularly careful about prescribing stimulants for ADHD if there is a risk of addictions and/or diversion for cognitive enhancement or appetite suppression. One should not offer immediate-release stimulants or modified-release stimulants that can be easily injected or insufflated, if this may be an issue.

Coexisting Conditions

In ADHD the comorbidity for other conditions is quite high, which can play a significant role in treatment. The same medication choices can be offered to people with ADHD and anxiety disorder, tic disorder or autism spectrum disorder as other people with ADHD.

Studies indicate that co-occurrence of clinically significant ADHD and autistic symptoms is common, and that some genes may influence both disorders. However, the DSM basically does not allow for the concurrent diagnosis of ADHD and autism.

Children with the combination of ADHD and motor coordination problems are particularly likely to suffer from an autism spectrum disorder. These co-occurrences of symptoms are important since children with ASD in addition to ADHD symptoms may respond poorly to standard ADHD treatments or have increased side effects. Such children may benefit from additional classes of pharmacologic agents, such as α-agonists, selective serotonin reuptake inhibitors and neuroleptics. They may also benefit from social skills therapy, individual and family psychotherapy, behavioral therapy and other nonpharmacologic interventions. (Reiersen & Todd, 2008)


Stimulants need to be used with care and caution, and it is important to have as much information about the medical and psychological state of the patient as possible. The following list just gives some examples, but is by no means comprehensive or factually up to date:

  • Some contraindications for methylphenidate are marked anxiety, tension, and agitation are contraindications to Methylphenidate, since the drug may aggravate these symptoms. Methylphenidate is contraindicated also in patients known to be hypersensitive to the drug, in patients with glaucoma, and in patients with motor tics or with a family history or diagnosis of Tourette’s syndrome.
  • Methylphenidate is contraindicated during treatment with monoamine oxidase inhibitors, and within a minimum of 14 days following discontinuation of a monoamine oxidase inhibitor (hypertensive crises may result).
  • Because of possible effects on blood pressure, methylphenidate should be used cautiously with pressor agents.
  • Methylphenidate may decrease the effectiveness of drugs used to treat hypertension. Human pharmacologic studies have shown that racemic methylphenidate may inhibit the metabolism of coumarin anticoagulants, anticonvulsants (e.g., phenobarbital, phenytoin, primidone), and tricyclic drugs (e.g., imipramine, clomipramine, desipramine). Downward dose adjustments of these drugs may be required when given concomitantly with methylphenidate. It may be necessary to adjust the dosage and monitor plasma drug concentration (or, in case of coumarin, coagulation times), when initiating or discontinuing methylphenidate.

Stimulant medications cause a modest increase in average blood pressure (about 2-4 mmHg) and average heart rate (about 3-6 bpm), and individuals may have larger increases. While the mean changes alone would not be expected to have short-term consequences, all patients should be monitored for larger changes in heart rate and blood pressure. Caution is indicated in treating patients whose underlying medical conditions might be compromised by increases in blood pressure or heart rate, such as those with preexisting hypertension, heart failure, recent myocardial infarction, or ventricular arrhythmia.


Psychosis is an important, unpredictable side effect of stimulant medication. In the case of acute psychotic or manic episodes, ADHD medication should be stopped because it can exacerbate or even trigger them under certain conditions. Restarting the ADHD medication after the episode has resolved can be considered, taking into account the individual circumstances, risks and benefits of the ADHD medication. The potential for psychotic side effects are well known, but usually reported as rare. Long acting preparations appear to be a contributory factor to the development of psychotic side effects, while symptoms resolve with discontinuation of treatment. (Shibib & Chalhoub, 2009)

Administration of stimulants may exacerbate symptoms of behavior disturbance and thought disorder in patients with a preexisting psychotic disorder.

Mosholder and colleagues analyzed data from 49 randomized, controlled clinical trials in the pediatric development programs for these products. A total of 11 psychosis/mania adverse events occurred during 743 person-years of double-blind treatment with these drugs, and no comparable adverse events occurred in a total of 420 person-years of placebo exposure in the same trials. The rate per 100 person-years in the pooled active drug group was 1.48. The analysis of spontaneous postmarketing reports yielded >800 reports of adverse events related to psychosis or mania. In about 90% of the cases, there was no reported history of a similar psychiatric condition. Hallucinations involving visual and/or tactile sensations of insects, snakes, or worms were common in cases in children. (Mosholder, Gelperin, Hammad, Phelan, & Johann-Liang, 2009)

Bipolar Disorder

ADHD in combination with bipolar disorder may be associated with more severe symptoms and worse outcomes of both conditions. Prior to initiating treatment with a stimulant, patients with comorbid depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. The frequent coexistence with alcohol and substance abuse may further complicate treatment management. A hierarchical approach is desirable, with mood stabilization preceding the treatment of ADHD symptoms.

Atomoxetine may be effective in the treatment of ADHD symptoms in patients with bipolar disorder, with a modestly increased risk of (hypo)manic switches and destabilization of the mood disorder when utilized in association with mood stabilizers. (Perugi & Vannucchi, 2015)


Aggressive behavior or hostility is often observed in children and adolescents with ADHD and has been reported in clinical trials and the post-marketing experience of some medications indicated for the treatment of ADHD. Patients beginning treatment for ADHD should be monitored for the appearance of or worsening of aggressive behavior or hostility.


There is some clinical evidence that stimulants may lower the convulsive threshold in patients with prior history of seizures, in patients with prior EEG abnormalities in absence of seizures, and, very rarely, in patients without a history of seizures and no prior EEG evidence of seizures. In the presence of seizures, the drug should be discontinued.


Prolonged and painful erections, sometimes requiring surgical intervention, have been reported with methylphenidate products in both pediatric and adult patients. Priapism usually developed after some time on the drug, often subsequent to an increase in dose. Priapism has also appeared during a period of drug withdrawal (drug holidays or during discontinuation). Patients who develop abnormally sustained or frequent and painful erections should seek immediate medical attention.

Peripheral Vasculopathy, Including Raynaud’s Phenomenon

Stimulants are associated with peripheral vasculopathy, including Raynaud’s phenomenon. Signs and symptoms are usually intermittent and mild, although less frequently permanent tissue damage can occur. Signs and symptoms often improve after reduction in dose or discontinuation of the drug. Careful observation for digital changes is necessary during treatment with ADHD stimulants.

Visual Disturbance

Difficulties with accommodation and blurring of vision have been reported with stimulant treatment. However, in a study by Martin and colleagues in children, visual acuity increased significantly in the ADHD group after treatment with a stimulant. Also, more ADHD subjects had subnormal visual field results without stimulants, compared with controls, but with stimulants the difference was no longer significant. (Martin, Aring, Landgren, Hellström, & Andersson Grönlund, 2008)

Drug Dependence

Methylphenidate should be given cautiously to patients with a history of drug dependence or alcoholism. Chronic abusive use can lead to marked tolerance and psychological dependence with varying degrees of abnormal behavior. Psychotic episodes can occur, especially with parenteral abuse. Careful supervision is required during withdrawal from abusive use, since severe depression or another underlying condition may surface.


The number of pregnancies exposed to ADHD medication has increased similarly to the increase in use of ADHD medication among women of childbearing age. Use of ADHD medication in pregnancy was associated with different indicators of maternal disadvantage and with increased risk of induced abortion and miscarriage.

Haervig and colleagues studied data from the Danish national health registries to identify all recorded pregnancies from 1999 to 2010. From 2003 to the first quarter of 2010, use of ADHD medication during pregnancy increased from 5 to 533 per 100 000 person‐years. Compared with unexposed, women who used ADHD medication during pregnancy were more often younger, single, lower educated, received social security benefits, and used other psychopharmaca. Exposed pregnancies were more likely to result in induced abortions on maternal request, induced abortions on special indication, and miscarriage compared with unexposed pregnancies. (Haervig, Mortensen, Hansen, & Strandberg-Larsen, 2014)

However, ADHD treatment could put both mother and baby at risk. This has to be balanced against the possible risks to the baby of continuing treatment. Although the data remain inadequate, the risk of the latter appears to be quite small overall, at least for methylphenidate, (Besag, 2014) while there is evidence, that the rates of fetal loss both through abortion and through miscarriage are increased with methylphenidate. Discussions about ADHD treatment with women of childbearing age should be balanced, open and honest, acknowledging the lack of information on the possible risks to the offspring of continuing treatment, while also drawing attention to the possible risks to both mother and child of discontinuing treatment. (Besag, 2014)


Medication is an important element of therapeutic strategies for ADHD. While medications for ADHD are generally well‐tolerated, there are common, although less severe, as well as rare but severe adverse events that can occur during treatment with ADHD drugs. Cortese and colleagues reviewed the literature. The review covers monitoring and management strategies of loss of appetite and growth delay, cardiovascular risks, sleep disturbance, tics, substance misuse/abuse, seizures, suicidal thoughts/behaviors and psychotic symptoms. Most AEs during treatment with drugs for ADHD are manageable and most of the times it is not necessary to stop medication, so that patients with ADHD may continue to benefit from the effectiveness of pharmacological treatment. (Cortese et al., 2013)


Monitor the behavioral response to medication, and if behavior worsens adjust medication and review the diagnosis.


Growth should be monitored during treatment with stimulants, and patients who are not growing or gaining height or weight as expected may need to have their treatment interrupted.

Research on the issue of growth suppression is lacking, mostly owing to insufficient follow-up on patients’ final heights. However, it has been argued that the rate of height loss seems relatively small and is likely reversible with withdrawal of treatment. (Goldman, 2010)


Some young adults are misusing prescription stimulants for weight loss. This behavior is associated with other problematic weight loss strategies. Interventions designed to reduce problematic eating behaviors in young adults may wish to assess the misuse of prescription stimulants. (Jeffers, Benotsch, & Koester, 2013) In the study by Jeffers and colleagues, undergraduates who reported using prescription stimulants for weight loss had greater appearance-related motivations for weight loss, greater emotion and stress-related eating, a more compromised appraisal of their ability to cope, lower self-esteem, and were more likely to report engaging in other unhealthy weight loss and eating disordered behaviors.

Weight should be measured at least once at 3 and 6 months after starting treatment in children over 10 years and young people, and at least once every 6 months thereafter. In adults, weight should be measured at least once every 6 months. Monitoring the BMI of adults is in many cases important.

If a child or young person’s height over time is significantly affected by medication (that is, they have not met the height expected for their age), stopping the medication or at least a break in treatment over school holidays to allow ‘catch‑up’ growth may be considered.

Cardiovascular System

Stimulants agents can increase heart rate and blood pressure and cause other cardiovascular symptoms. Since increased BP and HR in general are considered risk factors for cardiovascular morbidity and mortality, heart rate and blood pressure should be monitored closely. Patients who are being considered for treatment with stimulant medications should have a careful history (including assessment for a family history of sudden death or ventricular arrhythmia) and physical exam to assess for the presence of cardiac disease and should receive further cardiac evaluation if findings suggest such disease (e.g., electrocardiogram and echocardiogram).

Statistically significant pre–post increases of SBP, DBP and HR were associated with amphetamine and atomoxetine treatment in children and adolescents with ADHD, while methamphetamine treatment had a statistically significant effect only on SBP in these patients. These increases may be clinically significant for a significant minority of individuals that experience larger increases. (Hennissen et al., 2017)

Among young and middle-aged adults, current or new use of ADHD medications, compared with nonuse or remote use, does not seem associated with an increased risk of serious cardiovascular events. Habel and colleagues examined whether current use of medications prescribed primarily to treat ADHD is associated with increased risk of serious cardiovascular events in young and middle-aged adults. Participants were adults aged 25 through 64 years with dispensed prescriptions for methylphenidate, amphetamine, or atomoxetine at baseline. The sample size was 443 198 users and nonusers. The multivariable-adjusted rate ratio (RR) of serious cardiovascular events for current use vs nonuse of ADHD medications was 0.83. Among new users of ADHD medications, the adjusted RR was 0.77. The adjusted RR for current use vs remote use was 1.03; for new use vs remote use, the adjusted RR was 1.02. (Habel et al., 2011) In the study including data about 1,200,438 children and young adults between the ages of 2 and 24 years and 2,579,104 person-years of follow-up, including 373,667 person-years of current use of ADHD drugs, Habel et al showed no evidence that current use of an ADHD drug was associated with an increased risk of serious cardiovascular events, although the upper limit of the 95% confidence interval indicated that a doubling of the risk could not be ruled out. (Habel et al., 2011)

Children and Adolescents

Sudden death has been reported in association with CNS stimulant treatment at usual doses in children and adolescents with structural cardiac abnormalities or other serious heart problems. Although some serious heart problems alone carry an increased risk of sudden death, stimulant products generally should not be used in children or adolescents with known serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place them at increased vulnerability to the sympathomimetic effects of a stimulant drug.


Sudden death, stroke, and myocardial infarction have been reported in adults taking stimulant drugs at usual doses for ADHD. Although the role of stimulants in these adult cases is also unknown, adults have a greater likelihood than children of having serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, or other serious cardiac problems. Adults with such abnormalities should also generally not be treated with stimulant drugs.


If a person taking stimulants develops tics, one should consider whether the tics are related to the stimulant (tics naturally wax and wane) and the impairment associated with the tics outweighs the benefits of ADHD treatment. If tics are stimulant related, one may need to reduce the dose or switch the medication.

Sexual Dysfunction

Erectile and ejaculatory dysfunction are potential adverse effects of atomoxetine.


If a person with ADHD develops new seizures or a worsening of existing seizures, their ADHD medication needs to be reviewed and any medication that might be contributing to the seizures stopped.

Patients with ADHD seem to be at a higher risk of seizures. However, ADHD medication was associated with lower risk of seizures within individuals while they were dispensed medication, which is not consistent with the hypothesis that ADHD medication increases risk of seizures. Wiggs and colleagues followed a sample of 801,838 patients with ADHD medication. Patients with ADHD were at higher odds for any seizure compared with non-ADHD controls (odds ratio [OR] = 2.33). In adjusted within-individual comparisons, ADHD medication was associated with lower odds of seizures among patients with (OR = 0.71) and without (OR = 0.71) prior seizures. Long-term within-individual comparisons suggested no evidence of an association between medication use and seizures among individuals with (OR = 0.87) and without (OR = 1.01) a seizure history. (Wiggs et al., 2018) Koneski and colleagues evaluated 24 patients ranging from 7 to 16 years of age who took MPH for 6 months. Inclusion criteria were at least two epileptic seizures in the previous 6 months and a diagnosis of ADHD based on DSM-IV criteria. There was an overall improvement in ADHD symptoms in 70.8% of patients, and there was no increase in frequency of epileptic seizures in 22 patients (91.6%). (Koneski, Casella, Agertt, & Ferreira, 2011)


Changes in sleep pattern should always be asked for, the timing and dose of the medication adjusted. Immediate release methamphetamine should usually not be administered after 4pm.


Experiences of adverse effects are a frequent explanation for discontinuation among youth. Despite impaired functioning during adolescence, many discontinue medication treatment. Beliefs and attitudes may differ widely. Some families understand that ADHD is a neurobiological condition and accept that medication is indicated, for others, such treatment is unacceptable. Converging evidence describes negative perceptions of the burden associated with medication use as well as concerns about potential short- and long-term adverse effects. Ways to improve shared decision making among practitioners, parents and youth, and to monitor effectiveness, safety and new onset of concurrent difficulties are likely to optimize outcomes. (Alice Charach & Fernandez, 2013).


Psychotherapy should always be part of a comprehensive treatment plan for ADHD. Communication-Focused Therapy® (CFT) as it was developed by the author focuses on internal and external communication patterns which has shown to be helpful in ADHD. (Haverkampf, 2017b, 2017d, 2017c)

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at or on the websites and


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