Do You Have Trauma or ADD? Understanding Trauma-Based Dissociation and ADD/ADHD: How Are They Different?

By Robert Espiau

Understanding the differences between dissociation due to trauma, Post-Traumatic Stress Disorder (PTSD), and Attention Deficit Disorders (ADD/ADHD) is crucial for accurate diagnosis and treatment. While these conditions may share overlapping symptoms, such as inattentiveness or emotional dysregulation, they stem from different causes and require distinct therapeutic approaches. I compiled this research to present at a university class where I was invited to speak. My goal was to elucidate the differences between these conditions, based on available research, and address common misconceptions.

The Misdiagnosis Dilemma

I have grown increasingly frustrated with American colleagues misdiagnosing people with Post-Traumatic Stress Disorder as having ADD or ADHD. Having predominantly worked with trauma for the last 20 years of my 35-year career in mental health, I feel that I can speak about this with some understanding. I want to begin by also stating that I have been teaching classical forms of meditation, such as Shamata and Vipassana, for over 35 years and am a former Buddhist monastic. In classical meditation training received in a monastery, you sit and meditate for 6 to 8 hours a day, literally studying dissociation in yourself through working to make the mind still and silent. This is a huge difference between the paradigms of eastern psychological training and western psychological training; as in eastern psychological training you sit and watch the subconscious mind for 6-8 hours a day studying how it functions by creating an inner separation between thoughts, emotions and the consciousness. In western university systems there is no direct training on how to see and recognize what the subconscious is and how it influences the way we pay attention.

Is ADD a culture bound diagnosis?

In the early 90s, when Attention Deficit Disorder was first announced by the medical community as a diagnosis to be included in the upcoming revised version of the DSM, our Zen master brought this to our attention in a Dharma talk. We were literally falling on the floor laughing when we heard about this diagnosis. It was so crystal clear to every monk in the room that this was a diagnosis invented by pharmaceutical companies to make money. One of the monks in the room said, “Doesn’t everybody have ADHD? Isn’t that the reason Buddhist monasteries have existed for the last 2,500 years?”

Historical Perspectives from Buddhist Teachings

If you read the first few chapters of a Buddhist sutra called the Dhammapada, you will see immediately that 2,500 years ago, Shakyamuni Buddha was speaking about a method to cure the suffering of all human beings. What he claims is the root of all suffering is based on the way we pay attention to life moment by moment. According to Gotama, we all share some level of attention deficit and suffer because of it. He speaks extensively on this in his own way in the Dhammapada. In it, he says: “The mind is frivolous and difficult to control, alighting on whatever it pleases. It is good to tame the mind. A tamed mind brings happiness. The mind is extremely subtle and difficult to grasp, alighting on whatever it pleases. Let the man of understanding keep watch over the mind. A guarded mind brings happiness.”

Cultural Differences in Understanding Attention

I have become increasingly concerned about this subject because therapists are not trained to understand the relationship between concentration and attention in any university. It is very hard for Western therapists to understand that there is a significant difference in how Euro-Americans view concentration and attention compared to Asians. It is important to emphasize that ADD, ADHD, and dissociation all stem from the way we pay attention. These are all issues of attention, so it is difficult to see the differences except when we examine the brain, the body, and the behavior of the person. It is also crucial to understand the background of the person and the symptoms they are experiencing.

The Importance of Differentiation; Defining Symptomatology

I want to reiterate this important point: dissociation and attention deficit disorder may look the same, but they have different origins and actually function differently. Let’s examine this more closely and hopefully both clinicians and anyone struggling with trauma or attention can benefit. Dissociation is a psychological defense mechanism triggered by overwhelming stress or trauma. It involves a disconnection between thoughts, identity, emotions, and memory. Individuals with dissociation often experience:

• Feeling detached from reality or oneself.
• Loss of memory or gaps in awareness of recent events.
• A sense of being disconnected from one’s body or surroundings (depersonalization or derealization).
• Difficulty being with emotions that are present. In fact, dissociation is a defense to help one move away from the experience of their emotional states.

When therapists think of dissociation, they would say that it often occurs in the context of traumatic experiences, including childhood abuse, sexual assault, or significant emotional neglect. In cases of trauma, dissociation serves as a protective mechanism, allowing individuals to escape the emotional and psychological pain of the event.

Dissociation Spectrum

In normal life, we call it spacing out. We all dissociate yet it has degrees. Dissociation exists on a spectrum, ranging from mild, everyday experiences to severe and chronic conditions. In its mildest form, dissociation can occur as a common coping mechanism, where an individual temporarily disconnects from reality to escape stress or discomfort. For instance, binge-watching a Netflix series or drinking a beer can serve as a form of mild dissociation, allowing a person to momentarily disengage from the demands of everyday life. These activities provide a temporary reprieve and are often considered normal behaviors. Again, dissociation refers to moving away unconsciously from emotional states. We smoke weed, for example, to “relax” or get away from the internal stress of unresolved emotional states.

As dissociation intensifies, it can manifest in more problematic ways, such as through addiction. Substance abuse or compulsive behaviors often represent an attempt to escape from emotional pain or trauma, leading to a deeper level of disconnection from one’s thoughts, feelings, and surroundings. At the most extreme end of the spectrum are dissociative disorders, such as Dissociative Identity Disorder (DID) or Dissociative Amnesia, where individuals experience significant disruptions in their sense of self and reality. In these cases, dissociation becomes a pervasive and chronic condition, severely impacting a person’s ability to function in daily life. The spectrum of dissociation underscores how a common psychological defense mechanism can range from harmless to profoundly disabling, depending on its intensity and persistence.

Post-Traumatic Stress Disorder (PTSD)

PTSD arises in response to traumatic events and is marked by recurring, intrusive thoughts of the trauma. It includes emotional numbing, hypervigilance, and flashbacks. The symptomatology of PTSD includes:

• Re-experiencing traumatic events through flashbacks or nightmares.
• Emotional distress when reminded of the trauma.
• Hypervigilance and exaggerated startle response.
• Avoidance of reminders of the trauma.

Dissociation can also occur in PTSD as a coping mechanism for individuals who are overwhelmed by the emotions tied to their trauma.

Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD)

ADD and ADHD are neurodevelopmental disorders primarily characterized by difficulties in attention, impulse control, and hyperactivity. These disorders are not trauma-related but stem from biological and genetic factors. The key symptoms include:

• Inattention: Difficulty focusing, forgetfulness, and frequent distractions.
• Impulsivity: Acting without thinking, interrupting others, and difficulty waiting for one’s turn.
• Hyperactivity (in ADHD): Excessive fidgeting, talking, or restlessness.

Individuals with ADD/ADHD often struggle with executive function, planning, and time management. Unlike dissociation, which is a response to trauma, ADD/ADHD originates from brain function differences, particularly in areas that regulate attention and impulse control.

Distinctions in Origins

• Dissociation due to trauma and PTSD are both linked to overwhelming psychological stress, often from external traumatic events such as abuse, violence, or major accidents. In these cases, dissociation and PTSD serve as coping mechanisms that allow individuals to process or shield themselves from the impact of trauma.
• ADD and ADHD, on the other hand, are thought to arise from neurobiological factors, including genetics and differences in brain structure and activity, particularly in the prefrontal cortex. They are not considered trauma-based conditions, although some studies suggest that trauma can exacerbate symptoms in individuals with ADD/ADHD.

Symptom Overlap and Misdiagnosis

While dissociation due to trauma, PTSD, and ADD/ADHD are fundamentally different in origin, they can appear similar in presentation, leading to misdiagnosis. For example:

• Individuals with PTSD may experience distractibility and difficulty concentrating, which can mimic symptoms of ADD/ADHD.
• Dissociative symptoms, like feeling detached or “zoning out,” may be confused with the inattentiveness commonly seen in ADD/ADHD.
• Hyperarousal in PTSD can be mistaken for hyperactivity in ADHD, especially in children who struggle to regulate their emotions.

However, the key distinction lies in the origin of the symptoms. Dissociation and PTSD are primarily responses to trauma, whereas ADD/ADHD are neurodevelopmental conditions with a genetic or biological basis.

Research Supporting Distinctions

Several studies underscore the differences between these conditions:

1. Trauma and Dissociation: Research by van der Hart et al. (2006) shows that dissociation arises as a coping mechanism in response to trauma, protecting the individual from overwhelming emotional pain. Dissociative symptoms are prevalent in individuals with a history of trauma and are often linked to more severe PTSD.
2. PTSD vs. ADD/ADHD: Studies such as those by Ford et al. (2013) demonstrate that while PTSD and ADD/ADHD may share certain outward behaviors, such as difficulty concentrating or hypervigilance, they are neurologically distinct. Functional MRI studies reveal that PTSD is associated with hyperactivation of the amygdala (responsible for emotional responses) and a hypoactive prefrontal cortex (involved in executive function), while ADHD is marked by reduced activity in the prefrontal cortex but does not show the same heightened emotional reactivity.
3. Mindfulness and Symptom Management: Mindfulness practices have been shown to improve outcomes for both trauma survivors and individuals with ADD/ADHD, but the mechanisms differ. For trauma survivors, mindfulness helps in grounding and reducing dissociative episodes by enhancing present-moment awareness and reducing the need to dissociate from overwhelming emotions (Bremner et al., 2017). For individuals with ADD/ADHD, mindfulness helps in improving attention and executive function by training the brain to focus and manage distractions more effectively (Zylowska et al., 2008).

Expanding on the Research of Dr. Bessel van der Kolk and Dr. Gabor Maté

Understanding trauma, dissociation, and how these conditions differ from neurodevelopmental disorders like ADHD is further reinforced through the extensive research of Dr. Bessel van der Kolk and Dr. Gabor Maté. Both of these leading experts have contributed substantial insights into how trauma alters brain function and behavior. It seems obvious when we consider their research.

The Work of Dr. Bessel van der Kolk

Dr. Bessel van der Kolk, a leading authority on trauma, has extensively studied how traumatic experiences affect the brain and body, particularly in his seminal work, The Body Keeps the Score. Van der Kolk emphasizes that trauma fundamentally alters the brain’s structure, especially regions like the amygdala, hippocampus, and prefrontal cortex, which are involved in emotional regulation, memory, and decision-making.

• Trauma-Induced Dissociation: In trauma survivors, van der Kolk has observed that dissociation can be a pervasive symptom, where individuals disconnect from their thoughts, feelings, and bodily sensations to cope with overwhelming emotions. This mechanism differs from the inattentiveness seen in ADD/ADHD, which is not caused by trauma but by neurodevelopmental irregularities.
• Brain Activation: Van der Kolk’s research using neuroimaging shows that during flashbacks or trauma reminders, the emotional brain (the limbic system) becomes hyperactive, while areas responsible for executive functioning and verbal reasoning become underactive. This is not seen in ADD/ADHD, where there are deficits in executive function but no specific trauma triggers.

Supporting Studies

1. van der Kolk et al. (1996) – “Trauma and the Development of PTSD and Dissociative Symptoms”: This study connects childhood trauma with the later development of dissociative symptoms and PTSD, showing a clear correlation between trauma and altered brain functioning.
2. Lanius et al. (2005) – “Trauma-Related Dissociation and Altered Brain Activity”: This study used neuroimaging to demonstrate how trauma survivors display different brain patterns compared to individuals with ADD/ADHD, solidifying the case for trauma-induced dissociation as distinct from attention disorders.

The Work of Dr. Daniel Amen

Dr. Daniel Amen, a well-known psychiatrist and brain health expert, has conducted extensive brain imaging studies using Single Photon Emission Computed Tomography (SPECT) to investigate various mental health conditions, including ADHD. He is famous for using SPECT to identify brain patterns associated with attention deficit disorders, depression, anxiety, trauma, and other mental health conditions.

Dr. Amen’s studies on ADHD using SPECT imaging reveal that individuals with ADHD often have decreased activity in the prefrontal cortex, particularly when they are asked to focus or complete tasks that require sustained attention. The prefrontal cortex is responsible for executive functions such as decision-making, impulse control, and attention regulation. His research has shown distinct brain patterns for different subtypes of ADHD (e.g., inattentive type, hyperactive type).

While Dr. Amen’s research emphasizes the biological differences between ADHD and trauma-related conditions, he has categorized various brain patterns associated with trauma, PTSD, and ADHD separately. Based on his findings, trauma often leads to brain patterns associated with overactivity in certain areas (e.g., amygdala) that contribute to emotional dysregulation, while ADHD is characterized by underactivity in regions responsible for focus and impulse control.

Dr. Gabor Maté’s Contributions

Dr. Gabor Maté has focused much of his work on the impact of early childhood experiences, particularly stress and trauma, on the development of addiction and mental health disorders. Dr. Maté argues that many of the symptoms of ADHD may stem from early relational trauma or attachment disruptions, though the disorder itself may be neurobiological.

• Trauma and ADHD: In his book, Scattered Minds, Dr. Maté suggests that early trauma or stress can exacerbate the symptoms of ADHD, particularly emotional dysregulation. However, he agrees that ADHD is a neurological condition that exists independently of trauma in many cases.
• Trauma Responses: Dr. Maté’s work emphasizes that trauma often leads to a hyperaroused nervous system, leading to emotional volatility and disconnection from the present moment, which can sometimes mimic inattentiveness or hyperactivity but is qualitatively different from ADD/ADHD.

Supporting Studies

3. Perry et al. (1995) – “Neurobiological Adaptations to Trauma”: This study supports Dr. Maté’s claims by showing how early trauma can disrupt normal brain development, particularly in the areas of the brain responsible for self-regulation, mimicking some symptoms of ADHD.
4. Teicher et al. (2002) – “The Neurobiological Effects of Childhood Maltreatment”: This study provides additional evidence of how trauma impacts brain regions similarly affected in ADHD but emphasizes that the origins are trauma-specific.

Further Studies Supporting the Distinction

5. Ford et al. (2013) – “Neurobiological Differences in PTSD vs. ADHD”: This research highlights the distinct brain patterns seen in individuals with PTSD versus those with ADHD, focusing on the role of the amygdala in emotional reactivity (common in PTSD) and the prefrontal cortex in attention regulation (common in ADHD).
6. Bremner et al. (2017) – “Mindfulness in Trauma Therapy“: This study shows the effectiveness of mindfulness in reducing dissociative symptoms in trauma survivors, reinforcing that trauma-based dissociation is different from the attentional issues seen in ADHD.

Mindfulness and Its Role in effecting Trauma and ADHD

Mindfulness techniques have been shown to help individuals with both trauma-related dissociation and ADHD, but the mechanisms by which they operate are very different:

• Trauma Survivors: For trauma survivors, mindfulness helps by fostering present-moment awareness, which can mitigate dissociative symptoms and reduce flashbacks or emotional numbing (Bremner, 2017). This aligns with van der Kolk’s recommendation of body-based therapies, which aim to reconnect trauma survivors with their bodily sensations.
• ADHD: In individuals with ADHD, mindfulness aids in improving attention and impulse control by training the brain to focus on the present and reduce distractions. Zylowska et al. (2008) conducted a pioneering study demonstrating that mindfulness practices significantly improved attention regulation in individuals with ADHD.

Supporting Studies

7. Zylowska et al. (2008) – “Mindfulness Meditation for ADHD”: This study found that mindfulness meditation improved attention, working memory, and impulse control in adults and adolescents with ADHD.
8. Bremner et al. (2017) – “Mindfulness for Trauma Survivors”: This study reinforces the importance of mindfulness for individuals experiencing dissociation due to trauma, showing reduced symptoms of emotional numbing and flashbacks.

What Should We Do?

The distinction between dissociation due to trauma, PTSD, and ADD/ADHD lies primarily in their origins: trauma-based dissociation and PTSD are responses to overwhelming stress and emotional pain, while ADD/ADHD are neurodevelopmental conditions with biological underpinnings. Despite overlapping symptoms, such as difficulty focusing and hyperarousal, the underlying mechanisms are distinct, and treatment approaches must be tailored accordingly. Mindfulness and meditation research further validate these differences by showing how these techniques address each condition’s unique challenges.

Considerations for Clinicians and those who feel afflicted by these conditions

In our opinion based upon 35 years of working in mental health as a therapist and psych nurse, western clinicians do not understand the differences between these 2 because they are both issues involving attention. Both involving how the action of consciousness, “our attention” is functioning. This is why they both look alike, however the etiology is totally different. Something clinicians might want to consider in the future is not being too quick to diagnose someone with attention deficit disorder without first doing an assessment for post-traumatic stress disorder. Just in the same way as we should differentiate between schizophrenia and someone who’s been using methamphetamine and has not slept for over 72 hours. With everyone using the word trauma these days to describe any kind of difficulty this makes the issue more confusing. While the need for differential diagnosis is clearly stated in the DSM regarding schizophrenia and addiction, it is not for post-traumatic stress disorder and attention disorders. For me, the issue here becomes should these things be treated differently?

In my experience, not treating the dissociative symptoms in somebody with depersonalization as a result of religious trauma because they’ve been given medication for ADD makes things very complicated and much more difficult to help them resolve what’s happening. Many of the clients who come to see us at Seattle Trauma Counseling for religious trauma specifically have reported feeling misunderstood by other therapists because of the way they pay attention. Perhaps there is something wrong with the way that we are paying attention to our clients and ourselves if we are not paying attention to the way we pay attention. Understanding attention and how attention functions is not a strong point historically in Western psychology, and we really don’t like to admit this. It is, in fact, one of the biggest differences between Eastern and Western psychology.

“For him who has conquered the mind, the mind is the best of friends; but for one who has failed to do so, his mind will remain the greatest enemy.”
— Bhagavad Gita 6.6

“The scientific literature is clear that although genetics and biology are involved in ADD, the disorder is not purely biological or inherited. It is, in fact, a neurological response to early stress that becomes ingrained in a child’s developing brain through environmental factors. We are, in essence, training ADD into our children by the way we raise them and the conditions we expose them to.”
– Gabor Maté, Scattered Minds (1999).

You can read more in-depth about the origins of psychology originating in Asia in my book online, entitled: The True Origins of Psychology and the Influence of Euro-American Ethnocentrism Upon It.

References

1. van der Kolk, B. A., McFarlane, A. C., & Weisaeth, L. (1996). Traumatic stress: The effects of overwhelming experience on mind, body, and society. Guilford Press.
2. Lanius, R. A., Williamson, P. C., Hopper, J., Densmore, M., Boksman, K., Gupta, M. A., … & Neufeld, R. W. (2005). Functional connectivity of dissociative responses in posttraumatic stress disorder: a functional magnetic resonance imaging investigation. Biological psychiatry, 57(8), 873-884.
3. Ford, J. D., Grasso, D. J., Elhai, J. D., & Courtois, C. A. (2013). Complex PTSD: Research directions for nosology/assessment, treatment, and public health. European journal of psychotraumatology, 4(1), 20706.
4. Perry, B. D., Pollard, R. A., Blakley, T. L., Baker, W. L., & Vigilante, D. (1995). Childhood trauma, the neurobiology of adaptation, and “use-dependent” development of the brain: How “states” become “traits”. Infant mental health journal, 16(4), 271-291.
5. Teicher, M. H., Anderson, C. M., & Polcari, A. (2002). Developmental neurobiology of childhood stress and trauma. Psychiatric Clinics, 25(2), 397-426.
6. Maté, G. (1999). Scattered Minds: A New Look at the Origins and Healing of Attention Deficit Disorder. Penguin Random House.
7. Bremner, J. D., Lake, N., & Vermetten, E. (2017). Mindfulness-based interventions in PTSD: Neuroscientific perspectives. In E. Vermetten et al. (Eds.), Trauma, mindfulness, and resilience. Springer.
8. Zylowska, L., Ackerman, D. L., Yang, M. H., Futrell, J. L., Horton, N. L., Hale, T. S., … & Smalley, S. L. (2008). Mindfulness meditation training in adults and adolescents with ADHD: A feasibility study. Journal of Attention Disorders, 11(6), 737-746.
9. Amen, D. G. (2013). Healing ADD: The breakthrough program that allows you to see and heal the 7 types of ADD. Berkley Books.
10. Amen, D. G. (1998). Change Your Brain, Change Your Life. Three Rivers Press.