ADHD: Dopamine Deficiency or a Bodymind Protesting?
Chemical imbalance is a marketing myth, but the suffering is real.
Dopamine is the new serotonin, and people are blaming it for everything. Addicted? It’s the dopamine. Can’t concentrate? Not enough dopamine. No motivation? You need more dopamine! I’ve even seen people say that they can physically feel their lack of dopamine.
What they’re feeling, though, is not their actual neurotransmitter count, because that’s impossible. Researchers don’t have a test that can quantify the neurotransmitters in your brain. There are companies that claim to measure urinary neurotransmitter levels, but they’re sketchy — one was fined $6 million for manipulating results in order to sell supplements.
When someone says they’re feeling a lack of dopamine, they’re talking more about the cultural meaning of the word than the science; because we’ve been told that dopamine modulates pleasure and reward, it’s become a biochemical shorthand used to express certain experiences like disengagement or distraction.
ADHD is not a dopamine deficiency, though it is marketed as such to sell pharmaceuticals. Blaming dopamine for ADHD is just the newest iteration of the chemical imbalance myth that made everyone think depression is caused by low serotonin, despite research dating back to the 70’s demonstrating that it’s not.
Pay close attention to the phrasing that’s used when articles claim this — you’ll see vague verbs that make almost-claims, as in this copy on Adderall’s website that Jonathan Leo and Jeffrey Lacasse analyzed in their Study of Consumer Advertisements:
“Research suggests an imbalance in the levels of dopamine and norepinephrine, two neurotransmitters (substances that may transmit messages in the brain), may account for many of the signs and symptoms of ADHD” [emphasis mine]
The ADHD industry’s premier marketing publication ADDitude Magazine, however, eschews the vague verbs and makes outright claims:
“ADHD was the first disorder found to be the result of a deficiency of a specific neurotransmitter,” reads a March 2021 article that cites exactly zero sources. This is because ADDitude considers itself a source with a “Medical Review Panel” full of doctors who have ties to pharma companies and vested interests in furthering bioessentialist arguments about ADHD.
Why does the medical establishment want to push this story so badly? Because bioessentialism locates the problem inside individual brains, and does not require schools or workplaces to change at all.
It forces humans to standardize themselves into social structures, and completely glosses over the ways those structures cause dysfunction. This benefits the rich and the government alike, because it means they’re not the problem, you are, and all you need to do is take the drugs they’re selling to fix yourself.
Poking Holes in the Dopamine Deficiency Story
There’s nothing wrong with drugs — consenting and fully informed adults should take whatever drugs they want if they’re helpful — but presenting amphetamines as a treatment that fixes a deficiency in the brain is just an outright marketing scam. Short-term studies show good results, sure, but long-term studies? Not so much.
The largest study on the long-term effects of stimulants on children, the Multimodal Treatment of ADHD Study by the National Institute of Mental Health, published good initial results in 1999, but a 3-year follow up of their participants found that:
“…medication use was a significant marker not of beneficial outcome, but of deterioration. That is, participants using medication in the 24-to-26 month period actually showed increased symptomatology during that interval relative to those not taking medication.”
The latest follow-up in 2017 wasn’t any better, showing that “extended use of medication was associated with suppression of adult height but not with reduction of symptom severity.”
Stimulants work great at first, but over time, you have to up the dose more and more to get the same effects. This is well-documented in the literature— the American Academy of Child and Adolescent Psychiatry’s guidelines “state that ‘most’ children will ‘require dose adjustment upward as treatment progresses.’”
Any recreational user of stimulants could tell you this — it’s tolerance. Your body adjusts to the increase of dopamine levels by downregulating dopamine receptors.
This Critical Review of ADHD Neuroimaging Research compiles some supporting data; one study in 2001 found that methylphenidate (Ritalin) downregulated D2 receptors in people diagnosed with ADHD “similar to that observed in healthy adults” and a 2003 study found a downregulation of dopamine receptors and transporters after 3 months of methylphenidate use.
If your body is naturally adjusting to accommodate the influx of dopamine brought on by stimulants, are they really fixing a chemical imbalance in your brain, or are they actually causing a new one?
Long-term use of stimulants can cause a worse baseline of the symptoms they’re intended to treat — this is called “paradoxical decompensation” and this adverse effect has been shown to occur with anti-depressants and depression, and anti-psychotics and psychosis.
Here’s psychiatrist Jason Yanofski’s reasoning on the paradox of prescribing stimulants for dopamine deficiency:
“…the pre- and postsynaptic [dopamine] regulatory mechanisms associated with stimulants lead not only to tolerance of the stimulants, but to the brain’s endogenous [dopamine], as well. Since low dopamine is theorized to be the cause of ADHD, decreasing the brain’s sensitivity to [dopamine] is the opposite of what patients with ADHD need…”
Dopamine deficiency can happen, but truly lacking the dopamine you need would do a lot more to your body than just make you feel unmotivated, because dopamine has a ton of physiological functions far beyond pleasure and reward.
Parkinson’s disease is an example of low dopamine — it affects not just your mood, but your motor functions, too. Antipsychotic drugs that alter the dopaminergic system have been shown to induce parkinsonian symptoms over time, and also (because dopamine regulates milk production) cause people to lactate.
Many doctors recommend “drug holidays” from stimulants because of this well-known tolerance effect, which means taking weekends off or going on periodic breaks when possible. Letting the dopaminergic system reset can make the drugs more effective when you take them again.
Dopamine Deficiency As a Language of Suffering
Saying that your lack of motivation is not caused by a dopamine deficiency is not the same as saying that your lack of motivation isn’t real or disabling. I understand this feeling well because I have struggled with it my entire life (and racked up the psych diagnoses to describe it), but I think it has a lot more to do with the social context than brain chemistry.
Disengagement causes low motivation, distraction, and hyperactivity, too, and the factory-like way our schools and workplaces are structured contribute to widespread disengagement in students and workers. Kids check out in class or act up because they’re bored or distressed in some way, but we are made to believe it’s purely a neurological disorder that has nothing to do with the classroom around them.
Research has shown that boredom is “uniquely associated with feelings of meaninglessness,” according to psychologists James Danckert and John D. Eastwood in their book, Out of My Skull: The Psychology of Boredom. They point to the work of Lars Svenden, who describes boredom as “meaning withdrawal”.
Danckert and Eastwood explain that the endless repetition of our schools and workplaces has physiological effects:
“Monotonous tasks are boring because they demand our attention but at the same time fail to fully occupy our mental resources…As monotony drags on, our energy levels dip — a kind of habituation to the repetitive, unchanging nature of what we’re doing.”
Many people would argue that our modern world is full of stimulation, so still being disengaged and unmotivated despite this must be some kind of biological disorder, but daily information overload can be equally distressing:
“Simply being awake and engaged with the world can feel like drinking from a fire hose. It’s too much — too much mental stimulation, too little meaning, and after the rush of stimulation, ultimately boring.”
Most jobs, especially those done by the working class, are devoid of personal meaning — why would I feel engaged in finishing a spreadsheet or stocking shelves all day? How is that a “dopamine deficiency” and not an entirely reasonable response to a deep, everyday lack of purpose in my life?
Much of the biomedical ADHD discourse insists that we are “wired differently” from all other humans in that we need constant stimulation, a sense of passion in our work, and interest in the work we’re doing, but I think this is a dehumanizing idea.
All humans need a sense of purpose and interest to stay engaged and all humans experience burnout and exhaustion at some point — some of us are just more sensitive and have a lower tolerance for stimulation. The idea that ADHDers are unique in our need for the right level of stimulation and interest positions everyone else as emotionless automatons, happy to do repetitive, meaningless work their whole lives, and that’s just not true of humanity.
“Disengagement is a global phenomenon, with 85 percent of all employees feeling ‘not engaged’ or ‘actively disengaged’ from their work,” writes Susan Rosenthal in her book Rebel Minds. “Disengagement is so distressing that 90 percent of employees would be willing to trade up to 23 percent of their entire future earnings in order to have jobs that are always meaningful.”
There’s a reason “dopamine deficiency” resonates with so many people, and a reason so many people are seeking out ADHD diagnoses for inattention, hyperactivity, and a lack of motivation. We have medicalized this widespread disengagement and the only way we can understand it or see it as valid in our culture is to use diagnostic language.
Psychologist Svend Brinkmann calls this our “language of suffering” — but medical language is not the only way to understand distress, it’s just the only way we see distress as deserving of accommodation and support.
But there’s also existential language, which “sees various human problems as inescapable parts of our existence” and the capacity for despair as “precisely what makes us human” and political language, which deals with social injustice and refers to “the rights and interests of the citizenry as a whole”.
Brinkmann writes:
“In recent years, however, some analysts have argued that political language is gradually being transformed into a diagnostic language. Mary Boyle has argued that this is a process of ‘making the world go away’, which converts ‘distress and problem behaviours to ‘symptoms’ and ‘disorders’.”
I prefer to position my inattention, distraction, and distress within the citizenry as a whole, not to see myself as uniquely “disordered” and set apart from humanity. Even if research can one day quantify my dopamine levels and compare them to everyone else, there would still be the issue of cause-and-effect.
Our brains do not exist separate from the environment, but as part of a dynamic system, an interconnected relationship between our bodies, our health, and what happens to us. There’s no way to prove a “dopamine deficiency” came first, or that it has nothing to do with my social context, because my experiences literally shape my brain and my very sense of self.
It’s wildly inappropriate to treat such widespread distress and disengagement as a purely biological dysfunction to be fixed with pharmaceuticals without ever considering what kind of society is shaping that biology, but it’s not hard to see the political and economic motivations for pushing that narrative.
Rosenthal describes these symptoms of distress as our bodies protesting, but says instead of trying to understand why this protest is happening, “the protest itself is viewed as the problem, and the goal is to stop the protest.”
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