The ADHD Iceberg: 12 Overlooked Symptoms

There is a common misconception that Attention Deficit Hyperactivity Disorder (ADHD) merely means that a person cannot concentrate and is hyperactive.

In reality, ADHD is a complex neurodivergent condition that is characterized by many different symptoms. While the hallmark criteria of hyperactivity, impulsivity, and inattention, are typically observable in individuals with ADHD, these are just the tip of the iceberg. The symptoms that lie beneath the surface tend to be “invisible” and are frequently overlooked, often resulting in misunderstanding, misdiagnosis, and failed treatment for people with ADHD.

There are 3 subtypes of ADHD listed in the DSM-5: predominantly hyperactive/impulsive presentation, predominantly inattentive presentation, and combined presentation (both hyperactive/impulsive and inattentive symptoms are present). ADHD symptoms are experienced with different levels of severity ranging from mild to significant impairment.

In general, some of the most visible external symptoms of ADHD include constant fidgeting, interrupting conversations, blurting things out, excessive talking, losing things, “bouncing off the walls,” not following instructions, always being late, forgetting important appointments, and being disorganized. The visible symptoms and behaviors are barely scratching the surface of what it is like to live with ADHD. There are many unassuming symptoms, and these symptoms are commonly missed or attributed to character flaws, personality defects, bad behavior, or other personal deficits.

It is important to recognize the whole spectrum of ADHD symptoms—both internal and external—to understand an individual’s experience and how ADHD can impact functioning.

Hidden Symptoms

1) Executive Functioning Deficits

Deficits in executive functioning are very common in individuals with ADHD and present many challenges. Executive functioning refers to the cognitive and mental abilities that drive behavior. These functions are responsible for processes like planning, organizing, problem-solving, decision-making, impulse control, task initiation, and emotion regulation. Low levels of dopamine (the neurotransmitter responsible for feelings of pleasure and reward) are thought to play a key role in executive functioning deficits among those with ADHD compared to those with neurotypical brains.

2) Emotional Dysregulation

Emotional dysregulation suggests an impaired ability to control emotional responses, which can lead to extreme “all or nothing” reactions, as well as reactions that are disproportionate to the situation. Some of the signs of emotional dysregulation include emotional flooding, intense or overwhelming emotions, sudden mood swings, difficulty managing anger, low frustration tolerance, difficulty calming down or self-regulation, and difficulty recovering from negative emotions.

3) Rejection Sensitive Dysphoria:

Rejection Sensitive Dysphoria (RSD) has been used to describe a tendency to experience strong emotional responses to perceived or actual rejection (or criticism) from others and is commonly associated with ADHD brains. RSD is triggered by the perception that a person has been rejected/criticized by important others. It may also be triggered by a sense of failure or disappointment when unable to meet their own high standards or others’ expectations, which is often internalized as the loss of approval, love, and/or respect. Individuals with rejection sensitivity may experience intense emotional reactions or anxiety in response to rejection (perceived or actual), even if the rejection/criticism is relatively minor or unintentional. For people with RSD, this can feel unbearable, restricting, and highly impairing. Attempts to cope with the emotional impacts of RSD can have significant negative consequences including people-pleasing, the anticipation of rejection, social withdrawal, task avoidance, and emotional shutdown.

4) Hyperfocus

Hyperfocus is an intense fixation on something interesting for an extended period. Hyperfocus is the opposite of distractibility and is very common among both adults and children with ADHD. People with ADHD often exhibit hyperfocus when working on things that interest them, becoming so absorbed into an activity or task that they tune out everything around them. Similar to distractibility, hyperfocus is thought to result from abnormally low levels of dopamine, which is particularly active in the brain’s frontal lobes. This dopamine deficiency makes it hard to transition from interesting tasks or activities to boring-but-necessary tasks.

Hyperfocus can be an asset and at times, harmful. Some individuals can harness their hyperfocus as a powerful tool for staying engaged and motivated, thus accomplishing tasks and achieving goals; they can channel their focus on something productive like academic or work-related activities. However, unrestrained hyperfocus can become problematic; left unchecked, it can lead to academic failure, lost productivity, and strained relationships.'

5) Sleep Disturbance

Sleep disturbance is a common concern among individuals with ADHD. About 80% of ADHD adults report some form of sleep disturbance including difficulty falling asleep, frequent awakenings, restless sleep, waking up too early, or difficulty waking up. Sleep problems in ADHD seem to differ depending on the subtype. Individuals with predominantly inattentive symptoms are more likely to have a later bedtime, while those with predominantly hyperactive-impulsive symptoms are more likely to struggle with insomnia. Researchers have suggested sleep problems in ADHD may be an effect of impaired arousal, alertness, and regulation circuits in the brain.

6) Time Blindness

Time blindness is a frequently shared experience of ADHDers and suggests difficulty in accurately perceiving and managing time. People with time blindness have difficulty estimating how much time has passed, struggle to adhere to schedules or deadlines, and may be challenged in planning and prioritizing tasks based on time requirements. Time blindness is related to executive functioning deficits, particularly deficits in working memory, attention, and impulse control. The ability to accurately perceive time and plan accordingly relies heavily on these executive functions, which can be disrupted in individuals with ADHD. Individuals with time blindness may struggle to meet deadlines or complete tasks on time, which can cause stress, frustration, and consequences including missed opportunities or reduced productivity.

7) Anxiety

Although anxiety is not included in the DSM-5 as a diagnostic marker for ADHD, the link between the two conditions is strong. Individuals with ADHD are around 50% more likely to have a co-morbid anxiety disorder than individuals without ADHD. Anxiety can develop as a response to ADHD; individuals become so overwhelmed by masking and attempting to manage symptoms that they are on edge, fearful, restless, and irritable. Anxiety can exacerbate ADHD symptoms, potentially creating more challenges with symptoms such as focus, task completion, time management, inflexibility, and oppositional emotional outbursts. ADHD symptoms that coexist with an anxiety disorder often significantly impair functioning.

8) Sensory Processing Issues

Sensory processing refers to the brain’s ability to receive, interpret, and respond appropriately to sensory information from the environment. Sensory processing issues can include hypersensitivity to stimuli such as loud noises, bright lights, or certain textures; hyposensitivity, frequently leading people to seek out intense sensory experiences; difficulty filtering sensory information; overstimulation when exposed to too much sensory input; and motor coordination difficulties. Issues with sensory processing can contribute to distractibility, irritability, and difficulty with emotion regulation.

9) ADHD Paralysis:

ADHD paralysis or choice paralysis is used to describe the common experience of individuals with ADHD feeling overwhelmed and unable to start or complete tasks, despite a strong desire or intention to do so. This leads to a sense of “paralysis” or “feeling stuck,” which can have significant negative impacts on functioning. Mental paralysis occurs when a person becomes overwhelmed with thoughts, emotions, and information, or experiences sensory overload, which causes a lack of clarity. Choice paralysis (analysis paralysis) occurs when someone is faced with too many choices; overthinking or overanalyzing can lead to emotional overwhelm and indecision. Task paralysis is represented by task avoidance, difficulty initiating tasks, and struggles with prioritization, regularly bringing up feelings of frustration, anxiety, and shame.

10) Procrastination

The tendency to delay or put off tasks, even when important or necessary, is very characteristic of ADHD brains. Like time blindness, procrastination in ADHD is also linked to difficulties with executive functioning, including working memory, organization, and time management. Initiating tasks, distractibility, poor time management skills, and a tendency to prioritize short-term rewards over long-term goals can all contribute to procrastination in individuals with ADHD.

11) Masking

ADHD masking is a way of hiding symptoms through learned behaviors that can be healthy or unhealthy. ADHD masking is conforming to neurotypical standards to avoid the shame and stigma that often surrounds an ADHD diagnosis. Masking develops as a coping strategy to relieve uncomfortable feelings and is deeply embedded into how ADHD people function in their daily lives. Depression and anxiety can be unfortunate consequences of ADHD masking, developing because of often lifelong feelings of inadequacy and low self-esteem.

12) Perfectionism

A form of masking, perfectionism is strongly associated with ADHD. Perfectionism causes individuals to place an extremely high standard on their own performance and in turn may be overly critical of themselves when standards go unmet. Used as an attempt to override executive dysfunction, perfectionism can ultimately result in an unhealthy overcompensation for perceived or actual deficits that accompany other ADHD symptoms. Increased anxiety, rejection sensitivity, all-or-nothing thinking, hyperfocus, and fear of failure, all features of ADHD, can contribute to and exacerbate perfectionism.

The Takeaway

The ADHD Iceberg analogy provides a glimpse into the complexities of living with ADHD and how misunderstood people with ADHD often feel. Untreated ADHD can be extremely disruptive, having a significant impact on an individual’s quality of life, as well as relationships, academic success, work performance, and other important areas of functioning. Understanding both the observable symptoms and the hidden symptoms of ADHD is critical in finding the most effective treatments to manage symptoms. When we understand what lies beneath, we can develop and implement strategies to overcome those difficulties, ultimately helping people become more confident and self-aware while living with ADHD.

Begin Bozeman Counseling Services

Recognizing and managing ADHD symptoms can be challenging; seeking appropriate support and understanding from experienced and ADHD-affirming mental health professionals can help you improve your well-being and quality of life. Our team of caring therapists would be honored to offer our support. To get started with Bridger Peaks Counseling, follow these simple steps:

1. Contact us to speak with a staff member

2. Meet with a caring therapist.

3. Start becoming the best version of yourself!

Other Services Offered in Bozeman, MT

Our team of caring counselors at Bridger Peaks Counseling is happy to provide a variety of mental health services. Our team is happy to offer services including adult counseling, teen counseling, group therapy, rising strong workshops, and marriage counseling. Furthermore, we provide anxiety therapy, depression treatment, substance use counseling, and online grief counseling. Along with EMDR, postpartum depression support, body image therapy, and psychiatric care

5 Tips for Navigating Life’s Transitions

Spring brings change and with it, many are experiencing life transitions.

A life transition is anything that alters your life  - whether that is graduating, moving, beginning a new job, getting married, or ending a relationship - life’s changes bring about new emotions that impact the way we navigate these events. As changes can come in so many different forms, they can elicit different and, at times, unexpected responses and reactions. Checking in with yourself during times of transition can be a powerful tool in understanding how you to best navigate change and bringing awareness to what you might be needing.

Sometimes life’s transitions can be exciting and motivating and other times they can be tough and painful, leading to feelings of fear, anxiety, depression, or overwhelm. Change tends to amplify the unfamiliar and unfamiliarity can illicit discomfort for many. Some discomfort during life transitions is expected - most of us don’t particularly like change. But, when these negative emotions begin to interfere with your life, it’s a good sign it’s time to take action.

Working intentionally to incorporate healthy coping skills and mindfulness tools into your life can empower you to manage future change and transitions (good or bad) more effectively.

Consider these 5 steps when facing significant changes in your life:

1. PRACTICE ACCEPTANCE

Whether you are navigating a big life transition or a small event, the first step in beginning to effectively navigate change is to embrace change as a part of being human - as the saying goes, “the only constant in life is change.” When we resist and avoid change, we are often left feeling stuck, which can leave room for difficult emotions such as anxiety and depression to persist. When we embrace change rather than avoiding it, we begin to leave room for growth.

2. BRING AWARENESS TO YOUR EMOTIONS

Ask yourself, “What am I feeling in this moment” when you begin to feel uncomfortable or ill at ease. Some emotions are easy to misinterpret - have you ever noticed how similar anxiousness and excitement can feel? Both can bring the experience of butterflies in your stomach, a racing heart, and difficulty sitting still.

Being able to accurately name your emotions during a life transition can significantly impact the way in which we experience the process of change. Sometimes, when emotions feel so overwhelming they feel difficult to face, naming the emotion can allow them to feel less powerful and can provide insight into what we might be needing. Emotions are data points that can give provide valuable information when accurately attended to. Practice being an active observer of your emotions so that you can effectively understand what they are signaling is needed.

3. CONNECT WITH YOUR VALUES

During life changes and transitions, we can often feel overwhelmed by the number of decisions we need to make. Connecting with your values - asking yourself “What is most important to me and the life I am building,” and reflecting on if your choices are connecting you with these values or moving you away from what you value most. Feeling out of alignment with our values can create a sense of incongruence and increase feelings of discomfort and anxiety. As a result, it is important to connect intentionally with your values, especially as things around you are changing.

4. DEVELOP AND STICK WITH A ROUTINE

A good way to connect with things you value and engage in meaningful behaviors is to work toward building and/or maintaining consistency with a routine even when life transitions may be breeding chaos in your day-to-day. Falling out of doing the things that bring us joy and help regulate our emotions can make managing change and difficult emotions even more challenging.

Engaging with a consistent routine can activate the reward centers of our brains and lead to feelings of accomplishment that often breed motivation and improves our moods, overall. Routines and daily habits allow us to engage in values-centered activities and provide a sense of familiarity and predictability during transitions.

5. DECIDE WHAT YOU WANT YOUR STORY TO BE

Consider how you want to look back on this time in your life. We often internally narrate, as well as tell the stories of our lives to those who support us. How we tell these stories is integral to how we experience, reflect on, and remember significant events in our lives. Take time to thoughtfully consider the way in which you frame these stories.

You can, at times, even intentionally begin to create the narrative you desire and then take action to live in congruence with the vision you have created. This takes reflection and integration of the previous steps - being accepting of the change that is occurring, being aware of your emotions, connecting to what you value, and being consistent in the habit of framing your experience in a way that supports your overall well-being.

Interested in Beginning Bozeman Counseling Services?

Life’s changes, while often challenging, can be an opportunity for self-exploration, self-reflection, and growth. Engaging with these tips, as well as reaching out for support, can help make life’s transitions more manageable. If you are needing support as you navigate change, our team of caring therapists would be honored to help you in your journey. To start therapy with Bridger Peaks Counseling, please follow these simple steps:

1. Make an appointment online

2. Meet with one of our professional Bozeman mental health therapists

3. Begin to embrace change!

Other Therapy Services We Offer in Bozeman, MT

Our team of caring counselors at Bridger Peaks Counseling is happy to provide a variety of mental health services. Our team is happy to offer services including adult counseling, teen counseling, group therapy, rising strong workshops, and marriage counseling. Furthermore, we provide anxiety therapy, depression treatment, substance use counseling, and online grief counseling. Along with EMDR, postpartum depression support, body image therapy, and psychiatric care. Visit our blog or FAQ to learn more today!