ADHD and the shame-rage cycle

Published on 5 February 2023 at 14:26


ADHD is more than just a deficit in the capacity for attention. It involves a general difficulty in the brain’s management of itself, including particularly the regulation of emotion and impulse. These deficits, paradoxically, contain potential advantages in the realms of creativity and innovation. The child with ADHD reacts adversely, often with rage, to being thwarted in the pursuit of a desire or expression of an impulse. He or she will also be disinclined to devote energy to a task that is of no interest. Conversely, an activity that is of interest may evoke an obsessive hyperfocus. These attributes can contribute to success in endeavours requiring a disregard for convention and a curiosity about novel perspectives and unusual cognitive links, but can render the ADHD temperament difficult to live with – both for the person with this condition and those around them.

All children are naturally egocentric and narcissistic, but these qualities gradually give way to an appreciation of the subjectivity of others as well as the self, and an increased tolerance of reality, limits, and boundaries. The original grandiosity is transformed into mature ambitions and early form of idealisation are internalised as lasting ideals. These two developmental pathways of narcissism form crucial building blocks of the self as a structure (see writings by Heinz Kohut). They depend on the availability of empathic caregivers who are able to soothe and moderate the narcissistic insults of life and function as external supports to the ego (which Kohut termed ‘selfobjects’).

There are two related differences in children and adults with ADHD, compared to those who do not have this condition. First the process of accepting the frustrations of reality occurs less easily and more slowly – and, second, such people have a greater need for the continual presence of selfobjects to provide assistance in regulating emotions and in tolerating narcissistic injuries (injuries to self-esteem). For the person with ADHD, emotional wounds can lead to massive destabilisation of the entire ‘narcissistic economy’, with ensuing rage (which Kohut called ‘narcissistic rage), potentially spiralling to a state of psychic catastrophe where all normal rationality and modulation of emotion and impulse are lost. The primitive grandiosity takes on a drive-like quality, pushing for expression, along with the rage. A part of the person may helplessly observe with some horror and shame these eruptions of the unmodified infantile tantrum.

The difficulty in self-regulation gives rise to feelings of shame and humiliation. It is in itself a further narcissistic injury, resulting in more dysregulation and rage – which causes more shame, and so on, in a self-perpetuating spiral.

These ADHD cycles, where the narcissistic economy follows a kind of ‘boom and bust’ pattern, can result in a clinical picture similar to that of bipolar disorder – and indeed it may be that ADHD is a key component of that condition. In a positive mood state, the lack of regulatory functioning may lead to grandiose elation, and a search for stimulants of euphoria, whether these be experiences or drugs. When the dopamine and serotonin levels inevitably collapse, the state of shame-filled depression prevails.

The shame-rage-depression cycle may begin with experiences felt to be intolerable, to do with shame, loneliness, and feelings of rejection, or of feeling ‘different’. A common defensive strategy at this point is to recruit the grandiose self and accompanying state of mind to counter the narcissistic wounds. This structure and state of mind are inherently unstable, inevitably challenged by encounters with reality and the ‘slings and arrows of outrageous fortune’ – at which point the explosive helter-skelter of rage, shame, and depression is triggered.

People suffering from these common ADHD-based disturbances of the narcissistic economy can be helped by a combination of (a) information and assistance in understanding, and (b) the use of energy psychotherapy modalities to soften the pain of narcissistic injuries and increase the brain and mind’s capacity for self-regulation.

Phil Mollon, Psychoanalyst