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What's the difference between perseveration and hyperfocus?

What's the difference between perseveration and hyperfocus?


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Dr. Russell Barkley says hyperfocus goes with autism while perseveration goes with ADHD.

I read that perseveration is the same as hyperfocus or that hyperfocus goes with ADHD.

So what's the difference? Is Dr. Russell Barkley right?


I myself have never found evidence to suggest a difference between perseveration and hyperfocus when referring to ADHD. However, while 'hyperfocus' can be a psychiatric or non-psychiatric condition, perseveration is typically considered a psychiatric condition in all instances.

The wikipedia page for hyperfocus has an entire section dedicated to the confusion between hyperfocus and perseveration, particularly as it pertains to ADHD.

Hyperfocus may in some cases also be symptomatic of a psychiatric condition. In these cases it is more commonly and accurately referred to as perseveration (or perseverance) - the inability to, or impairment in, switching tasks or activities ("set shifting"), or desisting from mental or physical response repetition (gestures, words, thoughts) despite absence or cessation of a stimulus, and which is not excessive in terms of quantity but are apparently both functionless and involve a narrow range of behaviours, and are not better described as stereotypy (a highly repetitive idiosyncratic behaviour).

It is typical for individuals with ADHD to say they 1), can not focus on boring things and 2), can only focus on stimulating things, and that focus is often extreme. Thus it is both a concentration deficit and over-concentration, or generically: "hyperfocus.


Actually,if you saw a few of Dr. Barkley's presentations. He referred to people with autism spectrum disorder as hyperfocus because they focused immensely on fine details of their sensations and their environments. While this hyperfocus, lacks the big picture perception. For instance, the child with autism might focus on the car wheel, while not attending to the car itself.

While perseveration was well defined by the "upstairs" author.

EDIT: Scientists would agree that they have what the ADHD community defines hyperfocus, but some (not all) psychologist/psychiatrist would not appreciate the use of this term based on the definition alone. They would disagree on the word used to define it. They would agree that people with ADHD have perseveration, but not hyperfocus (based on the definition alone). There is science to backup issues related to perseveration. While positive aspects of perseveration is probably lacking in the literature (since that's harder to look for). Hyperfocus would be kept for the autistic symptoms of focusing far too much on one element or detail and not perceiving the remaining of the item for instance.

To make things more complicated, I know there is one psychiatrist who uses the term hyperfocus (although probably not in thescientific literature). His name is Edward Hallowell. He's more of a clinicians and a book writer than a scientist from what I remember.


Hungarian psychologist Mihaly Csikszentmihalyi first coined the term “flow state” in 1975. Of course, the concept has been around much longer than that. However, this was the first time a modern researcher put a specific name to it.

The concept of flow has grown even more popular in recent years. Modern society places a heavy emphasis on creativity and productivity. We highly value entrepreneurs, developers, and creatives. Many jobs now require more innovation and self-starting than ever before. As machines replace manual jobs, people are more valued for their brain power than anything else.

These changes have made the flow state more desirable. And for a long time, it was thought that the hyperfocus was benign. Often experienced by people with ADHD, many believed hyperfocus was basically the same as flow. Maybe even better. However, we now know there are some important differences in hyperfocus vs flow.


The “Whys" of Perseveration

Why do some children with autism perseverate? There are two main possibilities. One is that they use perseverations to control what seems to them to be a chaotic existence. The perseveration is something that they can control, as opposed to the rest of the world that they believe is arbitrary and confusing. Other children may receive sensory input from their perseverations that is easy to integrate. For autistic children who have symptoms of Sensory Integration Disorder, perseverations may give them visual or auditory stimulation that can calm them down, especially when they are overwhelmed by normal (in our eyes) sounds or situations.


What's the difference between perseveration and hyperfocus? - Psychology


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The Mental Status Examination (MSE) is a standardized procedure used to evaluate the client’s mental and emotional functioning at the time the client is seen by the mental health professional. It involves a precise series of observations as well as some specific questions.

Each of the topics listed below is included in the MSE because it provides valuable information about the client’s function. A completed MSE analysis is usually only a short paragraph of condensed information, yet it contributes greatly to the diagnostic picture.

  • Appearance, behavior, and attitude
  • Characteristics of speech
  • Affect and mood
  • Thought content, thought form, and concentration
  • Orientation
  • Memory
  • General intellectual level
  • Insight and judgement


APPEARANCE, BEHAVIOR, AND ATTITUDE

An MSE usually begins by describing the person’s age, marital status, race, and manner of dress. Appearance is important because a person suffering from serious mental impairment may lose interest in grooming and personal hygiene or may be unable to perform these normal functions.

Psychomotor behavior is described to give some further indication about a person’s ability to maintain normal control. Agitated, restless behaviors suggest one clinical picture whereas frozen posture with a lack of eye contact suggests an entirely different clinical situation. The skilled clinician uses subtle cues such as eye contact or avoidance to aid in diagnosis.

This can be followed with a description of the client’s attitude, cooperation, and ability to provide reliable information. Assessment of attitude provides an indication of the client’s motivation for treatment. An example of this element follows:

This 35-year-old divorced, Caucasian male was casually dressed in a T-shirt, jeans and tennis shoes. He was pacing throughout the interview, although he was very cooperative. He was judged to be a reliable historian.

CHARACTERISTICS OF SPEECH

  • Mutism, or no verbal response
  • Circumstantiality, or excessively irrelevant detail
  • Perseveration, or the repetition of the same words or phrases
  • Flight of ideas or rapid, loose association of content, including:
  • Quick topic changes
  • Minimal or unusual connection between ideas
  • Simple rhymes
  • Clang associations (associations linked by sound)
  • Puns
  • Blocking, or a sudden interruption in thought processes that is thought to occur because an unconscious process interferes with the client’s concentration or because the client is responding to internal stimuli such as auditory or visual hallucinations

An example of this element follows:

Speech volume was normal rate of speech was pressured with a tendency to focus on the negative circumstances surrounding his recent divorce.

Affect is the visible reaction a person displays toward events. Mood is the underlying feeling state. Affect is described by such terms as constricted, normal range, appropriate to context, flat, and shallow. Mood refers to the feeling tone and is described by such terms as anxious, depressed, dysphoric, euphoric, angry, and irritable.

  • Incongruent affect, in which the client’s expression is of feelings opposite the ones appropriate for the context
  • Lack of affect, in which emotional subjects are described in a detached manner
  • Overreactions, in which a client may display an emotional response that is excessive in relation to the situation

Examples of this element follow:

Affect constricted, with mood dysphoric. Mood congruent with content.
Affect irritable, hostile and labile. Mood depressed and angry.

THOUGHT CONTENT, THOUGHT FORM, AND CONCENTRATION

Thought content is examined to identify whether the person is having irrational thought, thought fixations, or disturbances in thought that would suggest the presence of delusions, illusions, or hallucinations.

  • persecution or special attention
  • grandeur
  • nihilism
  • alien control
  • self-deprecation
  • somatic delusions

Illusions are false perceptions in response to an external object that other people can also see. For example, a person may perceive a cord lying on the floor as a coiled snake.

Hallucinations are false sensory perceptions. Auditory or visual distortions are the most common.

The sequence of thoughts, logical connections, and the ability to provide specific information are elements of thought form. When a thought disorder exists, associations between thoughts may be disconnected, constantly changing, or blocked. The person may use vague, nonspecific terms that indicate an impoverishment of content or he or she may have difficulty with abstract ideas. Proverbs are used to evaluate this response. A person who is reasoning normally will interpret such common proverbs as "a rolling stone gathers no moss" and "people who live in glass houses shouldn’t throw stones" abstractly. A person with a thought disorder will attempt to explain the statement literally, replying, "The moss can’t stick to the stone" or "Glass breaks easily."

Concentration inability is another indicator of thought disturbance. A good evaluation tool is the Serial 7 test, in which a person is asked to sequentially subtract 7 from 100. Many people with thought disorders cannot perform more than one or two calculations.

Orientation in terms of time, place, person, and self is assessed to determine the presence of confusion or clouding of consciousness. This is important information for determining whether the person has organic mental impairment.

  • Can you tell me today’s date?
  • Do you know the day of the week?
  • What month is it?
  • What year is it?
  • Do you know where you are?
  • Do you know who I am?
  • Do you remember your name?

These questions are usually asked in this sequence. With increasing impairment, the client will tend to have more difficulty with these questions. Orientation to self is usually retained with early stages of confusion or disorientation.

Both recent and remote memory are assessed. If the person has an organic brain dysfunction, memory for remote past events commonly remains intact, with loss of memory for more recent events. Any changes in memory or ability to recognize familiar surroundings or people should be cause for further investigation because it can be an early sign of a neurological problem that may respond to medical treatment.

  • Where did you live when you were growing up?
  • What was the name of the school you went to?


GENERAL INTELLECTUAL LEVEL

The client’s basic knowledge (often called the fund of knowledge) and awareness of social events are assessed.

  • Who is the president of the United States?
  • Who is the vice president?
  • Who were the last five presidents, in order?
  • What is the state capital?

Insight is the client’s ability to identify the existence of a problem and to have an understanding of its nature. This is a very important factor in assessing the client’s potential for compliance with treatment. A person will not follow treatment recommendations when he or she does not believe that problems are really there.

Social judgement is also evaluated. A question commonly used is "If you were to find a stamp, addressed envelope lying on the sidewalk, what would you do?

SAMPLE MENTAL STATUS EXAMINATION

The client is a 33-year-old married woman who is morbidly obese. She is slightly disheveled. She is cooperative with the interviewer and is judged to be an adequate historian. Her mood and affect are depressed and anxious. She became tearful throughout the interview. Her flow of thought is coherent and her thought content reveals feelings of low self-esteem as well as auditory hallucinations that are self-demeaning. She admits to suicidal ideas but denies active plan or intent. Her orientation is good. She knows the current date, place, and person. Recent and remote memory are good. Fund of knowledge is adequate. The client shows some insight and judgment regarding her illness and need for help.


Excerpted from Mabbett, P. D. (1996) Delmar’s Instant Nursing Assessment: Mental Health. Albany, NY: Delmar Publishers.


What Does Hyperfocus Look Like?

When someone is in hyperfocus mode they become so immersed in the task that they are oblivious to everything else going on around them. You may notice this when a child with ADHD is playing a video game and you try to get their attention. You call them, but you get no answer. You try calling louder, but you still get no answer. Finally, you try raising your voice to a shout, and you still get no answer.

In her book, Adventures in Fast Forward, Kathleen Nadeau shares a story about a woman with ADHD who became so hyperfocused on a paper she was writing that she was completely unaware her house had caught fire. “She had missed the sirens and all the commotion and was finally discovered by firemen, working contentedly in her room while the kitchen at the back of the house was engulfed in flames,” writes Nadeau. Luckily, this woman was able to get out of the house safely. (Her paper was probably extraordinarily well written, as well!)


Clinical Geropsychology

7.17.6.2.2 Perseveration

Perseveration , or difficulty in stopping or shifting behavior, is a second possible characterization for the overall high activity levels of wanderers. In other words, once walking is initiated, wanderers may have difficulty terminating an episode. Present with focal damage to the parietal and temporal lobes ( Goldberg, 1986 Sandson & Albert, 1984 ) and with more diffuse central nervous system pathology ( Goldberg, 1986 ), perseveration manifests as repetitive behavior, usually without a discernible stimulus. Perseveration is a documented feature in many cases of AD, MID, and PD ( Fuld, Katzman, Davies, & Terry, 1982 Marley, 1982 ) and can involve repetitious speech patterns (e.g., echolalia, word intrusions) and motor behaviors.

This possible view of wandering was the basis of a study by Ryan et al., (1995) . Eighteen community-residing subjects (72% female) with mild to moderate dementia were classified as wanderers (n = 6) or nonwanderers on the basis of caregiver ratings. Three types of perseverative motor behavior were quantified from subjects' drawings on the Bender Gestalt and clock drawing tests. The groups did not differ with regard to attention and concentration, spatial orientation, age, gender, or dementia severity. Wanderers demonstrated significantly greater perseveration than nonwanderers, although nonwanderers did perseverate. Wanderers were especially likely to have an ongoing, continuous, or repeated response to a singular stimulus, a form of perseveration associated with the right hemisphere and with attention or motor output deficits ( Marley, 1982 ) or to carry over elements of one drawing into another, a form of perseveration associated with bilateral frontal or frontotemporal impairments ( Sandson & Albert, 1987 ). Interestingly, authors of this study did not confirm spatial orientation deficits of wanderers reported above. They attributed this lack of difference to either their method for scoring the clock drawing test or to the earlier stage of dementia of their subjects.


What's the difference between perseveration and hyperfocus? - Psychology

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What is the difference between Hyperfocus, Perseveration and Rumination?

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Hyper focus - to be fixated on something / task and concentration is usually difficult to break if the task is enjoyable to the said person.

Perseverance- kinda like sitting back and observing someone /something.
Ruminating- going over and over something .. and over and over.

Correct me if I am wrong.. google is unavailable in my country.

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Hyperfocus -
I think it's task-oriented, even if it's a mental task. It means that you are able to put all your mental energy into one thing for a sustained period of time, even if it's something dull like sewing the face on a 50 year old rag doll for eight hours reading a book or painting a wall.

Perseverance -
To persevere (v) means to keep trying over and over again even if you aren't successful
Perseveration (n) can also mean that you are fixated on saying something over and over again. Being "stuck" on it.

Ruminating -
I think this is more related to worry and anxiety - like scripting conversations ahead of time and micro-analysing them afterward to make sure you didn't sound like an idiot decide if you did anything wrong.

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Hyperfocus: Becoming engrossed in an activity, usually a fun one, for hours on end, without drinking, eating or resting. Sometimes it can be used for less fun activities as well, such as the ability to give your all to a test in school and perform well. It is an ability.

Perseverance: Not giving up even though you have plenty of reasons to. Unlike hyperfocus, perseverance can stretch over years, such as persevering in employment despite facing hurdles everyday. If you make it a habit, it can be very useful.

Ruminating: Obsessively overthinking negative stuff you did or experienced, or negative stuff that might happen. Usually generates more negativity about everything, and might lead to paralysis. It can become a very un-useful habit if you let it.

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This is why autism is both a superpower and a disability.
Superpower traits: hyperfocus, perseverence.
Disability traits: perseveration and rumination
Seems like you don't get the one without the other, it's a package deal.

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Sometimes I find I am "stuck" on something and cannot let go until it is "done".
This can be good or bad - for me - that is my experience.

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This is how I had been explaining what is "Hyperfocus".

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Hyperfocus -
I think it's task-oriented, even if it's a mental task. It means that you are able to put all your mental energy into one thing for a sustained period of time, even if it's something dull like sewing the face on a 50 year old rag doll for eight hours reading a book or painting a wall.

Perseverance -
To persevere (v) means to keep trying over and over again even if you aren't successful
Perseveration (n) can also mean that you are fixated on saying something over and over again. Being "stuck" on it.

Ruminating -
I think this is more related to worry and anxiety - like scripting conversations ahead of time and micro-analysing them afterward to make sure you didn't sound like an idiot decide if you did anything wrong.


Dive deeper

Perseveration can show up in different ways. Kids or adults may:

Worry about something that might happen because it happened before

Have trouble getting past being angry or scared

Continue to ask the same question long after getting an answer

Keep thinking about previous conversations or interactions (This is sometimes called “looping thoughts.”)

Fidget or repeat an action over and over again

Give the same answer to a different set of questions, even when the answer doesn’t make sense

Look for a lost item in the same place without looking anywhere else because it “must be there”

Getting “stuck” on emotions is common in people with ADHD. Learn more.

There are a number of reasons why people get stuck. They include trouble with:

Finding ways to calm the body or mind

Flexible thinking , which makes it hard to change a reaction in response to your reaction

Slow processing speed , which makes it hard to sort through and understand a situation

For people with sensory processing challenges, getting stuck is often a sign of a sensory overload. Learn more about sensory overload and why it makes it hard to get “unstuck.”

Knowing kids are reacting to a challenge can help you find ways to respond — both in the moment and proactively. Some ways to help include:

Talk to kids about getting stuck. Talk about it when they’re not perseverating and describe what you’ve been seeing.

Respond with empathy. It can go a long way in reducing kids’ anxiety — and yours, too. And since getting stuck can be a response to being anxious or overwhelmed, being empathetic and calming may help in getting kids unstuck.

Keep in mind, though, that when kids are stuck, they may not be willing to hear you.

Self-monitoring to know when you’re stuck is key in being able to learn how to move on. Try to:

Reflect and revisit. Think about what happened and try to recognize what started the loop.

Ask for support. It can help to have a phrase or action you can use to let people know you’re stuck. It can be as simple as a signal like putting your hand in the air.

Have a plan for getting “unstuck.” Identify what can be done to stop perseverating when you recognize it’s happening. You may need to take a break to regroup. Or you may need someone to tell you they’re ending the conversation.


Hyperfocus in psychiatric disorders

References to hyperfocus most frequently arise in research on ADHD, schizophrenia, and autism. Each disorder is reported to increase the frequency and/or magnitude of hyperfocus states, sometimes in different contexts. This phenotypic overlap may not be surprising given evidence for a genetic overlap across the three conditions (Cross-Disorder Group of the Psychiatric Genomics Consortium, 2013). For each population, we will review how hyperfocus has been measured, the general consensus on how hyperfocus affects these populations, and we will provide constructive criticism about the methods and analyses used in each. There will also be a discussion about whether the measures of hyperfocus used across populations reflect the same process or not.

Hyperfocus and ADHD

Attention deficit hyperactivity disorder (ADHD) is characterized by clinically significant (i.e., it interferes with daily life) hyperactivity, impulsivity, and inattention. It should be noted that, despite its seemingly self-descriptive name, ADHD is not solely a disorder of attention, but also executive functions (Roberts, Martel, & Nigg, 2017 Castellanos, Xavier, Sonuga-Barke, Milham, & Tannock 2006 Willcutt, Doyle, Nigg, Faraone, & Pennington 2005). Moreover, there are three subtypes of ADHD (inattentive, hyperactive, and combined), which may even be distinct disorders (Milich, Balentine, & Lynam 2001 Roberts and Milich, 2013). According to the DSM-V (APA, 2013), one of the symptoms of ADHD is that the child “often does not seem to listen when spoken to directly”. While the DSM-V does not explicitly refer to this symptom (or any other symptom for that matter) as hyperfocus, references to it as a symptom of ADHD are pervasive in academic literature (Goodwin and Oberacker, 2011 Travis, 2010 Carver, 2009 Kahl and Whal, 2006 Ozel-Kizil et al., 2013 Schecklmann et al., 2008 Sklar, 2013 see also Table 1). Indeed, Hupfeld et al. (2019) found that patients with ADHD experience hyperfocus more often than healthy, neurotypical controls both in general and across a range of specific settings (in school, during hobbies, during “screen time”, and in the “real world”). In addition, although hyperfocus is seemingly antithetical to the association of ADHD with inattention and impulsivity, it is often reported as a positive state in individuals with ADHD because they actually engage in tasks for longer periods of time than is typical (Goodwin and Oberacker, 2011 Travis, 2010).

Research into hyperfocus and ADHD is extremely limited. We were only able to find one study that explicitly attempted to measure cognitive and neural differences in hyperfocus between ADHD and neurotypical populations. In this study, Sklar (2013) took EEG measurements while ADHD and neurotypical participants played a first-person shooter game, ostensibly measuring brain activity during a hyperfocus state. In this study, hyperfocus was essentially defined to be identical to flow, as described by Csikszentmihalyi (1997, 2000). There were a few important findings. First, patients with ADHD showed reduced alpha and beta levels in the frontal lobe relative to controls while playing the game and although not significant (but mentioned in light of small sample sizes) alpha and beta levels decreased over the course of the game for the ADHD patients, but increased for the controls. This was interpreted as evidence that ADHD patients required less cognitive effort to play the game, in line with the reported experiences of hyperfocus. Second, in the frontal midline, delta wave activity increased significantly over the course of the game (and it was reported that theta wave activity increased at a trend level p < .10). It was speculated that this might reflect the “experience of the activity as intrinsically rewarding” element of hyperfocus. Third, in the parietal lobe, the mean absolute power was higher in the ADHD patients than the controls. This was notable because typically ADHD patients show lower parietal activation than controls, which is thought to reflect impaired attentional process in ADHD. Sklar (2013) argued that these results supported the notion that impairments to attention may be context-specific in patients with ADHD. In other words, it is possible that patients with ADHD are not impaired when in a hyperfocus state and may even have enhanced attentional control. And fourth, a post-experiment questionnaire revealed that patients with ADHD experienced a more distorted perception of time, possibly supporting the notion that they did in fact experience hyperfocus during the task.

However, some methodological aspects need to be considered for a better understanding of the results. First, there is a question of whether or not the participants (both ADHD and neurotypical) experienced hyperfocus while playing the games. Sklar (2013), like Weber et al. (2009), argued that media, such as video games, provided the appropriate environment to induce hyperfocus/flow states. Noteworthy, Weber et al.’s (2009) framework is predicated on the notion that hyperfocus is the result of enhanced neural synchronization between attentional and reward networks in the brain. However, Hoekzema et al. (2014)showed that patients with ADHD exhibited reduced functional connectivity between the dorsolateral pre-frontal cortex and various brain networks, and notably the DMN, during attention demanding tasks. Additionally, Querne et al. (2014 see also Fassbender, Scangos, Lesh, & Carter 2014) reported that, in contrast to neurotypical participants, children with ADHD did not show significant anti-phase synchronization (a form of inhibitory synchronization) between the DMN and task positive networks (TPN brain regions that activate during “externally oriented” task—including the dorsal and ventral fronto-parietal attention networks). This was interpreted as an impairment in the ability of the TPN to suppress the DMN due to immaturity in ADHD-related brain development, even in adult ADHD (Castellanos and Elmaghrabi, 2017 Catellanos et al., 2006 Kelly, Margulies, & Castellanos 2007 Scheres, Milham, Knutson, & Castellanos, Scheres et al., 2007). Based on this evidence, it is questionable whether Weber et al.’s (2009) synchronization-based theory of hyperfocus is likely, and by extension if simply playing games is enough to consistently induce hyperfocus across subjects. That being said, if attention deficits are contextual, as suggested by Sklar (2013), then perhaps the connectivity deficits identified by Hoekzema et al. (2014) and Querne et al. (2014) would not be found if the task induced hyperfocus.

Second, Sklar (2013) did not assess behavioral measures that might correspond with neurological measurements. Although this was an understandable methodological choice, the use of a video game provides a unique opportunity because performance over the course of the game can theoretically be measured (for example, most games have some kind of scoring mechanism) without having to probe the subject (admittedly, this is easier said than done). In general, it is good practice to include behavioral measurements to compare to neurological measurements, so as to be able to establish a relationship between brain activity and behavior (i.e., linking hypotheses Teller, 1984 Morgan, Melmoth, & Solomon, 2013).

ADHD is synonymous with a high degree of distractibility and having a short attention span. However, the oft reported hyperfocusing states in this condition suggest that individuals with ADHD can, paradoxically, sustain attention excessively. In fact, attentional control may not be as impaired in patients with ADHD as once thought. For example, Roberts, Ashinoff, Castellanos, and Carrasco (2018) have shown that spatial covert attention is functionally intact in adults with ADHD. Therefore, sophisticated investigation of the nature of hyperfocus in ADHD is critically important as it may provide important etiological clues that have been previously overlooked due to a focus on “distractibility”. Moreover, despite the ubiquity of reports of hyperfocus in patients with ADHD, it is not reflected in the DSM criteria for a diagnosis. Perhaps this should be reconsidered since, based on anecdotal evidence, hyperfocus appears to be a core symptom.

Hyperfocus and autism

Autism spectrum disorders (ASD) are neurodevelopmental disorders associated with impairments in social development, language, and repetitive, circumscribed behaviors/interests. Two defining symptoms of ASD are “(B1) Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases)” and “(B3) Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest)” (APA, 2013). Of particular interest here are the cases where individuals with autism exhibit an intense focus on a particular behavior or topic, which are sometimes explicitly referred to as hyperfocus (although usually anecdotally Mayes, 2014 Clark, 2016 Fein, 2015 Bombaci, 2012). The term hyperfocus is also sometimes used to refer to stereotypic behavior or stimming (short for self-stimulatory behavior Bombaci, 2012—see Table 1). However, these are distinct phenomena that co-occur in ASD and need to be treated as such, with hyperfocus referring to symptom B3 and not B1, although we recognize that the two sets of symptoms may be difficult to tease apart from a phenomenological and clinical perspective. Here, we focus on studies that appear to get at the phenomenon of hyperfocus in ASD, rather than stereotyped behaviors or stimming.

To our knowledge, there are no studies that specifically attempt to measure behavior or cognitive performance during hyperfocus or flow states in ASD. In a review paper, Geurts et al. (2009) defined hyperfocus in the context of ASDs as “difficulties in shifting attention, disengaging from details”. So, it might be surprising to learn that some fundamental attentional processes appear to be intact in patients with ASD, including exogenous and endogenous spatial attention (Grubb et al., 2013a, b) and attentional disengagement (Fischer, Plessow, Dreisbach, & Goschke 2014), although other aspects of attention have been shown to be deficient. For example, Keehn, Westerfield, Müller, & Townsend, (2017) found that children with ASD, unlike typically developing children, showed no behavioral or electrophysiological evidence of attentional capture.

Geurts, Corbett, and Solomon (2009) also proposed that hyperfocus in ASD was associated with cognitive flexibility (the ability to re-allocate cognitive resources based on the situation Brady et al., 2017 South, Ozonoff, & Mcmahon, 2007 Hill and Bird, 2006 Lopez, Lincoln, Ozonoff, & Lai, 2005). The neural correlates of cognitive flexibility in ASD are usually assessed using attention or task switching paradigms, such as the Wisconsin card sorting test (WCST Yeung, Han, Sze, & Chan 2016) or reversal learning tasks (D’Cruz, Mosconi, Ragozzino, Cook, & Sweeney, 2016). In these tasks, individuals with ASD have exhibited hypoactivation in the prefrontal cortex, striatum, and parietal cortex (Shafritz, Dichter, Baranek, & Belger, 2008 Gilbert, Bird, Brindley, Frith, & Burgess 2008 Yeung et al., 2016 D’Cruz et al., 2016 Gomot et al., 2006), which is thought to reflect impairments in the ability to shift between different behaviors. Important to our purposes, this hypoactivation has been associated with stereotyped behaviors, which may be confounded with hyperfocus. However, D’Cruz et al. (2016) noted that hypoactivation in a reinforcement learning task was specifically associated with unpredictable task outcomes. They suggested that uncertainty may induce anxiety in patients with ASD, motivating them to maintain behaviors with predictable outcomes and resist novelty. Thus, it is unclear if ASD-related deficits in cognitive flexibility are related to hyperfocus, stereotyped behaviors, or other processes.

Overall, it appears as if hyperfocus is a real phenomenon that occurs in ASD, but care must be taken to distinguish it from other symptoms such as stereotypic behaviors. Research into hyperfocus in ASD is important because, as of now, it is unclear if hyperfocus is a primary symptom or a secondary symptom that is merely induced by other ASD-related behaviors. It is possible that mechanisms underlying hyperfocus behaviors are not autism-specific, but rather that ASD behaviors happen to trigger the same kind of hyperfocus seen in the general population more frequently or strongly.

Hyperfocus and schizophrenia

Schizophrenia is a disorder characterized by abnormal social behavior, deficits in emotional processing, and psychosis. Symptoms of schizophrenia are divided into three categories: positive symptoms, negative symptoms, and cognitive dysfunction (APA, 2013). Positive symptoms are those that individuals with schizophrenia can experience that are not present in the healthy population. These include hallucinations, delusions, and other forms of psychosis. Negative symptoms are deficits in cognition or emotion in individuals with schizophrenia that are not impaired in the healthy population. These include, but are not limited to, anhedonia, flat affect, and lack of motivation. Cognitive dysfunction refers to deficits across a wide range of cognitive abilities. In the last few years, a hyperfocusing hypothesis of schizophrenia has been developed (see Luck, Hahn, Leonard, & Gold, 2019 for a review of this hypothesis Luck et al., 2014 Gray et al., 2014 Hahn et al., 2016 Sawaki et al., 2017 Kreither et al., 2017). Here, hyperfocus is defined as the use of processing resources more intensely (i.e., stronger working memory representation), but more narrowly compared to healthy control subjects.

Luck et al. (2014 Gray et al., 2014) showed that a colored distractor that matched a color held in working memory had a greater distracting effect during saccadic eye movements in individuals with schizophrenia than in healthy controls. They argued that the individuals with schizophrenia had generated a more intense working memory representation of the color because they had focused more intensely (i.e., hyperfocused) on it. Additionally, Leonard et al. (2013) showed that the neural mechanisms underlying the working memory differences between individuals with schizophrenia and healthy controls are not the same as those that underlie general individual differences in working memory. They argued this reflected a deficit in the ability of individuals with schizophrenia to distribute their attention broadly. Though the authors are careful to note that attributing these results to hyperfocusing is a conjecture, they do suggest that it provides converging evidence for such a theory.

More recent studies have also supported the hyperfocusing theory of schizophrenia. Sawaki et al. (2017) found that individuals with schizophrenia showed electrophysiological evidence of abnormal attentional focus towards goal-relevant stimulus features. Participants had to respond when a centrally located circle matched a pre-defined target color, while ignoring two colored distractor circles that horizontally flanked the central circle. On some trials, when the central circle was a non-target color, one of the distractor circles could match the target color (i.e., a goal-relevant feature embedded in a distractor). To account for frequently reported deficits in goal maintenance, the target color was presented constantly between trials throughout the experiment. They found that on these trials, neurotypical controls exhibited a significant distractor positivity event related potential (ERP) component, a measure of attentional suppression. This suggested that attention was not directed towards the distractor containing goal-relevant information. However, the individuals with schizophrenia exhibited a significant N2pc (N2 posterior-contralateral) ERP component, a measure of spatial attention shifts and focus towards a lateralized stimulus. This suggested that they actually focused their attention (or hyperfocused) on the distractor containing goal-relevant information. The authors argued that this was evidence that individuals with schizophrenia hyperfocused on goal-relevant information when maintaining a task set. This is consistent with some of the most commonly reported features of hyperfocus, particularly improved task performance. In fact, Beck et al. (2016) reported that, as a consequence of hyperfocusing on goal-related information, people with schizophrenia showed significantly better performance on a probabilistic visual search task.

Kreither et al. (2017) addressed another prediction of the hyperfocus hypothesis, namely that individuals with schizophrenia would focus attention more narrowly, in addition to more intensely. They interpreted this to mean that hyperfocus would be strongest for stimuli in central vision, but weak in peripheral vision. Participants had to discriminate between standard and oddball stimuli at either central or peripheral locations. They found, based on an abnormal P3b ERP component (a measure of higher-level processing resources), individuals with schizophrenia were able to suppress peripheral stimuli when they were responding to centrally located stimuli, but could not suppress central stimuli when they were responding to peripheral stimuli. The healthy controls exhibited the opposite pattern of results. Moreover, they showed that the P3b results correlated with performance in the useful field of view task (UFOV), which measures distributed attention. Individuals with schizophrenia showed worse performance than controls.

Considering the symptom variability associated with schizophrenia, a natural question is whether hyperfocus is associated with negative symptoms, positive symptoms, or cognitive dysfunction. Luck et al. (2014) tested for, but did not find, a correlation between hyperfocusing and the severity of positive (BPRS Faustman and Overall, 1999) or negative (SANS Andreasen, 1989) symptoms in their individuals with schizophrenia. However, they obtained a single subscale score for each symptom type (positive and negative) and did not assess if individual symptoms were associated with hyperfocus. If only a subset of positive (like delusions) or negative symptoms are associated with hyperfocus or hypersalience, then a generalized subscale score may not be sensitive enough to reflect these effects. Luck et al. (2019) reported that there is an association across several studies between cognitive dysfunction and the intensity of hyperfocus. Furthermore, they proposed that hyperfocus may be a cause of cognitive dysfunction, rather than a consequence, but are careful to note that this is speculative. They further note that it is unclear, due to a lack of research in unmedicated patients and patients with current psychotic symptoms, if hyperfocus is associated with the positive and/or negative symptoms of schizophrenia. Prentky (2001) argued that patients that exhibit positive symptoms show “higher left than right hemispheric activity. Thus, there is a hypothetical optimal hemispheric imbalance that promotes a constructive, task-specific hyperfocus on detail”. There is also evidence that patients with schizophrenia show a greater preoccupation with delusional beliefs than healthy controls (Sisti et al., 2012), which could be interpreted as hyperfocusing on the belief. In fact, many descriptions of individuals with schizophrenia report the experience of hallucinations being distracting and engrossing, even to the point of exhaustion (Walsh, Hochbrueckner, Corcoran & Spence, 2016 Flanagan et al., 2012). This suggests that individuals with positive symptoms are more likely to experience hyperfocus, or at least that positive symptoms may induce hyperfocus.

More generally, although we do not doubt the results or value of the “hyperfocusing theory of schizophrenia”, it is debateable if its operational definition of hyperfocusing reflects the same process that is typically described in anecdotal reports of hyperfocusing. The hyperfocusing theory does appear to reflect intense concentration and improved task performance. And, although it is generally consistent with reports that people who hyperfocus “tune everything else out”, it is not clear if, in anecdotal reports, people were always focused on stimuli at the center of vision. A future study will need to assess if hyperfocus can only occur at the center of vision or the loci of hyperfocus can move, such as with the spotlight of attention. Moreover, there was nothing particularly fun or interesting about the tasks. A further consideration was that the effect of “hyperfocus” was relatively consistent over time in these studies, which is inconsistent with the notion that hyperfocus reflects an irregular, inconsistent state of attention that is difficult to induce. One possibility is that the “hyperfocus theory” studies were tapping into a visual attention counterpart of hypersalience (rather than hyperfocus) that has been previously reported in individuals with schizophrenia in decision-making tasks. Speechley, Whitman, and Woodward (2010) showed that individuals with delusions exhibited a bias for evidence that matched their expectations, which may explain the results of Luck et al. (2014).

Is hyperfocus the same phenomenon across psychiatric conditions?

Does hyperfocus, reported in the ADHD, autism, and schizophrenia literature, refer to the same phenomenon in all three conditions? Before we can address this, we must first consider more generally if these disorders present with similar symptoms.

ADHD and autism Panagiotidi, Overton, and Stafford (2017 also see Kern, Geier, Sykes, Geier, & Deth, 2015 Banaschewski et al., 2005) investigated co-occurring traits in autism spectrum disorder (ASD) and ADHD. They assessed 334 healthy, neurotypical participants with two ADHD questionnaires and two ASD questionnaires. Their most relevant finding for our purposes was a moderate positive correlation between the attention switching subscale of the autism quotient (AQ Baron-Cohen, Wheelwright, Skinner, Martin, & Clubley 2001) and the inattention subscales from both ADHD questionnaires (The Wender Utah Rating Scale and the Adult ADHD Self-Report Scale Ward, Wender, & Reimherr 1993 Kessler et al., 2005). They defined hyperfocus as “difficulties in diverting attention between tasks” and inattention as “difficulty in sustaining attention”, suggesting that these phenomena were reflected in the questionnaire results. They suggested that ADHD and ASD may share a common etiology, and that hyperfocus and inattention may be related to a common mechanism. Therefore, ADHD and autism present with similar symptoms, possibly including a similar form of hyperfocus.

ADHD and schizophrenia Research has shown that ADHD and schizophrenia present with similar cognitive deficits in executive functions and attentional function (Banaschewski et al., 2005). In fact, ADHD and schizophrenia cohorts are frequently used as psychiatric control groups for each other. However, there has been no explicit comparison of hyperfocus in these groups. That being said, it is possible that both ADHD and schizophrenia present with a similar form of hyperfocus.

Autism and schizophrenia According to Crespi and Badcock (2008), “psychosis and autism represent two extremes on a cognitive spectrum with normality at its center. Social cognition is thus underdeveloped in autism, but hyper-developed to dysfunction in psychosis”. Recent studies have provided support for this spectrum account showing opposite attentional effects based on the relative expression of autism and psychosis in healthy participants (Abu-Akel et al., 2016a, b, c, 2018) and in patient populations (Abu-Akel et al., 2018). In comparing attentional set shifting, Abu-Akel et al. (2018) showed that children with autism had difficulties with extra-dimensional shifts, and children with schizotypal disorders had difficulties with intra-dimensional shifts. Based on this, it seems unlikely that patients with autism and schizophrenia would exhibit a similar form of hyperfocus, since their attentional control patterns seems to reflect a diametric relationship.

However, an alternative interpretation is that patients with these disorders simply hyperfocus on different types of stimuli, making it difficult to see a direct comparison. Crespi and Backcock (2008) conceptualized symptoms of ASD and schizophrenia related to under- and over-mentalizing (i.e., capacity for theory of mind), respectively (see also Abu-Akel and Bailey, 2000 Frith, 2004). In this conception, patients with ASD under-interpret social cues, leading to social withdrawal which would arguably result in focusing on things rather than people, and patients with schizophrenia over-interpret social cues, leading to symptoms like paranoid delusions, which is interpretable as a focus on people and their intentions. Langdon and Brock (2008), however, argued that this interpretation is incomplete as patients with schizophrenia in particular exhibit both over- and under-mentalizing. Furthermore, using a social judgement task, Stanfield et al. (2017) showed that deficits in social cognition in ASD and schizophrenia are mediated by distinct neural correlates. Thus, although additional research is needed to confirm if phenomenon like hyperfocus is expressed via similar mechanisms in these disorders, it does not appear likely.

Are they the same? Based on the evidence, we propose that the version of hyperfocus described in this review and more generally in anecdotal reports, occurs in both ADHD and autism, although in autism the term is often incorrectly used to refer to stereotypic and self-stimulatory behavior. The evidence for hyperfocus in schizophrenia is less clear. Although there is a so-called “hyperfocus theory of schizophrenia”, we propose that the effects they have identified reflect hypersalience rather than hyperfocus. Aside from these studies, references to hyperfocus in the schizophrenia literature are few.


Hyperfocus

Hyperfocus is an intense form of mental concentration or visualization that focuses consciousness on a subject, topic, or task. In some individuals, various subjects or topics may also include daydreams, concepts, fiction, the imagination, and other objects of the mind. Hyperfocus on a certain subject can cause side-tracking away from assigned or important tasks.

Psychiatrically, it is considered to be a symptom of ADHD together with inattention, and it has been proposed as a symptom of other conditions, such as autism spectrum disorder (ASD). [4] [5]

Hyperfocus may bear a relationship to the concept of flow. [5] In some circumstances, both flow and hyperfocus can be an aid to achievement, but in other circumstances or situations, the same focus and behavior could be a liability, distracting from the task at hand. However, unlike hyperfocus, "flow" is often described in more positive terms, suggesting they are not two sides of the same condition under contrasting circumstance or intellect. [3]



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