Psychiatric Annals

CME Article 

Emotional Dysregulation in Adult ADHD

Lenard A. Adler, MD; Michael J. Silverstein, BA

Abstract

Adult attention-deficit/hyperactivity disorder (ADHD) is a developmental disorder that persists into adulthood in about one-half of all patients. Although the current Diagnostic and Statistical Manual of Mental Disorders, fifth edition diagnostic formulation limits ADHD symptoms to those of inattention and hyperactivity-impulsivity, there has been a substantial amount of research supporting symptoms of emotional dysregulation (ED) as being either a part of the ADHD syndrome or co-traveling symptoms. This article reviews the description of emotional dysregulation, how emotional dysregulation fits in the diagnostic schemata of ADHD, methods of assessment of emotional dysregulation, and treatment of emotional dysregulation. [Psychiatr Ann. 2018;48(7):318–322.]

Abstract

Adult attention-deficit/hyperactivity disorder (ADHD) is a developmental disorder that persists into adulthood in about one-half of all patients. Although the current Diagnostic and Statistical Manual of Mental Disorders, fifth edition diagnostic formulation limits ADHD symptoms to those of inattention and hyperactivity-impulsivity, there has been a substantial amount of research supporting symptoms of emotional dysregulation (ED) as being either a part of the ADHD syndrome or co-traveling symptoms. This article reviews the description of emotional dysregulation, how emotional dysregulation fits in the diagnostic schemata of ADHD, methods of assessment of emotional dysregulation, and treatment of emotional dysregulation. [Psychiatr Ann. 2018;48(7):318–322.]

Adult attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by symptoms of inattention, hyperactivity, and impulsivity, such as easy distraction, forgetfulness, daydreaming, restlessness, fidgetiness, talking out of turn, difficulty waiting, and interrupting others.1 ADHD often persists throughout the life-span, and the cardinal elements of making a diagnosis of adult ADHD include having a significant number of the 18 ADHD symptoms (5 of 9 inattentive [IA] and/or 5 of 9 hyperactive-impulsive [HI]) defined in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition1 (DSM-5), a childhood onset of multidimensional symptoms, impairment in 2 of 3 domains of a person's life (home, school/work, or social), and ascertaining that the symptoms and impairments are from ADHD and not from potential comorbidities such as mood disorders or substance use disorders. Adult ADHD affects 4.4% of the population in the United States, meaning that between 8 and 9 million adults are affected.2 Most adults with ADHD remain undiagnosed.3 The burden of undiagnosed adult ADHD is substantial, with untreated adults having higher rates of divorce, separation, unemployment, sexually transmitted diseases, motor vehicle accidents, and changing jobs.2–6

Although symptoms of ADHD were originally described in children, interest has recently been extended beyond the symptoms of inattention and hyperactivity/impulsivity not classically included in the diagnostic criteria in DSM-5.1 Executive functions are higher level processes of organization, planning, self-control, and working memory, and adults with ADHD and often are impaired in some of these areas. Barkley7 has posited that executive function deficits (EFDs) are critical to the core of ADHD symptomatology. Barkley et al.8 have defined a number of EFDs, including response inhibition, nonverbal working memory, verbal working memory, self-regulation of emotion and motivation, and planning and problem-solving. Self-regulation of emotion is one of the EFDs defined by Barkley et al.;8 however, others9–13 have defined emotional dysregulation as a separate set of symptoms co-occurring in ADHD. Symptoms of emotional dysregulation that are commonly noted include rapidly shifting affect, mood lability, changeable mood, impulsivity, mood lability, and emotional overreactivity.9–13 These symptoms have been referred to in a variety ways in the literature to refer to overemotionality/emotional dyscontrol, including mood dysregulation,9 emotional impulsivity,9,12 emotional impairment,14 deficits of emotional control,15 or deficient emotional self-regulation.9 By convention, in this article, we will use emotional dysregulation (ED) to describe all terms for overemotionality and moodiness in adult ADHD.

Relationship Models of Emotional Dysregulation and ADHD

Wender13 has asserted that ED is a core feature of the ADHD syndrome and should be formally included in the diagnostic criteria. The data originally came from clinical observation and evaluation of patients in an ADHD research clinic where he saw patients who did not have mood disorders but who did have affective lability and reactive dysphoria. He established the Wender-Reimherr Adult Attention-Deficit Disorder Scale (WRAADDS),13 which will be discussed in the section on evaluation, and used this scale to establish the Utah criteria for ADHD. Wender13 proposed diagnostic criteria that contained two factors: (1) attentional items (inattention and disorganization), and (2) ED items (affective lability, temper, and emotional overactivity). Of note, the HI symptoms loaded on both factors. One major critique of these proposed criteria has been that that they were established mostly in patients participating in clinical trials who were without comorbidities.

ED As a Core Feature of ADHD but not a Distinct Subtype

Barkley11 and other researchers16,17 have argued that emotional dysregulation is part of the core executive dysfunction syndrome that is critical to ADHD but is not a pure subtype of ADHD. Barkley and Fischer12 and Barkley and Murphy18 have found that ED symptoms loaded highly on adult ADHD patients with HI or combined and not IA subtypes. Barkley11 postulated that difficulties with inhibition of emotional reactions and self-regulation of actions were core features of ED and related to IA and HI symptoms and, therefore, part of the ADHD syndrome. One critique of this conceptualization is that ED symptoms are present in less than one-half of ADHD patients.9,19

ED as a Co-Traveling Symptom in ADHD

We have worked with Dr. Ronald Kessler at the Harvard School of Public Health on two studies that examined factor analyses of ED symptoms in large samples of ADHD patients. These studies used an expanded version of the Adult ADHD Clinical Diagnostic Scale (ACDS) v1.2 (discussed further below), which included prompted assessments of not only the 9 IA and 9 HI adult ADHD symptoms in DSM-5,1 but also 13 to 14 additional symptoms of executive function deficits (EFDs) and ED. In the original study in community and health care samples (n = 345), Kessler et al.20 found three factors (executive dysfunction, inattention-hyperactivity, impulsivity), with ED not tracking as a specific factor. Adler et al.21 followed up this study by adding a clinically referred sample (an additional sample of 191 adults referred to the New York University Adult ADHD Program for evaluation). These authors found four factors: (1) EFDs-IA (some but not all DSM-5 IA symptoms), (2) hyperactivity, (3) impulsivity, and (4) ED. Additionally, ED symptoms were more likely to load on the combined subtype (presentation) of ADHD (and therefore in people with higher levels of ADHD symptoms) or in people who had subthreshold forms of ADHD (who were felt to have subtle comorbidities not originally identified). Therefore, it seemed that ED traveled with, but separately from, ADHD symptoms. A subsequent study was conducted by Silverstein et al.24 from the same group on 171 adults with ADHD and 128 controls using the expanded Adult ADHD Investigator Symptom Rating Scale (AISRS), which uses the same adult module from the ACDS (and prompts) with a differing time frame and includes measures of EFDs and ED. They examined a variety of psychometric properties, including internal consistency (via Cronbach's alpha) of IA, HI, EFD, and ED symptoms; internal consistency was less for ED (0.84) compared with IA, HI, and EFD (0.91–0.95), indicating that ED symptoms were less homogeneous and consistent than other ADHD symptom sets, which is consistent with the factor analyses from Adler et al.21

Assessment

Nothing replaces a careful clinical evaluation of the patient, but collateral sources of information also can be be useful. As in many other branches of medicine, rating scales can be quite helpful in quantifying the symptom burden, and this is also true for ED. The scales that have been validated differ in terms of whether they are (1) diagnostic or symptom assessment scales, (2) self- or clinician report, and (3) specifically designed to assess ED or whether ED is assessed as part of an expanded symptom set of ADHD symptoms or co-traveling with ADHD symptoms. The following text contains a selected review of these scales. See Faraone et al.10 and Silverstein et al.9 for further discussion of ADHD scales that include ED assessments.

The ACDS v1.220,22,23 is a clinician-administered scale, validated for DSM-5,1 that contains separate childhood and adult modules with prompted questions for DSM criteria to ensure adequate probing of ADHD symptoms. A formal presence or absence of ADHD as defined by DSM-51 is endorsed via the scale. The expanded version of the scale contains prompted versions of 13 additional EF and ED symptoms that are used to asses these co-traveling symptoms and have been used in the studies by Kessler et al.20 and Adler et al.21 mentioned previously. The scale rates symptoms on a severity basis of “none,” “mild,” “moderate,” or “severe” (1–4 range). The AISRS expanded version contains the symptom section of the adult ADHD portion (with prompts) of the expanded ACDS v1.2 as discussed previously, which is similarly rated on a severity basis from none to severe (but scored with a range of 0–3).20,24

The Adult ADHD Self Report Scale (ASRS) v1.1 Symptom Checklist is a frequency-based, patient-report scale containing the 18 items in the DSM-51 (IA and HI) rated 0 (“never”), 1 (“rarely”), 2 (“sometimes”), 3 (“often”), and 4 (“very often”). The scale was developed as part of the work by Kessler et al.,25 which established the ASRS v1.1 Screener for DSM-IV26 Adult ADHD, and the ASRS v1.1 Symptom Checklist, which is an expanded version of that scale including the full 18 items in DSM-5.1 The expanded version of the ASRS v1.1 Symptom Checklist contains the 13 items of EF and ED noted above, and the core IA/HI symptoms that have been validated by Silverstein et al.24 for DSM-5.1 As noted for the AISRS, there is a suggestion of higher variability of ED symptoms, as Silverstein et al.27 also examined cut-offs suggestive of DSM-51 diagnoses (IA and HI symptoms only) and found high symptom levels overall were necessary to predict the presence of ED. This is consistent with the factor analyses reported earlier by Adler et al.21 in which ED symptoms loaded highly on combined subtypes/presentation or in patients with presumed comorbidities.

The Conners Adult ADHD Rating Scale28 rates ADHD symptoms on a self-report scale of 0 to 3; it contains a 6-item emotion lability scale. The scale is psychometrically validated for DSM-IV26 and also comes in an “other” reporter version.

The Brown Attention-Deficit Disorder Scale29 for adults is a 40-item, frequency-based (0–3) symptom scale that can be reported either by clinician or patient. One of the five subsets centers on ED: managing frustration and modulating emotions. The scale has been validated for DSM-IV.26

WRAADDS13,30,31 is a symptom scale based on the Utah Criteria and not DSM-51 and is a clinician-administered instrument. It assesses seven classes of symptoms, three of which (temper, mood liability, and emotional overreactivity) form an ED subscale. The individual items are rated 0 (“not present”) to 2 (“clearly present”), and the symptom classes are then summarized on a scale of 0 (“none”) to 4 (“very much”). Two critiques of the scale are that it is not based on DSM-51 criteria and that the use of individual item and symptom class scoring reinforces symptom presence by multiplying the scoring.

Scales of EF that Include ED

The Emotional Impulsiveness Scale contains the seven items of ED, reported by patient or observed by clinician, from the Barkley Deficits in Executive Functioning Scale.12,18,32 The Behavior Rating Inventory of Executive Function–Adults is a 75-item self- or clinician-reported scale of executive dysfunction on a three-point scale33,34 that contains an emotional control subscale of the behavioral regulation index. The scale has been validated in ADHD35 and in normative populations; scores can be T-transcribed versus normal populations, such than T-scores of 65 or higher are considered significant.34

Differential Diagnosis

Adults who present with ADHD symptoms, particularly those with ED, should be screened for comorbid psychiatric disorders to determine if the ED is merely symptoms associated with ADHD or a result of a psychiatric comorbidity. Adults with ADHD often have psychiatric comorbidities with ED features, including major depressive disorder (35%), bipolar disorder (15%), and anxiety disorders (40%).2,25,30–32,36 Irritability, a symptom that more than one-half of adults with ADHD experience, is also associated with many disorders, including anxiety, autism spectrum disorder, and personality disorders.1,10 Nonetheless, the features of ED in an adult with ADHD can be used to determine if there are comorbidities, including persistence of anger (eg, those with ADHD tend to not have episodic anger and not have it persist throughout most of the day) and nature of irritability (eg, those with ADHD tend to have episodic and not chronic irritability).10 Faraone et al.10 recently published a table that discusses many of the clinical traits that can be used to discriminate between ED in ADHD and a potentially comorbid disorder, and the reader is suggested to refer to that when evaluating an adult with a potential diagnosis of ADHD and ED.

Treatment

The major treatment modalities that have been investigated include psychotherapeutic and psychopharmacologic interventions. In terms of psychotherapy, the most extensively investigated modality has been cognitive-behavioral therapy (CBT), both group and individual.37 Meta-cognitive therapy, which is a group-based CBT therapy including self-management skills over a 10-session treatment paradigm, includes specific modules addressing ED and has been psychometrically validated.38 Although less extensively studied, mindfulness approaches to ED in ADHD, including relaxed breathing, have been preliminarily shown to be helpful.39,40

A variety of studies have examined the effects of stimulants (methylphenidate and amphetamine compounds) and the nonstimulant selective norepinephrine reuptake inhibitor atomoxetine on ED symptoms in adults with ADHD. In general, effects on ED symptoms have been of lower magnitude from these medications than on classic ADHD symptoms of IA and HI.41 One exception to this finding are studies that have found osmotic release oral system extended-release methylphenidate,42 transdermal methylphenidate,43 and atomoxetine.40 These studies generally used the WRAADDS, which as noted above was specifically designed to measure ED symptoms and may reinforce symptoms via the structure of the rating system. Studies that found positive but lower effects on ED and that did not exclusively use the WRAADDS include Retz et al.44 (extended-release methylphenidate), Adler et al.45 (lisdexamfetamine), Adler et al.46 (lisdexamphetamine vs mixed amphetamine salts), Adler et al.35,47 (atomoxetine), and Asherson et al.48 (atomoxetine pooled studies).

Conclusion

Although not currently included in DSM-5,1 symptoms of ED commonly co-occur in adults with ADHD and should be considered when treating adults with ADHD. There is still debate as to whether ED should be included as part of the diagnostic criteria for adult ADHD, as a core symptom, or as a co-traveling symptom. A variety of scales can help clinicians evaluate ED symptoms and have also been used at baseline and during treatment. Treatment studies have suggested that both CBT and pharmacotherapy can be helpful in treating ED symptoms, but there is a suggestion that ED symptoms may be less responsive to treatment than classical adult ADHD symptoms of inattention and hyperactivity-impulsivity. Future research may focus on improving our understanding of ED symptoms and their relationship to core adult ADHD symptoms and improving their responsivity to treatment.

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Authors

Lenard A. Adler, MD, is the Director, Adult ADHD Program, and a Professor of Psychiatry and Child and Adolescent Psychiatry, New York University (NYU) School of Medicine. Michael J. Silverstein, BA, is Research Data Associate, Department of Psychiatry, NYU School of Medicine; and a Doctoral Student in Clinical Psychology, Department of Psychology, Drexel University.

Address correspondence to Lenard A. Adler, MD, Department of Psychiatry and Child and Adolescent Psychiatry, NYU School of Medicine, One Park Avenue, 8th Floor, New York, NY 10016; email: Lenard.adler@nyumc.org.

Disclosure: Lenard A. Adler, MD, has disclosed the following relevant financial relationships: research grants paid to NYU on Dr. Adler's behalf from Sunovion Pharmaceuticals, Shire Pharmaceuticals, Lundbeck, Enzymotec, Purdue Pharma; personal fees for consulting or advisory boards from Sunovion Pharmaceuticals, Enzymotec, Shire Pharmaceuticals, the National Football League, Major League Baseball, Shire Pharmaceuticals, Otsuka Pharmaceuticals, Alcobra Pharmaceuticals; and royalty fees from NYU School of Medicine for license of Adult ADHD rating scales and training materials. The remaining author has no relevant financial relationships to disclose.

10.3928/00485713-20180607-01

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