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10. Emotional dysregulation / emotion symptoms in ADHD


10. Emotional dysregulation / emotion symptoms in ADHD

Emotional dysregulation is an original symptom of ADHD.123456789101112131415

Barkley refers to this as deficient emotional self-regulation (DESR).3

Original means that ADHD can directly and immediately trigger the symptom. It is not meant that the symptom occurs exclusively with ADHD. Emotional dysregulation can therefore result originally from ADHD, but can also be caused by other disorders.

One study found a relationship between hyperactivity/impulsivity and emotional dysregulation, but not between inattention and emotional dysregulation.11 This study further reported that deficits in working memory contributed to emotional dysregulation. This is not readily consistent with data from our ADxS symptom test (as of June 2020, n = 1889). According to this, emotional dysregulation correlates more strongly with attention problems (total 0.57: task switching problems 0.46, concentration problems 0.63, distractibility 0.61) than with hyperactivity (0.49). Impulsivity (0.57) correlated equally strongly with attention problems. We found the strongest correlation to Impatience (0.79) and Inner Restlessness (0.76). Organization problems as an element of working memory problems correlated with 0.56. Overall, emotional dysregulation correlated more strongly with ADHD-HI (0.69) than with ADHD-I (0.40). This is consistent with the study by Schutko et al16

10.1. Dysphoria with inactivity

See Dysphoria with inactivity (passivity-induced mood lows, to be distinguished from depression) Under drive problems.

10.2. Mood swings

Frequent swings between normal mood, sadness and mild excitement - and back again.17
Temporally limited, but frequently occurring mood dips are a typical consequence of inactivity (for this, see dysphoria with inactivity). Dysphoria is characterized by a weaker intensity compared to depression; however, since the ADHD-typical dysphoria only occurs during inactivity, this causes frequent mood changes, since each phase of inactivity causes a change in mood toward mild depression and each new activity started from it raises the mood again out of dysphoria.

ADHD sufferers often report that they have more intense emotions and moods than those around them and that these change much more quickly. This applies not only to mood dips, but also to mood highs.1819

The mood of ADHD sufferers seems to be influenced more than average by the immediate momentary experience, i.e. to refer more to shorter periods of time than in the case of non-affected persons. Incidentally, this is also true for borderline sufferers. In ADHD, the perception of time is often altered.

10.2.1. Mood swings as symptoms of stress

Mood swings are known as symptoms of stress:

  • Frequent sadness,20 frequent being depressed, depression.21222322
  • Despair24
    • Despair is a direct effect of the stress hormone CRH.25

10.3. Irritability and aggression

Affect breakthroughs / irritability / irritability / outbursts of rage can be regarded as a momentary, situational manifestation of aggression in the broader sense. Aggression in the narrower sense can at the same time be described as a more intensive variant of affect breakthroughs / irritability / irritability / outbursts of rage.
There is a close relationship with impulsivity. Affect breakthroughs are characterized on the one hand by aggression and on the other hand by an impulsive (unchecked) outburst of the same.

For the neurophysiological correlates and background of aggression and its distinction into hot and cold aggression, see Neurophysiological correlates of aggression.

10.3.1. Irritability / affect breakthroughs Irritability / affect breakthroughs as an ADHD symptom

Irritability is a common (comorbid) symptom in ADHD.1226 Another apt description is “Pronounced irritability with frequent but brief outbursts of anger”.17

These symptoms are particularly prevalent in ADHD-HI and in ADHD-C.

  • Tantrums
    mostly short and violent, after 5 minutes everything is over
  • Emotional short-term intensive reactions
  • Connection with ODD tendencies? Irritability / affect breakthroughs as a symptom of stress

Irritability is a common symptom of stress,2728 as are anger and rage.28

Irritability is a typical symptom of impending burnout.29

10.3.2. Aggression Aggression as an ADHD symptom

Aggression can be regarded as a form of expression of stress (evidence for this in the following paragraph). However, it is a stress symptom that not all people express equally. We assume that people differ according to their phenotypic stress expression response, which can be externalizing (aggression, anger, motor hyperactivity) - where responses can be externalizing (ADHD-HI/ADHD-C = fight) or internalizing (ADHD-I subtype = flight/freeze). Internalizing at this point does not mean a psychoanalytical concept, but that stress is acted out much less externally. The subtype groups meant here tend to differ based on the biomarker of cortisol stress response. More on this in the article ADHD subtypes - The different types - ADHD-HI, ADHD-I, and others.

Higher reactive aggression tendency in ADHD “as a result of altered perception.”

Dietrich describes a higher aggression tendency in ADHD sufferers (also in sufferers who do not suffer from a comorbid ODD or behavioral disorder).30 Aggression in ADHD sufferers often arises from a misjudgment of situations, after which they defend themselves (subjectively “rightly”). ADHD sufferers thus show reactive (hot) rather than proactive (cold) aggressiveness.31 We fully share this view. See “Aggression as a symptom of stress”.

Dietrich sees this as a consequence of an excessive need for autonomy, which in ADHD-HI takes the form of an inappropriately aggressive defense against violations of this autonomy and in ADHD-I takes the form of an inappropriately strong cooperation with parents in order to avoid a possible confrontation.30 We only partly share the view that ADHD is a consequence of an excessive need for autonomy. We rather see a connection with Rejection Sensitivity.

With regard to the excessively conflict-shy behavior of ADHD sufferers, conflict avoidance seems to be well explained by Rejection Sensitivity.
Rejection Sensitivity - Fear of Rejection and Criticism as a Specific ADHD Symptom.
In our impression, however, this does not primarily serve an autonomy defense in the sense of a motive-driven (conscious or unconscious) reaction, but is the result of an internal blockade in the face of too many stimuli and possibilities (perceived as stress) in the form of a neurophysiological consequence of an excessive noradrenaline level that deactivates the PFC.
According to data from our ADxS symptom test (as of June 2020, n = 1889), Rejection Sensitivity correlates most strongly with Frustration Intolerance (0.56) and Aggression and Impatience (0.53 each). In the DSM/ICD/Wender-Utah scales, Rejection Sensitivity correlates most strongly with the Wender-Utah scale of emotional dysregulation (0.47). Aggression as a symptom of stress

Aggression is a common symptom of stress.2228

Stress alters the pattern of perception. In severe stress, the behavioral control of the individual is under the guiding principle that survival is acutely threatened. In ADHD, according to this view, the thresholds of the stress systems are altered in such a way that they are activated and switched off again far too frequently (ADHD-I) or remain permanently activated (ADHD-HI). Even if there is no acute stressor that could cause an uncontrollable (existence-threatening) threat, the stress systems designed for these threats are active.
Stress is unconsciously perceived as a threat by people with an externalizing stress response. People with an externalizing stress response react aggressively to threat more often than others.

We believe that all typical ADHD symptoms are typical stress symptoms, but that not all typical stress symptoms are also ADHD symptoms.

10.4. Emotional overreactivity

Noticeable problems coping with “everyday stressors” leading to the pervasive feeling of being overwhelmed.17
However, emotional hyperintensity is not limited to increased sensitivity to stress. For this, see below.

10.5. Frustration Intolerance

Frustration intolerance is a recognized ADHD symptom in children, which in adults is more noticeable as worsened self-control.32 In contrast, data from the ADxS symptom test (as of June 2020, n = 1889) show consistently high (rather even increasing) levels of frustration intolerance in adults in the 10-year age groups from 20 to 60
Stimulants improve symptoms through their direct dopaminergic effect on the nucleus accumbens. Children with ADHD show more emotionally intense reactions to frustrating, stress-inducing tasks and reduced competence in dealing with anger.263334

Analysis of nearly 2000 records from the symptom test showed that frustration intolerance correlated significantly more strongly with ADHD-HI than with ADHD-I.

10.5.1. Frustration intolerance as a symptom of stress

Frustration intolerance is a typical symptom of the final state of a burnout.29 Burnouts regularly result from too much stress for too long and thus from a stress situation that cannot be managed.

10.6. Self-perception disorders

10.6.1. Self-perception disorders as an ADHD symptom

Self-perception disorders are described as a common symptom of ADHD.3536

ADHD sufferers often have not only decreased mindfulness, but also a massive aversion to mindfulness techniques of all kinds, such as yoga, meditation, mindfulness training (MBSR), or the like.

10.6.2. Manifestations of self-perception disorders in ADHD Alexithymia (reduced perception of feelings)

Alexithymia is the inability to perceive one’s own feelings.

In the extreme form, those affected lack any emotional perception. Nausea and stomach pain are interpreted as purely physical symptoms, but not as possible anxiety. As with psychopathy (the inability to perceive others’ emotions), this occurs without any intention.
In the extreme form of the complete lack of ability to perceive emotions, alexithymia is quite rare. Affected persons in the extreme form are perceived by others as ice-cold and their behavior very quickly triggers aggression and rejection in others.

The (slight) reduction in the perception of one’s own emotions that frequently occurs in ADHD is unlikely to represent “true” alexithymia in the sense of an actually impaired sensory ability to perceive emotions per se, but rather merely a superimposition or suppression of emotional perception in the form of a defense mechanism caused by constant mental preoccupation
In line with the mechanism outlined under empathy, we hypothesize a functional sensory feeling perception ability with a co-existing processing problem.

Alexithymia seems to be more frequent in ADHD-HI than in ADHD-I. ADHD-affected children showed a flattened cortisol response to the TSST, the more they showed psychopathic traits (callous unemotional traits = CU-traits) such as lack of empathy, callousness, etc.37 Further studies also found elevated levels of callous unemotional traits in ADHD, which were associated with increased psychopathic traits, but without reaching the pathological range of psychopathy.3839 Further, a close association between callous unemotional traits and impulsivity in ADHD40 and with irritability and aggression41 has been described. Anhedonia (reduced perception of joy)

Anhedonia is an impairment or inability to feel pleasure or enjoyment from normally pleasant or enjoyable situations.

According to the data from the symptom test, ADHD sufferers perceive negative feelings significantly more strongly than positive feelings. The data show such a tendency in non-affected individuals as well, but this phenomenon is considerably more pronounced in ADHD sufferers.

Anhedonia is a core feature of depression, where it describes a reduction in the number and strength of positive and joyful responses.
In survivor guilt syndrome (a form of PTSD), anhedonia is the persistent inability to enjoy distractions. The latter is strongly reminiscent of the symptom of inability to relax and enjoy, which is typical in ADHD-HI. However, the symptom of anhedonia in ADHD correlates much more strongly with the ADHD-I subtype than with the hyperactive ADHD-HI subtypes
Anhedonia is observed in other disorders such as schizophrenia (negative symptomatology), schizoid, schizotypal, anxious-avoidant or dissocial personality disorders, psychoses, addictive disorders and psychosomatoses.

It is believed that alexithymia always triggers anhedonia, while anhedonia can trigger alexithymia but does not have to….42 In any case, there seems to be a correlation between anhedonia and alexithymia in mental disorders.43 Inner emptiness (when inactive) / boredom

ADHD sufferers often describe being plagued by boredom and inner emptiness. Boredom can be an original ADHD symptom and is supposed to be reduced by MPH medication in ADHD.44

Inner emptiness and boredom could possibly be explained conclusively as a consequence of the massively collapsing activation of the frontal cortex during inactivity.

To understand this mechanism, a look at the phenomenon of hyperfocus helps.

ADHD is subject to devaluation of more distant rewards (reward discounting): Rewards that are more distant are less interesting to ADHD sufferers than to nonaffected individuals. Therefore, only when rewards are immediately available are ADHD sufferers as motivable as non-affected individuals. This is the counter-effect of hyperfocusing: ADHD sufferers may very well focus on something once they have begun an activity that gives them satisfaction, because the reward that then immediately arrives keeps the reinforcement center active. However, this interest is much harder to achieve due to the lower number of dopamine D2 and D3 receptors in the striatum.45
This latent disinterest in the absence of reward during the performance of uninteresting activities and the impaired ability to start an interesting activity by oneself (only the maintenance of a started interesting activity is promoted by corresponding dopamine release) could correspond to the symptom of inner emptiness (during inactivity) described by many ADHD sufferers. The feeling of inner emptiness and dysphoria during inactivity seem to belong closely together. Overestimation of one’s own social skills

This symptom is not so severe as to be considered carrying for ADHD.

In a test group of n = 82 girls aged 9-12 years, the n = 42 ADHD sufferers overestimated their social skills significantly more than non-affected compared to external assessments (teachers, parents, and third-party observers). If oppositional defiant behavior was added, this increased further, as did decreased depression symptomatology. Overestimation of self correlated only in ADHD sufferers with the tendency of sufferers to give responses in the direction of Social desirability (socially desirable reporting bias). In ADHD sufferers, self-overestimation of social competence was linked to measures of imbalance. With increasing balance, self-overestimation decreased, whereas it increased with balance in non-affected individuals.

We interpret this, especially due to the bias towards social desirability, as an effect of ADHD-typical rejection sensitivity. Now is always

For those who cannot perceive the here and now positively, “Now is always” is an expression of a state of pain.

We perceive a kind of temporal digitalization in ADHD sufferers. If something feels bad at the moment, it is interpreted as if this is now the case forever and ever and for all time, so there is no way out
It might be somewhat comparable to the black and white thinking that is often strong in Borderline: All or nothing, now is now, there is no gray, there is no after or later. Increased subjective perception of stress in ADHD

In addition to the ADHD-typical symptoms, which are also stress symptoms, the subjective perception of stress is increased in ADHD. The same physiological (measurable) stress suffered is followed by a higher (subjective) perception of stress than in non-affected persons.
An increased perception of stress could be a consequence of an increased “now is always” perception. If a stressful state is simultaneously perceived as never ending, this may result in a decreased perception of control and an increased perception of helplessness (and subsequently hopelessness), which are known to be strong stress-increasing factors
See below and atSubjective stress response in ADHD increasedt

10.6.3. Self-perception disorders as stress symptoms

Self-perception disorders are a typical symptom of severe stress. A worsened self-perception occurs, which can lead to an inability to recover. Alexithymia as a symptom of stress

Alexithymia (decreased perception of emotion) can be a symptom and consequence of stress:

  • Reduced perception of own feelings46
  • Avoidance of feelings (coolness)47
  • Low emotional self-control and spontaneity of feelings48
  • Emotional flattening (with persistent sickliness) is a typical symptom of the final state of burnout29 Anhedonia as a symptom of stress

Anhedonia can be triggered by stress (stress-induced anhedonia).4950

Animal studies showed that the MAO-A inhibitor moclobemide prevented the development of anhedonia under stress51 and that the SSRI escitalopram could reduce stress-induced anhedonia, although escitalopram normalized the thereby decreased gene expression level for BDNF in the hippocampus but not the decreased gene expression level of the D2 receptor gene in the striatum.52

10.7. Self-esteem issues

ADHD sufferers have pronounced self-esteem problems.53
A comprehensive account of self-esteem problems in ADHD can be found at
ADHD symptom severity correlates with self-esteem, life satisfaction, and depression traits.
There is a clear correlation between55

  • ADHD-HI symptoms
    (determined with ADHD screening for adults [ADHD-E])
  • Lowered life satisfaction
    (determined with the Satisfaction With Life Scale [SWLS]; cf. Diener, Emmons, Larsen & Griffin, 1985) and
  • The increase in the expression of depression symptoms
    (determined with the depression module of the Patient Health Questionnaire [PHQ-9]; cf. Kroenke, Spitzer & Williams, 2001)

When ADHD-HI is combined with Conduct Disorder (CD) or aggressive behavior or Oppositional Defiant Disorder (ODD), self-esteem is significantly lower than in ADHD-HI alone or nonaffected individuals.56

ADHD treatment (medication as well as non-drug treatment) improves self-esteem and social behavior.57

10.7.1. Rejection sensitivity and fear of rejection

For Rejection Sensitivity are characteristic:

  • Sickliness
  • Anxious expectation of rejection
  • Willing acceptance of rejection and
  • Intense reaction to (real or perceived) rejection

In Rejection Sensitivity (RS), which is known in quite a few mental disorders, there is no general inability to criticize or narcissistic tendency, but a particular sensitivity in the sense of a fear of rejection or rejection.
Nearly every ADHD sufferer we interviewed reported rejection sensitivity. Similarly, it was almost unanimously reported that this symptom was improved by stimulants (during the period of action). Dodson reported immediate effects of clonidine and guanfacine.
That ADHD-affected children were more sensitive to punishment than non-affected children,58 could be a reflection of RS.

Rejection Sensitivity could be understood as a direct expression of insecure attachment. Insecure attachment is known to be a risk factor for ADHD. See more at Attachment Styles In the chapter Prevention.

Rejection Sensitivity correlates primarily with frustration intolerance (0.56) and impatience and aggression (0.53 each) according to the symptom test (as of Jun 2020, n = 1889). The correlation with externalizing stress phenotype (0.42) (ADHD-HI) is significantly more pronounced than with internalizing stress phenotype (0.26) (ADHD-I). This is consistent with Rejection Sensitivity being fundamentally more likely to correlate with hypocortisolergic states such as atypical depression.59 Rejection Sensitivity further correlated with a flattened alpha-amylase stress response as well as more negative affect in healthy adolescents.60

We consider Rejection Sensitivity as an original neurophysiological symptom of ADHD.
Rejection Sensitivity - Fear of rejection and criticism as a specific ADHD symptom Rejection Sensitivity / Offense Sensitivity and Stress

Increased sickliness is a typical symptom of the end state of burnout29 and atypical depression.61 It is certain that burnout can result from too much stress for too long and thus from a stress situation that cannot be managed.
We have not yet been able to find any other descriptions of grievability / rejection sensitivity as a direct symptom of stress. In contrast, research suggests that Rejection Sensitivity has a significant impact on perceived stress.626364 Schizophrenia sufferers who are very concerned about being rejected by neighbors or work colleagues appeared to be more prone to perceive stigma as a stressor.65
Stress appears to be a mediator linking Rejection Sensitivity and Depression.66

10.7.2. Tend and Befriend

The opposite stress symptom to Rejection Sensitivity is a particular approach to others. This behavior is much more pronounced in women than in men and represents another behavioral alternative to fight, flight or freeze.
The biobehavioral mechanism of the tend-and-befriend mechanism is thought to be anchored in the attachment-supply system. Neuroendocrine findings suggest that oxytocin may be involved in endocrinological correlates in conjunction with female reproductive hormones and endogenous opioid peptide mechanisms.67

10.7.3. Perfectionism as an ADHD symptom

Perfectionism is often described as a symptom by ADHD sufferers.

ADHD sufferers often suffer from impaired performance due to their distractibility, forgetfulness and concentration problems. In addition, ADHD sufferers’ self-perception of their performance often seems considerably more negative than would be appropriate in reality. This symptom of an imagined underperformance (which goes beyond the actual performance impairment) could be a consequence of a dysfunctional perfectionist claim that is quite often found in ADHD. Manifestations of perfectionism

Functional (existing in a healthy degree) perfectionism strongly coincides with conscientiousness. Dysfunctional (excessive) perfectionism correlates with neuroticism. Perfectionism can be expressed in an (excessive) striving for perfection (as an approach goal) and/or in an (excessive) striving for error avoidance (as an avoidance goal).

Symptoms of dysfunctional perfectionism:

  • Excessive feeling of being an underachiever
  • Consider themselves lazy, although this is not objectively justified
  • Actions are exaggerated to safely exclude errors
    (less ADHD-typical, sometimes occurs as a coping mechanism)
    • Set off much too early not to be late, despite known route
    • Extremely tidy home (also reduces distractibility by minimizing stimuli)
  • Excessive control
    • Multiple control of own and external actions to protect against errors
  • Repeat and improve
    • Repetition of actions until perfect result is achieved (less ADHD-typical)
    • Improve others if result is not optimal
  • Intensive planning and organizing
    • Soft spot for (check-)lists / to-do lists
  • Decision problems
    • Fear of making the less than optimal choice/decision
  • Difficulties to finish projects
    • Cannot complete editing because result does not seem perfect enough yet
    • Avoidance of the start / continuation of activities
      • Where result could not be perfect
      • Where target could not be achieved
  • Problems delegating tasks
    • Prefer to do yourself, so that the result will be optimal.

Dysfunctional perfectionism can be an expression of an increased fear of not meeting others’ demands. This symptom is thus reminiscent of Rejection Sensitivity, which is a shift in perception towards an increased fear of perceived or actual rejection by third parties.

There are other disorders with faulty self-perception, e.g., anorexia, which involves body schema disorder.
Anorexia has been associated with abnormalities in ventral and dorsal brain areas (including the insula and striatum), as well as abnormalities in serotonin and dopamine balance.68
The striatum and the neurotransmitters dopamine and serotonin are also involved in the development of ADHD symptoms. Nevertheless, anorexia nervosa is rather rarely a comorbidity of ADHD. Perfectionism and stress

Perfectionism appears to moderate the stress response to an existing stressor.69

10.7.4. Self-esteem problems as symptoms of stress

Self-esteem problems are typical symptoms of severe stress.7048
Low self-esteem often correlates with

  • Self-hate
  • Suicidal tendency
  • Guilt and shame

This is equally true for listlessness,2223 which could be considered the equivalent of dysphoria when inactive, and feeling depressed.2223

In particular, a perceived uncontrollable threat to self-esteem triggers cortisol release.7172

Feelings of inferiority and failure are typical symptoms of the final state of burnout.73

10.8. Anxiety

10.8.1. Increased anxiety as an ADHD symptom

ADHD is often accompanied by increased anxiety.7475
Anxiety in ADHD appears to be strongly moderated by executive problems76

Anxiety/fearfulness is not supposed to be an original ADHD symptom according to some other voices. This is questionable insofar as anxiety/anxiousness is a symptom directly mediated by the stress hormone CRH (injected CRH increases anxiety). In ADHD, there is at least a high comorbidity to anxiety disorders, which occur in 34% of ADHD sufferers.

10.8.2. Catastrophize

Many sufferers report that they often make the worst assumptions in their minds. The relevant forums deal with this topic intensively.
The literature has not yet discussed this as a specific ADHD symptom.

If thoughts frequently revolve around worst-case scenarios, this has the advantage in a survival-threatening situation of being better prepared for various dangerous alternatives.

Anxiety symptomatology in ADHD is in tension with risk-taking, which is often increased in ADHD. Data from the symptom test show that anxiety symptoms in ADHD correlate primarily with rejection sensitivity and self-esteem problems. Further, Anxiety correlates significantly more strongly with the ADHD-I subtype than with the ADHD-HI subtypes, although this imbalance is not as pronounced as with Risk Taking, which correlates even more significantly with the ADHD-HI subtypes and even less with the ADHD-I subtypes. (n = 1889, as of June 2020).

10.8.3. Increased anxiety as a symptom of stress

Anxiety/fear is a symptom of stress.2377

Increased anxiety, increased fear conditioning, and increased caution in unfamiliar environments, open field, elevated plus maze, and conflict are direct effects of the stress hormone CRH.7879

Anxiousness depends on the stress phenotype. Anxiousness is mainly observed in people who internalize stress (ADHD-I). If such symptoms, which only occur in certain stress phenotypes, were not to be regarded as original ADHD stress symptoms, hyperactivity as a specific stress symptom of the externalizing stress phenotype would also have to be eliminated from the canon.

10.9. More sensitive response to penalties

ADHD-affected children were more sensitive to punishment than non-affected children.58

10.10. Stress intolerance / more sensitive reaction to stress

ADHD sufferers experience stress more intensely.8081

See⇒ for more information Subjective stress response increased in ADHDt

We consider stress intolerance to be a central symptom of ADHD. We suspect ADHD is associated with permanent damage to stress regulatory systems (primarily the HPA axis). This does not say that ADHD would be a causal consequence; however, ADHD probably mediates quite a few symptoms via disturbances in stress response systems.
ADHD as a chronicized stress regulation disorder ADHD symptoms are symptoms of stress Stress damage - effects of prolonged stress

The findings from stress research on which this view is based were first understood in the 1990s and have crystallized and condensed ever more clearly in recent years. To understand how far-reaching these findings are and how much they will change not only the treatment of mental disorders, but above all the prophylaxis for them, we recommend the German-language standard works on stress medicine

10.11. Hypersexuality

An anonymous online survey found increased hypersexual behavior, particularly among women with ADHD.
Hypersexual behavior, sexual risk-taking, and sexual dysfunction were closely related to emotional dysregulation, impulsivity, and oppositional symptoms, particularly in women.
In males with ADHD, the associations were less clear, but tended to be correlated with emotional dysregulation as well.82

The symptoms

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