10. Emotional dysregulation / emotional symptoms in ADHD

Author: Ulrich Brennecke
Review: Dipl.-Psych. Waldemar Zdero

Emotional dysregulation is an original symptom of ADHD^{12 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21} Wender named emotional volatility as a symptom of ADHD as early as 1971.²² Barkley refers to this as Deficient emotional self-regulation (DESR)³²³ , others Deficient emotional regulation (DER)²⁴.Studies found emotional dysregulation in 25% to 45% of children with ADHD and in 34%²⁵ to 70%^{2627 28 29 30 31 32} of adults with ADHD.³³
Original means that ADHD can trigger the symptom directly and immediately, but not that the symptom occurs exclusively with ADHD. Emotional dysregulation can therefore result originally from ADHD, but can also be caused by other disorders.
In some cases, emotional dysregulation is not regarded as an original symptom of ADHD, but as a comorbid dimension in its own right.²⁷²⁴ In a study with n = 102 children, emotional problems alone correlated with emotional lability, whereby it made no difference whether ADHD was present or not. In persons with ADHD, emotional lability only led to additional behavioral problems compared to non-affected people.³⁴ Two larger studies found moderate to weak correlations between ADHD leading symptoms and mood symptoms,³⁵³⁶ one smaller study found a strong correlation between cognitive and emotional problems in ADHD.³⁷ One study concluded that emotional dysregulation was linked between ADHD and gambling addiction.³⁸ A study on emotional dysregulation and aggression in ADHD found ADHD symptoms associated with both emotional lability and aggression, but emotional lability did not mediate the association between ADHD and aggression. Rather, increased aggression in ADHD appeared to have other causes.³⁹

Barkley had suggested including emotional dysregulation in the DSM-5 symptom list of ADHD.³¹ The fact that emotional dysregulation is nevertheless not listed as a symptom of ADHD in the current editions of the Statistical Manuals for the Classification of Diseases (DSM and ICD) is due to the fact that DSM and ICD only name the diagnostic symptoms, i.e. those that distinguish ADHD particularly well from other disorders.⁴⁴⁰⁴¹ More on the limitations of DSM and IDC in diagnosis and treatment at ⇒ ** DSM and IDC as diagnostic tools.

Emotions are temporary, qualitative states that are accompanied by a change at the level of feelings, expression and physical states.²⁹
There are various forms of emotional dysregulation in ADHD. One of these is emotional hyperreactivity, in which the speed and intensity of mood changes is increased. Another form is emotional hyporeactivity, which is characterized by anhedonia (reduced ability to feel pleasure) and alexithymia (reduced awareness of one’s own emotions).
Dysphoria with inactivity is an often overlooked and severe symptom of ADHD that is closely linked to self-esteem and often leads to an inability to relax. Dysphoria with inactivity occurs when the person with ADHD comes to rest and self-evaluates. A mood dip at this moment can lead to a distortion of self-esteem.
In addition to mood swings, emotional dysregulation also includes aggression, anxiety and depression.

Emotional dysregulation is one of the most serious and stressful ADHD symptoms for people with ADHD and those around them.
Emotional dysregulation causes much more serious impairments in the quality of life of people with ADHD than hyperactivity or inattention.⁴² Specific emotion regulation problems mean that ADHD indirectly increases the frequency of suicidal thoughts in comorbidly depressed persons with ADHD.⁴³
It is obvious that people with ADHD with inadequate emotional impulses hurt others more often and in turn experience rejection more often themselves. As people with ADHD can recognize the inappropriateness of their own emotions from a little distance, this leads to an awareness of “I feel wrong”. This can cause a deep sense of inadequacy, which is a deep root of self-esteem issues. What could be worse than the experience of feeling “wrong”? How far is it from that to the sentence “I am wrong”? And how much strength does it take to cope with these inaccurate emotions in order to get by in (social) life?

Emotional dysregulation can manifest itself in mood swings, irritability, social difficulties, conflicts in relationships as well as self-perception and self-esteem problems.
People with ADHD often have mood swings, which can be exacerbated by (dysphoria during) inactivity. The mood changes quickly and can be more intense than in people who are not affected.
Irritability and emotional outbursts are common symptoms of ADHD. People with ADHD can quickly become irritable and aggressive. These symptoms are closely linked to impulsivity.
People with ADHD often have difficulty coping with stressors in everyday life and often feel overwhelmed. They may have difficulties dealing with frustration (frustration intolerance).
Self-perception disorders such as alexithymia (reduced perception of emotions) and anhedonia (reduced perception of pleasure) are common in ADHD. People with ADHD can suffer from boredom and inner emptiness.
Self-esteem problems are also common with ADHD. People with ADHD often have low self-esteem and experience a negative self-perception.
Rejection Sensitivity (increased offendedness, anxious anticipation of rejection) is another common symptom of ADHD.
People with ADHD can tend to overestimate their social skills. It is assumed that this is related to insecure attachment.
Perfectionism can have functional or dysfunctional forms. Dysfunctional perfectionism often goes hand in hand with an exaggerated striving for perfection and avoidance of mistakes. Symptoms can include a feeling of underachievement, excessive checking, repetitive actions and difficulties in making decisions.
Anxiety is a common symptom of ADHD and can be influenced by executive problems. Anxiety symptoms are often associated with rejection sensitivity and self-esteem issues.
Children with ADHD have an increased risk of being rejected by their peers, which can lead to a lack of social support and social withdrawal.
Overall, the emotional symptoms of ADHD are diverse and affect the mood, emotions, behavior and self-perception of people with ADHD.

Emotional dysregulation in ADHD (and autism) has been linked to specific dopaminergic gene variants in one study.⁴⁴ Neurophysiological correlates have not yet been found.²⁹
The severity of ADHD symptoms correlates with more negative emotions.⁴⁵
Emotional dysregulation occurs more frequently in ADHD (with hyperactivity), in women with ADHD and correlates with greater symptom severity.²⁹
One study found a link between hyperactivity/impulsivity and emotional dysregulation, but not between inattention and emotional dysregulation.¹⁴ This study also reported that working memory deficits contribute to emotional dysregulation. This does not correspond directly with the 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 with impatience (0.79) and inner restlessness (0.76). Organizational 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 in line with the study by Schutko et al⁴⁶

A screening test is currently being developed.⁴⁷ We have not yet been able to find a usable version.

Emotional dysregulation in ADHD can be improved by treatment with ADHD medications such as MPH.⁴⁸ In our experience, atomoxetine is even more effective for emotional dysregulation than stimulants. If necessary, combination medication can be helpful.

• Forms of emotional dysregulation in ADHD
  • E. Excursus: What is emotional dysregulation?
    • E.1 Mood swings are affective disorders
      • E.1.1 Affect quality = which emotion
      • E.1.2 Affect regulation = appropriateness and intensity of an emotion
        • E.1.2.1 Affect adequacy = appropriateness of the emotion quality = “suitable” emotion
        • E.1.2.2 Affect intensity = intensity of emotion
        • E.1.2.3 Affect deflectability or stability.
    • E.2 Affective and emotional temperaments and mental disorders
    • E.3 Further concepts
  • 10.1. Dysphoria with inactivity
  • 10.2. Irritability and aggression
    • 10.2.1. Irritability / emotional outbursts
      • 10.2.1.1. Irritability / emotional outbursts as an ADHD symptom
      • 10.2.1.2. Irritability / emotional outbursts as a symptom of stress
    • 10.2.2. Aggression
      • 10.2.2.1. Aggression as an ADHD symptom
      • 10.2.2.2. Aggression as a stress symptom
  • 10.3. Altered emotional reactivity: over-intensity to alexithymia
    • 10.3.1. Emotional hyperreactivity
      • 10.3.1.1. Mood swings with ADHD
      • 10.3.1.2. Mood swings as symptoms of stress
      • 10.3.1.3. Emotional intensity
    • 10.3.2. Emotional hyporeactivity
      • 10.3.2.1. Anhedonia in ADHD
      • 10.3.2.2. Alexithymia (reduced emotional perception)
        • 10.3.2.2.1. Differentiation of alexithymia from similar disorders
        • 10.3.2.2.1.1. Callous-unemotional traits
        • 10.3.2.2.1.2. Split-brain problem
        • 10.3.2.2.2. Causal models of alexithymia
        • 10.3.2.2.2.1. Impaired exchange of information between brain hemispheres
        • 10.3.2.2.2.2. Impairment of individual brain regions
        • 10.3.2.2.2.3. Psychological explanatory models
        • 10.3.2.2.3. Alexithymia as a stress symptom
        • 10.3.2.2.4. Testing for alexithymia
        • 10.3.2.2.5. Treatment of alexithymia
  • 10.4. Frustration intolerance
    • 10.4.1. Frustration intolerance as a stress symptom
  • 10.5. Self-perception disorders
    • 10.5.1. Self-perception disorders as an ADHD symptom
    • 10.5.2. Manifestations of self-perception disorders in ADHD
      • 10.5.2.1. Alexithymia
      • 10.5.2.2. Anhedonia (reduced perception of pleasure)
      • 10.5.2.3. Inner emptiness (with inactivity) / boredom
      • 10.5.2.4. Overestimating one’s own social skills
      • 10.5.2.5. Now is always
      • 10.5.2.6. Increased subjective perception of stress in ADHD
    • 10.5.3. Anhedonia as a stress symptom
  • 10.6. Self-esteem problems
    • 10.6.1. Rejection sensitivity - offendedness and fear of rejection
      • 10.6.1.1. Rejection sensitivity / Offensiveness and stress
    • 10.6.2. Tend and Befriend
    • 10.6.3. Perfectionism as an ADHD symptom
      • 10.6.3.1. Manifestations of perfectionism
      • 10.6.3.2. Perfectionism and stress
    • 10.6.4. Self-esteem problems as symptoms of stress
    • 10.6.5. Self-esteem-enhancing medication
  • 10.7. Anxiety
    • 10.7.1. Increased anxiety as an ADHD symptom
    • 10.7.2. Catastrophize
    • 10.7.3. Increased anxiety as a symptom of stress
  • 10.8. More sensitive reaction to penalties
  • 10.9. Stress intolerance / more sensitive reaction to stress
  • 10.10. Hypersexuality
  • 10.11. Impatience

Forms of emotional dysregulation in ADHD¶

10.1. Dysphoria with inactivity¶

Dysphoria with inactivity was already reported by Wender around the turn of the millennium as an ADHD symptom in adults. It occurs in very many, but not all, people with ADHD. In our opinion, it is one of the most underestimated and severe ADHD symptoms. Dysphoria during inactivity is closely linked to self-esteem. While dysphoria does not occur during activity (at work, during the day), it occurs as soon as the person with ADHD comes to rest. But it is precisely in these moments of rest that the day is reflected upon: What did I manage to do today? What went well, what went badly? It is the moment of self-evaluation. If a slump in mood occurs in this state, this naturally leads to a distortion of the self-assessment scale and thus to a massively impaired self-esteem.

See also ⇒ Dysphoria during inactivity (passivity-induced low mood, to be distinguished from depression) Under drive problems.

ADHD is still far too often misdiagnosed as depression.
See in detail: ⇒ Depression and dysphoria in ADHD (from the perspective of differential diagnosis).

10.2. Irritability and aggression¶

Affective outbursts / irritability / irritability / outbursts of anger can be regarded as a momentary, situational manifestation of aggression in the broader sense. Aggression in the narrower sense can also be described as a more intensive variant of emotional outbursts / irritability / irritability / outbursts of anger.
There is a close relationship with impulsivity. Affective outbursts are characterized on the one hand by aggression and on the other by an impulsive (unrestrained) outburst of the same.

For the neurophysiological correlates and background of aggression and the distinction between hot and cold aggression, see ⇒ Neurophysiological correlates of aggression.

10.2.1. Irritability / emotional outbursts¶

10.2.1.1. Irritability / emotional outbursts as an ADHD symptom¶

Irritability is a common (comorbid) symptom of ADHD.¹⁵⁵² Another apt description is “marked irritability with frequent but brief outbursts of anger”.⁵³⁵⁴
These symptoms occur in particular in people with ADHD-HI or ADHD-C who, due to the subtype, act out stress and have impaired impulse control.

• Outbursts of anger
  usually short and intense, after 5 minutes it’s all over
• Emotional short-term intensive reactions
• Connection with ODD tendencies?

10.2.1.2. Irritability / emotional outbursts as a symptom of stress¶

Irritability is a common symptom of stress,⁵⁵⁵⁶ as are anger and rage.⁵⁶

Irritability is a typical symptom of impending burnout.⁵⁷

10.2.2. Aggression¶

10.2.2.1. Aggression as an ADHD symptom¶

More than half of all children with ADHD-C are said to exhibit clinically significant aggression, particularly of the impulsive subtype⁵⁸
Impulsive aggression is a strong predictor of an unfavorable developmental course with persistent ADHD, increasing psychosocial distress, accumulating comorbidities, severe lifelong functional deficits, delinquency and antisocial behavior in adulthood. Impulsive aggression can trigger a vicious cycle of peer rejection and escalating dysfunction, which favors psychosocial sequelae of ADHD.⁵⁸
If stimulants and behavioral therapy do not sufficiently improve severe aggressive behavior, treatment with medication that specifically targets aggressive behavior is possible.⁵⁸

The quota mentioned seems to us to have been translated, but the problem is relevant.

Among other things, aggression can be seen as a form of stress (see the following paragraph for evidence). However, it is a stress symptom that not all people express in the same way. We assume that people differ according to their phenotypic stress expression reaction - whereby the reactions can be externalizing in the form of aggression, anger, motor hyperactivity (ADHD-HI/ADHD-C = fight) or internalizing (withdrawal, eating into oneself) (ADHD-I subtype = flight/freeze). Internalizing here does not refer to a psychoanalytical concept, but rather that stress is much less acted out externally. The subtype groups referred to here tend to differ based on the biomarker of the 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 consequence of altered perception”.

Dietrich describes a higher tendency towards aggression in people with ADHD (even in persons with ADHD who do not suffer from a comorbid ODD or behavioral disorder).⁵⁹ Aggressiveness in people with ADHD often arises from a misjudgement of situations, after which they defend themselves (subjectively “rightly”). People with ADHD therefore show reactive (hot) and not proactive (cold) aggression.⁶⁰ We fully share this view. See “Aggression as a stress symptom”.

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 inappropriately strong cooperation with the parents in order to avoid a possible confrontation.⁵⁹ We only partially share the view that ADHD is a consequence of an excessive need for autonomy. Rather, we see a connection with rejection sensitivity.

10.2.2.2. Aggression as a stress symptom¶

Aggression is a common symptom of stress.⁶¹⁵⁶

Stress changes the pattern of perception. In cases of severe stress, the individual’s behavioral control is under the guiding principle that survival is acutely threatened. In ADHD, according to this view, the threshold values of the stress systems are so altered 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.
People generally perceive stress unconsciously as a threat. However, people with an externalizing stress response react aggressively to threats 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.

10.3. Altered emotional reactivity: over-intensity to alexithymia¶

Different types of emotional dysregulation are described in ADHD (and not only there). According to our as yet unverified hypothesis, these opposing forms could possibly be different manifestations of the same disorder, which merely shows different manifestations depending on the type of disorder, comparable to hyperactivity in ADHD-HI and hypoactivity in ADHD-I, which in our view represent different phenotypes of the stress response: externalizing and internalizing.

10.3.1. Emotional hyperreactivity¶

In ADHD, firstly the speed of mood changes is often above average and secondly the intensity of the emotions is excessive.

10.3.1.1. Mood swings with ADHD¶

Emotional overreactivity is described as “frequent rapid mood swings”, as a frequent and rapid change from “elated” to “saddened to death”, between normal mood, sadness and mild excitement.⁵³
People with ADHD 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.⁶²⁶³
The mood of people with ADHD appears to be influenced to an above-average extent by their immediate momentary experience, i.e. it tends to refer to shorter periods of time than people without ADHD. This also applies to people with ADHD, borderline personality disorder, bipolar disorder and depression. In ADHD, the perception of time is often altered.

10.3.1.2. Mood swings as symptoms of stress¶

Mood swings are known as stress symptoms:

• Frequent sadness,⁶⁴ frequent depression, depression.^65616661
• Despair⁶⁷
  • Despair is a direct effect of the stress hormone CRH.⁶⁸

10.3.1.3. Emotional intensity¶

Many people with ADHD report increased emotional intensity. Unfortunately, this seems to mostly relate to negative emotions. Increased emotional intensity is also often associated with increased sensitivity, which we believe is one of the core symptoms of ADHD.

10.3.2. Emotional hyporeactivity¶

10.3.2.1. Anhedonia in ADHD¶

A common symptom of ADHD is anhedonia. Anhedonia is a reduced ability to feel pleasure. In contrast to alexithymia, the ability to perceive negative emotions is retained in the latter. Anhedonia is therefore likely to be more strongly associated with motivational problems than alexithymia.

One known neurophysiological cause of anhedonia is endotoxins, which mediate anhedonia via increased levels of proinflammatory cytokines, in particular TNF (tumor necrosis factor).
Find out more at ⇒ Immune system and behavior.

10.3.2.2. Alexithymia (reduced emotional perception)¶

Furthermore, people with ADHD often report a significantly reduced emotional intensity, an inner emptiness. This is even more common in borderline and depression. This inner lack of emotion must be distinguished from certain neurophysiological phenomena (split brain) or disorders related to psychotic patterns (callous unemotional traits), which have nothing to do with ADHD. In our opinion, symptoms similar to alexithymia in ADHD are not consequences or correlates of neurophysiological specifics, but rather the result of an inability to relax and an aversion to relaxation, which can also be understood as a stress symptom of “not being able to relax”. The phenomenon that an excess of mental analytical activity can cause a lack of feeling describes the same process.

Alexithymia is a weakened perception of all one’s own emotions (both positive and negative), also known as emotional blindness, emotional coldness or emotional dyslexia. A generally understandable explanation of alexithymia, including a simple test, can be found at lernen.net.⁶⁹ A general article on alexithymia worth reading was published in 2009 in Die Zeit.⁷⁰

Alexithymia is the inability to perceive and name feelings. This applies in particular to one’s own feelings, but also to the feelings of others.
In the extreme form, people with ADHD 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 the emotions of others), this occurs without any intention.
Alexithymia is quite rare in the extreme form of a complete lack of ability to perceive emotions. People with ADHD in its 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 “real” alexithymia in the sense of an actually impaired sensory ability to perceive emotions per se, but merely a superimposition or suppression of emotional perception in the form of a defense mechanism caused by constant mental preoccupation
In accordance with the mechanism described under empathy, we assume a functional sensory ability to perceive feelings with a simultaneous processing problem.

Alexithymia appears to be more common in ADHD-HI than in ADHD-I. The stronger the psychopathic traits (callous unemotional traits = CU traits) such as lack of empathy, callousness, etc., the flatter the cortisol response to the TSST in children with ADHD.⁷¹ Further studies also found increased levels of callous unemotional traits in ADHD, which were associated with increased psychopathic traits, but without reaching the pathological range of psychopathy.⁷²⁷³ Furthermore, a close connection between callous unemotional traits and impulsivity in ADHD⁷⁴ and with irritability and aggression⁷⁵ was described.
In addition, many people with ADHD have considerable difficulty recognizing and controlling the expression of their own emotions.⁷⁶

One study found severe alexithymia in 22% of the adult people with ADHD examined. 40% met the DSM IV criteria for social phobia. Alexithymia is associated with difficulties in accepting one’s own feelings and correlated highly with social phobia in the aforementioned study.⁷⁷
Normally, alexithymia has a prevalence of 10% (men: 11.1%, women: 8.9%).⁷⁸ The prevalence in ADHD is therefore slightly more than doubled. Alexithymia also occurs more frequently in combination with other disorders than alone, e.g.

• Alcohol abuse⁷⁹⁸⁰
• Gambling addiction⁸¹
• Food allergies⁸²

The prevalence is⁷⁸

• Eating disorders: 39.6 % - 77 %
• Rheumatoid arthritis: 54 %
• Hypertension: 55.3 %
• Depressive disorders: 45 %
• Ulcerative colitis/Crohn’s disease: 37.5 %
• Asthma: 36 %

Trauma is also thought to trigger a reduction or blockage of feeling through a posteriorization of brain activity, i.e. a shift in behavioral control from younger, more frontal brain areas to older, more posterior brain areas.
Severe stress in early childhood can lead to a reduced corpus callosum, which connects the cerebral hemispheres.⁸³ Dysfunction of the corpus callosum is a major cause of alexithymia.

Alexithymia (of the parents) reduces respectful parental behavior and promotes authoritarian or permissive parental behavior.⁸⁴

10.3.2.2.1. Differentiation of alexithymia from similar disorders¶

Alexithymia is separate from callous-unemotional traits and the split-brain problem.

10.3.2.2.1.1. Callous-unemotional traits¶

Callous-unemotional traits refer to a persistent disregard for others, caused by a lack of empathy and a general lack of affect. Symptoms are weak, flattened emotions and low empathy. Callous-unemotional traits therefore have a clear (anti)social component that alexithymia lacks.

The severity of symptoms of callous-unemotional traits correlates negatively with connectivity between the amygdala and ventromedial prefrontal cortex.⁸⁵

Cold aggression is associated with reduced emotionality (callous unemotional traits, reduced empathy).⁸⁶

Cortisol and testosterone levels are elevated in callous-unemotional traits.⁸⁷
Higher CU values correlated with increased activity of the dlPFC in the perception of fearful faces.⁸⁸

Low dietary magnesium intake is thought to correlate with callous-unemotional traits.⁸⁹

Conduct disorder is a separate disorder, but it is often comorbid with ADHD. In one study, a link between conduct disorder and ADHD was not mediated by Callous unemotional traits or theory of mind ability (here: Reading the Mind in the Eyes Test). Callous unemotional traits were associated with conduct disorder, but independent of ADHD symptom severity.⁹⁰

10.3.2.2.1.2. Split-brain problem¶

Alexithymia can be distinguished from a split-brain problem in that in alexithymia the feelings are only perceived more weakly or cannot be named, whereas in split-brain all the processes taking place in the right hemisphere of the brain are completely inaccessible to the left hemisphere (which houses the descriptive processes).⁹¹ Alexithymia is therefore part of the split-brain problem.

10.3.2.2.2. Causal models of alexithymia¶

The following presentation is largely based on the compilation by Naundorf⁷⁸, unless otherwise indicated.

10.3.2.2.2.1. Impaired exchange of information between brain hemispheres¶

The two hemispheres of the brain have different tasks with regard to the perception and processing of information and the control of processes.

Right hemisphere:

• Unconscious information
• Emotional information
• Non-verbal information
• Attachment behavior (via oxytocin)
  • Impaired bonding ability in alexithymia indicates dysregulation of the right
    Hemisphere
  • Stroke patients with a lesion in the right hemisphere have significantly higher TAS-20 values than those with a lesion in the left hemisphere

Left hemisphere:

• Conscious, analytical processes
• Verbal processes
• Ongoing processes

An exchange between the two hemispheres via the corpus callosum that connects them is necessary in order to consciously perceive and verbalize emotional stimuli.

Alexithymia (more common in men than in women) could be a transfer disorder of the corpus callosum, which connects the two hemispheres of the brain.⁹² Patients with agenesis (= absence, atrophy) of the corpus callosum show alexithymic traits, as do epileptics after a commissurotomy (= callosotomy = severing of the corpus callosum).
A reduced exchange between the brain hemispheres appears to be a cause of alexithymia, particularly in PTSD, as well as a dysfunction of the cortisol stress response.⁹³

10.3.2.2.2.2. Impairment of individual brain regions¶

Alexithymia is associated with changes in the

• Anterior cingulate cortex
• Amygdala
  • Lower right hemispheric activation with negative visual stimulus (disgust)
• MPFC
  • Lower right hemispheric activation with negative visual stimulus (disgust)
• Cingulate gyrus
  • Lower activation in women with a negative visual stimulus
• Motor cortex
  • More active in processing emotional visual stimuli
• Sensory cortex
  • More active in processing emotional visual stimuli

In alexithymia, a lower cerebral blood flow was found in the ventral and dorsal parts of the cingulate gyrus, which is increasingly supplied with blood during the perception of emotionally charged stimuli (films).

10.3.2.2.2.3. Psychological explanatory models¶

It is assumed that even in neurologically healthy subjects (without structural lesions) a “functional comissurotomy” can develop in the form of an impaired exchange of information between the two hemispheres.
An increased cortisol stress response was found for emotion suppression and emotion reappraisal as coping strategies.⁹⁴

An increase in the relative number of mineralocorticoid receptors (MR) compared to glucocorticoid receptors (GR) in the limbic system results in reduced emotional reactivity in animals.⁹⁵
In ADHD-HI and ADHD-C in particular, there appears to be inadequate deactivation of the HPA axis due to impaired GR functionality or inadequate addressing of the GR due to insufficient cortisol stress responses.

A study in people with ADHD suggests that - as an alternative to deficits in interhemispheric transfer - cortical inhibition may also be a possible cause. The study describes magnetic stimulation of the motor cortex area for the muscles of one hand using an electromyogram, whereby the motor response of one hand and the inhibitory response of the other hand were measured. This revealed an increased flow of information between the brain hemispheres.

One study came to the conclusion that alexithymia can be the result of suppressing an unwanted fact (in this case, the existence of diabetes).⁷⁸

It is our impression that alexithymic disorders of the perception of (especially positive) emotions, which are more frequently reported in ADHD, particularly in ADHD-HI and ADHD-C), could be the consequence of persistent intellectualization. A typical symptom of ADHD is an aversion to relaxation and mindfulness techniques such as yoga, meditation and the like. In conjunction with the equally typical symptom of circling thoughts, this leads, according to our hypothesis, to increased cognitive, analytical perception, while relaxed emotional perception cannot be permitted. Only a few positive emotions can break through this armor, e.g. lust / sex. Negative emotions predominate because, according to the inner “logic” of stress, they are conducive to survival, as they have warning functions on the one hand and do not distract from the fight against the stressor on the other.

This evolutionary-biological view is supported by individual research results. Alexithymia correlates with negative emotions and a tendency towards avoidance behavior as a form of coping.⁹⁶
Alexithymia also correlates with an increased degree of rationalization.⁹⁷

In addition, the image that perception in ADHD is focused too much on thought processes and too little on emotional perception is already being used in therapies.

However, it has also been reported by individual persons with ADHD that medication with stimulants resulted in a reduction in emotionality. It is unclear whether this is due to an overdose or whether it is a side effect of certain preparations.

10.3.2.2.3. Alexithymia as a stress symptom¶

Alexithymia (reduced emotional perception) can be a symptom and a consequence of stress:

• Reduced awareness of one’s own feelings⁹⁸
• Avoiding feelings (coolness)⁹⁹
• Low emotional self-control and spontaneity of feelings¹⁰⁰
• A typical symptom of the final state of a burnout is a flattening of emotions (with persistent sickliness)⁵⁷

10.3.2.2.4. Testing for alexithymia¶

The most commonly used instrument for testing alexithymia is the Toronto Alexithymia Scale.
The questions concern 3 groups:

• Difficulties in identifying feelings
  • Alexithymia means having difficulties perceiving one’s own feelings and their accompanying physiological symptoms in an inadequate way. In extreme cases, the ability to adequately classify emotional and accompanying physiological changes is lacking
• Difficulties in describing feelings
  • Alexithymia is associated with problems showing and describing emotions. Communication about feelings is impaired.
• Externally oriented thinking style
  • Alexithymia is associated with a rather superficial approach to problematic situations or processes. There is little interest in analytical thinking or in reflecting on solutions to problematic situations.

10.3.2.2.5. Treatment of alexithymia¶

Cognitive behavioral therapy for alcohol addicts with alexithymia significantly reduced alexithymia symptoms within 3 months. The reduction was greater in women than in men.¹⁰¹

10.4. Frustration intolerance¶

Frustration intolerance is a recognized ADHD symptom in children, which tends to be more noticeable in adults as a deterioration in self-control.¹⁰² The data from the ADxS symptom test (as of June 2020, n = 1889), on the other hand, show consistently high (or even increasing) levels of frustration intolerance in adults in the 10-year age groups from 20 to 60
Stimulants improve the 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.^52103104

The analysis of almost 2000 data sets of the ADxS.org symptom test showed that frustration intolerance correlates significantly more strongly with ADHD-HI than with ADHD-I.

10.4.1. Frustration intolerance as a stress symptom¶

Frustration intolerance is a typical symptom of the final state of burnout.⁵⁷ Burnouts regularly result from too much stress for too long and therefore from an unmanageable stress situation.

10.5. Self-perception disorders¶

10.5.1. Self-perception disorders as an ADHD symptom¶

Self-perception disorders are described as a common symptom of ADHD.¹⁰⁵¹⁰⁶

People with ADHD often not only have reduced mindfulness, but also a massive aversion to mindfulness techniques of all kinds, such as yoga, meditation, mindfulness training (MBSR) or similar.

10.5.2. Manifestations of self-perception disorders in ADHD¶

10.5.2.1. Alexithymia¶

See above.

10.5.2.2. Anhedonia (reduced perception of pleasure)¶

Anhedonia is an impairment or inability to experience pleasure or enjoyment in normally pleasant or enjoyable situations.

According to the data from the ADxS.org symptom test, people with ADHD perceive negative feelings significantly more strongly than positive feelings. The data also show such a tendency in non-affected people, but this phenomenon is considerably more pronounced in people with ADHD.

It is assumed that alexithymia always triggers anhedonia, while anhedonia may or may not trigger alexithymia.¹⁰⁷ In any case, there seems to be a correlation between anhedonia and alexithymia in mental disorders.¹⁰⁸

10.5.2.3. Inner emptiness (with inactivity) / boredom¶

People with ADHD 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.¹⁰⁹

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

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

10.5.2.4. Overestimating one’s own social skills¶

This symptom is not serious enough to be considered a contributing factor for ADHD.

10.5.2.5. Now is always¶

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

We perceive a kind of temporal digitization in people with ADHD. If something feels bad at the moment, it is interpreted as if it will be like this forever and ever and for all time, so there is no way out
It could be somewhat comparable to the black-and-white thinking that is often strongly represented in borderline: All or nothing, now is now, there is no gray, there is no after or later.

10.5.2.6. Increased subjective perception of stress in ADHD¶

In addition to the symptoms typical of ADHD, which are also symptoms of stress, the subjective perception of stress is increased in ADHD. The same physiological (measurable) stress experienced results in a higher (subjective) perception of stress than in those not affected.
An increased perception of stress could be a consequence of an increased “now is always” perception. If a state of stress is also perceived as never ending, this can lead to a reduced perception of control and an increased perception of helplessness (and subsequently hopelessness), which are known to be strong stress-increasing factors
See below and at*⇒ Increased subjective stress response in ADHDt*

Problems in coping with “everyday stressors” that lead to the omnipresent feeling of being overwhelmed are common.⁵³

10.5.3. Anhedonia as a stress symptom¶

Self-perception disorders are a typical symptom of severe stress. There is a deterioration in self-perception, which can lead to an inability to recover.
Anhedonia can be triggered by stress (stress-induced anhedonia).¹¹¹¹¹²

10.6. Self-esteem problems¶

People with ADHD have pronounced self-esteem problems.¹¹⁵
A comprehensive description of self-esteem problems in ADHD can be found at adhspedia.de.¹¹⁶
The severity of ADHD symptoms correlates with self-esteem, life satisfaction and depression traits.
There is a clear connection between¹¹⁷

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

The self-image of many people with ADHD appears to us to be impaired to an extent that is no longer appropriate to the existing symptoms and the resulting behavioral characteristics. It often seems as if the self-esteem adequate to the existing symptoms (ADHD symptoms are not exactly conducive to increasing self-esteem) is further diminished by an additional impairment of self-perception that is no longer justified by the actual symptoms and behavior.

Put another way:
What if a person with ADHD (with a solid bundle of symptoms that clearly meets or exceeds the diagnostic criteria) went through the world cheerfully and humorously, met their symptoms with loving self-irony and liked themselves? If he also managed to keep the responsibility for his symptoms to himself and not assign it to others? Would the person then still have ADHD at all, even though the symptoms objectively disrupt or reduce the quality of social, academic or occupational functioning? Would the person with ADHD really have a disorder if it didn’t bother them (if they had the capacity for insight)? Can a diagnosis really be made without subjective suffering on the part of the person with ADHD?
If, on the other hand, there is subjective suffering, there is no doubt that a Disorder should be diagnosed.
And what is the contribution of suffering that makes the symptoms so undeniably Disorder? Is it not precisely the lack of self-worth that causes at least a large part of the subjective suffering?
When you look at it this way, it stands to reason that Dysphoria with Inactivity and Rejection Sensitivity are among the most distressing and combat-worthy symptoms of ADHD.
In addition, dysphoria during inactivity (especially in ADHD-HI and ADHD-C) often leads to an inability to recover, which contributes to the inability to sufficiently reduce stress levels, which naturally exacerbates ADHD symptoms.

When ADHD-HI and Conduct Disorder (CD) or aggressive behavior or Oppositional Defiant Disorder (ODD) are combined, self-esteem is significantly lower than in ADHD-HI alone or non-affected individuals.¹¹⁸

ADHD treatment (medication and non-medication) improves self-esteem and social behavior.¹¹⁹

10.6.1. Rejection sensitivity - offendedness and fear of rejection¶

In addition to more difficult emotion regulation, there are reports of an increased reaction to negative stimuli in people with ADHD.¹²⁰

The hypersensitivity to actual or perceived rejection reported by many of the people with ADHD we interviewed has so far gone largely unnoticed in the specialist literature. In our ADxS.org online symptom test, rejection sensitivity is a similarly strong indicator of ADHD as impulsivity, gross or fine motor problems or inner restlessness (as of June 2020, n = 1,889). We consider Rejection Sensitivity to be an original neurophysiological symptom of ADHD

A very high number of these persons with ADHD reported that rejection sensitivity decreased significantly with stimulants. Individual people with ADHD (about 10 %) reported that MPH increased RS, whereby even switching to another MPH preparation showed differences.

Rejection sensitivity is characterized by

• Sickliness
• Anxious expectation of rejection
• Willing acceptance of rejection and
• Intensive reaction to (actual or perceived) rejection

Rejection sensitivity (RS), which is known in a number of mental disorders, is not a general inability to accept criticism or a narcissistic tendency, but a particular sensitivity in the sense of a fear of rejection or being put down.
Almost every person with ADHD we interviewed reported rejection sensitivity. It was also almost unanimously reported that this symptom was improved by stimulants (during the active period). Dodson reports an immediate effect of clonidine and guanfacine.
The fact that children with ADHD reacted more sensitively to punishment than people without ADHD,¹²¹ could be an expression 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. More on this at ⇒ Attachment styles In the chapter ⇒ Prevention.

According to the ADxS.org symptom test (as of Jun 2020, n = 1889), rejection sensitivity correlates primarily with frustration intolerance (0.56) as well as impatience and aggression (0.53 each). The correlation with externalizing stress phenotypes (0.42) (ADHD-HI) is significantly more pronounced than with internalizing stress phenotypes (0.26) (ADHD-I). This is consistent with the fact that rejection sensitivity generally correlates more with hypocortisolerant states such as atypical depression.¹²² Rejection sensitivity also correlated with a flattened alpha-amylase stress response and more negative affect in healthy adolescents.¹²³

More on the topic of rejection sensitivity in the article ⇒ Rejection Sensitivity: Sensitivity to rejection and criticism as a specific ADHD symptom.

10.6.1.1. Rejection sensitivity / Offensiveness and stress¶

Increased sickliness is a typical symptom of the final stage of burnout⁵⁷, an atypical depression.¹²⁴ and typical of narcissistic personality disorder. It is certain that burnout can result from too much stress for too long and thus from an unmanageable stress situation.
So far, we have not been able to find any other descriptions of offendingness / rejection sensitivity as a direct symptom of stress. However, studies indicate that rejection sensitivity has a considerable influence on perceived stress.^125126127 People with ADHD who are very concerned about being rejected by neighbors or work colleagues appeared to be more susceptible to perceiving stigmatization as a stressor.¹²⁸
Stress appears to be a mediator that links rejection sensitivity and depression.¹²⁹

10.6.2. Tend and Befriend¶

The opposite stress symptom to Rejection Sensitivity is a special 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 probably anchored in the attachment supply system. Neuroendocrine findings suggest that oxytocin, in conjunction with female reproductive hormones and endogenous opioid peptide mechanisms, may be involved in endocrinological correlates.¹³⁰

10.6.3. Perfectionism as an ADHD symptom¶

Perfectionism is often described as a symptom by people with ADHD.

People with ADHD often suffer from impaired performance due to their distractibility, forgetfulness and concentration problems. In addition, the self-perception of people with ADHD with regard to their performance often seems considerably more negative than would be appropriate in reality. This symptom of an imagined underperformance (which goes beyond the actual impairment of performance) could be the result of a dysfunctional perfectionist demand that is quite common in ADHD.

10.6.3.1. Manifestations of perfectionism¶

Functional (healthy) perfectionism correlates strongly with conscientiousness. Dysfunctional (excessive) perfectionism correlates with neuroticism. Perfectionism can manifest itself in an (excessive) striving for perfection (as an approximation goal) and/or in an (excessive) striving to avoid mistakes (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 in order to rule out errors
  (less typical of ADHD, sometimes occurs as a coping mechanism)
  • Set off far too early so as not to be late, despite the known route
  • Extremely tidy home (also reduces distractibility by minimizing stimuli)
• Excessive control
  • Multiple checks of own and external actions to prevent errors
• Repeat and improve
  • Repetition of actions until a perfect result is achieved (less typical of ADHD)
  • Improve others if the result is not optimal
• Intensive planning and organizing
  • Fondness for (check) lists / to-do lists
• Decision problems
  • Fear of making a less than optimal choice / decision
• Difficulties in completing projects
  • Cannot complete processing because result does not yet seem perfect enough
  • Preventing the commencement / continuation of activities
    • Where the result might not be perfect
    • Where the target could not be achieved
• Problems delegating tasks
  • Prefer to do it yourself so that the result is optimal.

Dysfunctional perfectionism can be an expression of an increased fear of not meeting other people’s expectations. This symptom is thus reminiscent of rejection sensitivity, which is a shift in perception towards an increased fear of supposed or actual rejection by third parties.

10.6.3.2. Perfectionism and stress¶

Perfectionism appears to moderate the stress response to an existing stressor.¹³²

10.6.4. Self-esteem problems as symptoms of stress¶

Self-esteem problems are typical symptoms of severe stress.¹³³¹⁰⁰
Low self-esteem often correlates with

• Self-hatred
• Suicidal tendency
• Guilt and shame

This also applies to listlessness⁶¹⁶⁶ , which could be seen as the equivalent of dysphoria during inactivity and the feeling of being depressed.⁶¹⁶⁶

In particular, a threat to self-esteem that is perceived as uncontrollable triggers a release of cortisol.¹³⁴¹³⁵

Feelings of inferiority and failure are typical symptoms of the final state of burnout.¹³⁶

10.6.5. Self-esteem-enhancing medication¶

ADHD medications also reduce dysphoria during inactivity, albeit to varying degrees. It is therefore disadvantageous to give stimulants only for the activity phases of the day. Unfortunately, we see time and again that children are only medicated during school hours and adults only for working hours (or even only part of it), e.g. with a single dose of half-day retarded MPH (e.g. Medikinet or Ritalin adult). Such treatment pretends that the person with ADHD no longer has ADHD in the afternoon. Dosing into the early evening, on the other hand, can - with appropriate caution to avoid sleep problems - help to improve the emotional symptoms even outside of the activity period. These are in particular dysphoria during inactivity and rejection sensitivity (in the relationship area, which is also mostly experienced in the evening). Suitable all-day coverage can be achieved with two doses of half-day-released MPH (where the second dose is often lower than the first) or one dose of Vyvanse, followed by a small dose of immediate release MPH for the evening. It should be noted that around 15% of people with ADHD are rapid metabolizers, who therefore require up to twice as many single doses. With Vyvanse, the appropriate single dose works for a maximum of 7 hours in 2/3 of all people with ADHD, often less
It should also be taken into account that stimulants (MPH and AMP) dampen the limbic system, which reduces emotional dysregulation but at the same time has the undesirable side effect of a generally weakened sense of emotion, whereas atomoxetine and guanfacine do not have this disadvantage and also act as level preparations throughout the day. To avoid the higher side effects of the latter two active ingredients (compared to stimulants) and to improve the significantly weaker drive promoted by ATX and guanfacine, a combination medication should be considered in which atomoxetine at half the dose (compared to a single medication) can lay a healthy foundation on which half the dose of MPH or AMP (compared to a single medication) can improve drive and executive functions during the day. See Barkley for more details.³¹

10.7. Anxiety¶

10.7.1. Increased anxiety as an ADHD symptom¶

ADHD is often accompanied by increased anxiety.¹³⁷¹³⁸
Anxiety in ADHD appears to be strongly moderated by executive problems¹³⁹

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

10.7.2. Catastrophize¶

Many people with ADHD report that they often make the worst assumptions in their minds. The relevant forums deal intensively with this topic.
The specialist 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 (functional form). In an even more extreme form, it can contribute to the paralysis of any activity in the sense of assumed hopelessness (dysfunctional form).

Anxiety symptoms in ADHD are in tension with a frequently increased willingness to take risks in ADHD. It is conceivable that in individual cases it could also be a case of overreacting or panic reactions in the context of anxiety.
The data from the ADxS.org symptom test show that anxiety symptoms in ADHD correlate primarily with rejection sensitivity and self-esteem problems. Furthermore, 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 clearly with the ADHD-HI subtypes and even less with the ADHD-I subtypes. (n = 1889, as of June 2020).

10.7.3. Increased anxiety as a symptom of stress¶

Fear/anxiety is a symptom of stress.⁶⁶¹⁴⁰

Increased anxiety, increased fear conditionability and increased caution in unknown environments, in the open field, in the elevated plus maze and during conflicts are a direct effect of the stress hormone CRH.¹⁴¹¹⁴²

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

10.8. More sensitive reaction to penalties¶

Children with ADHD reacted more sensitively to punishment than people without ADHD.¹²¹

10.9. Stress intolerance / more sensitive reaction to stress¶

People with ADHD experience stress more intensely.¹⁴³¹⁴⁴

For more information, see*⇒ Subjective stress response increased in ADHDt*

We consider stress intolerance to be a central symptom of ADHD. We suspect that ADHD is associated with permanent damage to the stress regulation systems (primarily the HPA axis). This does not mean that ADHD is a causal consequence of this; however, ADHD probably mediates a number of symptoms via disorders of the stress response systems.
⇒ ADHD as a chronic stress regulation disorder ⇒ ADHD symptoms are stress symptoms ⇒ 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 consolidated more and 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 their prevention, we recommend the standard German-language works on stress medicine

• Rensing, Koch, Rippe, Rippe (2005): People under stress,
• Egle et al (2015): Sexual Abuse, Maltreatment, Neglect - Recognition, Therapy and Prevention of the Consequences of Early Stress Experience (861 pages plus 125 pages bibliography)

10.10. Hypersexuality¶

An anonymous online survey found increased hypersexual behavior, especially in women with ADHD.
Hypersexual behavior, sexual risk-taking and sexual dysfunction were - especially in women - closely related to emotional dysregulation, impulsivity and oppositional symptoms.
In men with ADHD, the correlations were less clear, but also tended to correlate with emotional dysregulation.¹⁴⁵

The symptoms

• Increased willingness to take risks
• Novelty Seeking
  we have moved under impulsivity problems.

10.11. Impatience¶

Not being able to wait is a well-known emotional ADHD symptom. It manifests itself in driving too fast, talking in between and similar behaviors.
Impatience is associated with impulse control problems, which is why we discuss them here.

Barkley, among others.³¹