Emotional dysregulation - mood swings and more in ADHD.

Emotions are temporary, qualitative states associated with change at the level of feelings, expression, and physical states.¹

Problems with emotion perception and emotion regulation are very common in ADHD.²³ About 34% to 70% of ADHD sufferers also have emotional lability.¹⁴ Emotional dysregulation is increased in ADHD.⁵⁶⁷
The fact that they are nevertheless not listed as symptoms of ADHD in the current editions of the Statistical Manuals for the Classification of Diseases (DSM and ICD) is due to the fact that the DSM and ICD only list those symptoms that are particularly specific to ADHD, i.e., well differentiated from other disorders. ⁷⁸⁹ Barkley had proposed that emotional dysregulation be included in the DSM-5 symptom list of ADHD.¹⁰ On the limited importance of DSM and IDC in diagnosis, see the article ⇒ DSM and IDC as diagnostic tools.

Emotional dysregulation is one of the most serious and stressful ADHD symptoms for those affected and those around them.
It is obvious that people with inadequate emotional reactions hurt others more often and thus experience rejection more often themselves.
Since ADHD sufferers can certainly recognize the inappropriateness of their own emotion from a little temporal distance, this leads to an awareness of “I feel wrong.” Even if the realization is not accepted cognitively, it still causes a deep sense of inadequacy, which is a profound root of self-esteem problems. What could be worse than the experience of feeling “wrong”? How far is it from that to the phrase “I am wrong” ? And how much power does coping with these wrong emotions cost in order to cope in (social) life?
This vicious circle reinforces the stress state of the affected person.
Since ADHD is characterized by lowered thresholds at which the stress systems (especially the HPA axis) are activated, this problem contributes significantly to the symptomatology of ADHD.

Emotions are not only consequences of perceptions, but at the same time the most important basis for the classification of perceptions. Cognitive cognitions get their measure of truth and meaning from what a person feels. The intensity of emotions controls what is important enough to be written into long-term memory. If this regulation is disturbed, it is very troublesome and in severe cases even impossible for the persons concerned to secure their respective decisions by healthy feeling.

• 1. What is emotional dysregulation?
  • 1.1. Mood swings are affect disorders
    • 1.1.1. Affect quality = which emotion
    • 1.1.2. Affect regulation = appropriateness and intensity of an emotion
      • 1.1.2.1. Affect adequacy = appropriateness of emotion quality = “appropriate” emotion
      • 1.1.2.2. Affect intensity = intensity of emotion
      • 1.1.2.3. Affect deflectability or stability.
  • 1.2. Affective and emotional temperaments and mental disorders
  • 1.3. More concepts
• 2. Frequency of emotional dysregulation in ADHD
• 3. Forms of emotional dysregulation in ADHD
  • 3.1. Altered emotional reactivity: overintensity to alexithymia
    • 3.1.1. Emotional hyperreactivity
      • 3.1.1.1. Mood swings
      • 3.1.1.2. Emotion intensity
    • 3.1.2. Emotional hyporeactivity
      • 3.1.2.1. Anhedonia in ADHD
      • 3.1.2.2. Alexithymia
        • 3.1.2.2.1. Differentiation of alexithymia from similar disorders
        • 3.1.2.2.1.1. Callous-unemotional traits
        • 3.1.2.2.1.2. Split brain problem
        • 3.1.2.2.2. Causal models of alexithymia
        • 3.1.2.2.2.1. Impaired information exchange between brain hemispheres
        • 3.1.2.2.2.2. Impairment of individual brain regions
        • 3.1.2.2.2.3. Psychological explanatory models
        • 3.1.2.2.3. Alexithymia testing
        • 3.1.2.2.4. Alexithymia treatment
  • 3.2. Dysphoria with inactivity
    • 3.2.1. Dysphoria with inactivity (self-esteem and depression)
    • 3.2.2. Self-esteem in ADHD - lower than appropriate for symptoms
    • 3.2.3. Self-esteem enhancing medication
    • 3.2.4. Dysphoria in inactivity and depression
  • 3.3. Impatience
  • 3.4. Frustration Intolerance
  • 3.5. Irritability
  • 3.6. Rejection Sensitivity
  • 3.7. Rapid excitability (i.e. excitement)
• 4. Emotional dysregulation in ADHD: symptom or comorbidity?
• 5. Impact of emotional dysregulation on the quality of life of ADHD sufferers
• 6. The importance of emotions in ADHD
  • 6.1. Motivation / drive / self-activation
  • 6.2. Self-regulation
  • 6.3. Emotion recognition and processing
• 7. Emotional reactions as an ADHD early indicator in infants
• 8. Neurophysiological correlates of emotional dysregulation
• 9. Emotional Dysregulation Treatment
  • 9.1. Medication
  • 9.2. Therapeutic treatment

1. What is emotional dysregulation?¶

Mood swings, aggression disorders, anxiety disorders, and depression or depression-related symptoms are the most commonly cited types of emotional dysregulation.

1.1. Mood swings are affect disorders¶

Affects have different dimensions.

1.1.1. Affect quality = which emotion¶

Examples:

• Joy
• Mourning
• Fear

1.1.2. Affect regulation = appropriateness and intensity of an emotion¶

1.1.2.1. Affect adequacy = appropriateness of emotion quality = “appropriate” emotion¶

• Is the type of emotion appropriate to the situation?
• Is the same emotion always felt in the same situations?
• Is the same emotion always felt in different situations?
  • Distrust among paranoids

1.1.2.2. Affect intensity = intensity of emotion¶

• Is the intensity of the emotion (appropriate / too high / too low) appropriate to the situation?
  • Is the emotion appropriately perceived?
    • E.g. fear of heights
  • Is the expression of the emotion appropriate?
    • E.g., exaggerated display of qualitatively adequate emotions in histrionic PS
    • E.g., reduced expression of qualitatively adequate emotions in schizoid PS

1.1.2.3. Affect deflectability or stability.¶

• How much an emotion can be triggered or changed by external stimuli
• How quickly the emotion arises / disappears
  • E.g. rapid change of emotions in ADHD, even more in Borderline
  • Healthy flooding / draining of emotions from several minutes to several hours

1.2. Affective and emotional temperaments and mental disorders¶

An extensive internet survey looked at the correlation of affective and emotional temperaments according to the AFECT temperament model¹¹ with mental disorders and found the most common correlations to be:¹²

• Dysphoric temperament: association with symptoms of ADHD (dysphoria with inactivity)
• Volatile temperament: association with symptoms of ADHD (mood swings)
• Melancholic temperament: association with major depressive symptoms
• Cyclothymic temperament: correlation mainly with symptoms of borderline personality
• Euphoric temperament: positive correlation with manic symptoms
• Euthymic temperament (euthymic: cheerful, well-tempered): negative correlation to all psychiatric symptoms
• Hyperthymic temperament (hypothymic: high activity, not yet hypomania): negative correlation to all psychiatric symptoms

In addition, the assessment of emotional traits of temperament revealed that high volition, low anger, low sensitivity, and high control are traits unrelated to psychopathology.

1.3. More concepts¶

An interesting concept is the description of emotional dysregulation as an emotional partial performance disorder¹³ in addition to the model of cognitive partial performance disorders such as dyslexia, dyscalculia, etc…, when “disorders of affect quality and regulation … occur as a largely singular and narrowly circumscribed disorder, with concurrent otherwise normal cognitive and psychological functioning … in association with typical cognitive patterns (e.g., paranoid PS: “everyone is against me,” dependent PS: “I can’t do it alone,” histrionic PS: “I need to make an impression”).“

The combination of ADHD and emotional dysregulation could also represent a separate category that has an independent meaning alongside the two phenomena of ADHD alone and emotional dysregulation alone.²

2. Frequency of emotional dysregulation in ADHD¶

Emotion dysregulation is sometimes not considered an original symptom of ADHD, but a comorbid dimension in its own right.²

Emotional dysregulation is nevertheless a central (and on closer inspection also diagnostically relevant) feature of ADHD.¹⁴ Studies found emotional dysregulation in 25% to 45% of children with ADHD and in 34%¹⁵ to 70% of adults with ADHD^{216 1 17 10} .¹⁸

Emotional dysregulation in ADHD (and autism) has been linked to specific dopaminergic gene variants in one study.¹⁹ Neurophysiological correlates could not be found so far.¹

ADHD symptom severity correlates with more negative emotions.²⁰

Emotional dysregulation is more common in ADHD (with hyperactivity), in females with ADHD, and correlates with greater symptom severity.¹

3. Forms of emotional dysregulation in ADHD¶

3.1. Altered emotional reactivity: overintensity to alexithymia¶

In ADHD (and not only there) different types of emotional dysregulation are described. According to our as yet unverified hypothesis, these opposing forms could possibly be different manifestations of the same disorder pattern, which merely shows different manifestations depending on the type of disorder expression, 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.

3.1.1. Emotional hyperreactivity¶

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

3.1.1.1. Mood swings¶

Emotional hyperreactivity is described as “Frequent rapid mood swings,” a rapid change from “sky high” to “sad to death.”

3.1.1.2. Emotion intensity¶

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

3.1.2. Emotional hyporeactivity¶

3.1.2.1. Anhedonia in ADHD¶

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

Endotoxins are known to be a neurophysiological cause of anhedonia, mediating anhedonia via elevated levels of proinflammatory cytokines, most likely TNF (tumor necrosis factor) in particular.
More on this at ⇒ Immune system and behavior.

3.1.2.2. Alexithymia¶

Furthermore, ADHD patients often report a clearly reduced emotional intensity, an inner emptiness. This lack of emotion, which is probably related to alexithymia, must be distinguished from certain neurophysiological phenomena (split-brain) or from disorders related to psychotic patterns (callous unemotional traits), which have nothing to do with ADHD. Alexithymia symptoms in ADHD are in our impression not consequences or correlates of neurophysiological specifics, but rather the consequence 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 of rationalization, in which an excess of mental analytical activity causes a lack of feeling, describes the same process.

Alexithymia is a weakened perception of all (positive as well as negative) own emotions, which is also called emotional blindness, emotional coldness or emotional dyslexia. A general explanation of alexithymia including a simple test can be found at lernen.net.²¹ A general article on alexithymia worth reading was published in Zeit in 2009.²²

One study found severe alexithymia in 22% of adult ADHD sufferers studied. 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.²³
Normally, alexithymia has a prevalence of 10% (men: 11.1%, women: 8.9%).²⁴ The prevalence in ADHD is thus slightly more than doubled. In combination with other disorders, alexithymia also occurs more frequently than alone, e.g.

• Alcohol abuse²⁵²⁶
• Gambling addiction²⁷
• Food allergies²⁸

The prevalence is²⁴

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

Trauma is also thought to be able to trigger a reduction or blockage of sensing by posteriorizing brain activity, that is, by shifting behavioral control from younger, more frontal brain areas to older, more posterior brain areas.
Early childhood severe stress can lead to a reduced corpus callosum, which connects the brain hemispheres.²⁹ Dysfunction of the corpus callosum is a significant cause of alexithymia.

Alexithymia (of parents) decreases respectful parental behavior and promotes authoritarian or permissive parental behavior.³⁰

3.1.2.2.1. Differentiation of alexithymia from similar disorders¶

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

3.1.2.2.1.1. 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 include weak, flattened emotions and low empathy. Callous-unemotional traits thus have a distinct (anti)social component that alexithymia lacks.

Callous-unemotional trait symptom severity correlates negatively with connectivity between the amygdala and ventromedial prefrontal cortex.³¹

Cold aggression is associated with decreased emotionality (callous unemotional traits, decreased empathy).³²

In callous-unemotional traits, cortisol levels and testosterone levels are elevated.³³

Low dietary magnesium intake is reported to correlate with callous-unemotional traits.³⁴

Conduct Disorder is a disorder in its own right, but is often comorbid with ADHD. An association 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) in one study. Callous unemotional traits were related to conduct disorder, but independently of ADHD symptom severity.³⁵

3.1.2.2.1.2. Split brain problem¶

Alexithymia is to be distinguished from a split-brain problem by the fact that in alexithymia the feelings can only be perceived more weakly or cannot be named, whereas in split-brain all processes taking place in the right brain hemisphere are completely inaccessible to the left hemisphere (which accommodates the descriptive processes).³⁶ Alexithymia is thus a subproblem of split-brain.

3.1.2.2.2. Causal models of alexithymia¶

The following presentation is largely based on the compilation by Naundorf²⁴, unless otherwise indicated.

3.1.2.2.2.1. Impaired information exchange between brain hemispheres¶

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

Right Hemisphere:

• Unconscious information
• Emotional information
• Nonverbal information
• Bonding behavior (via oxytocin)
  • Impaired bonding ability in alexithymia indicates dysregulation of the right
    Hemisphere towards
  • Stroke patients with right hemisphere lesion have significantly higher TAS-20 levels than those with left hemisphere lesion

Left Hemisphere:

• Conscious, analytical processes
• Verbal processes
• Ongoing processes

An exchange of the two hemispheres via the corpus callosum connecting them is necessary to consciously perceive and verbalize emotional stimuli.

Alexithymia could represent (more frequently in men than in women) a transfer disturbance of the corpus callosum, which connects the two cerebral hemispheres.³⁷ Patients with agenesis (= absence, atrophy) of the corpus callosum show alexithymic traits, as do epileptics after comissurotomy (= callosotomy = severing of the corpus callosum).
Reduced exchange between brain hemispheres appears to be a cause of alexithymia, particularly in PTSD, as well as dysfunction of the cortisol stress response.³⁸

3.1.2.2.2.2. Impairment of individual brain regions¶

Alexithymia is associated with changes in the

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

Alexithymia showed lower cerebral blood flow in the ventral as well as dorsal portions of the cingulate gyrus, which receives increased blood flow during the perception of emotion-occupied stimuli (movies).

3.1.2.2.2.3. Psychological explanatory models¶

It is suggested that even in neurologically healthy subjects (without structural lesions) a “functional comissurotomy” may develop in the form of impaired information exchange between the two hemispheres.
An increased cortisol stress response was found with emotion suppression such as emotion reappraisal as coping strategies.³⁹

Increases in the relative number of mineralocorticoid receptors (MR) versus glucocorticoid receptors (GR) in the limbic system causes decreased emotional reactivity in animals.⁴⁰
Specifically, in ADHD-HI and ADHD-C, there appears to be deficient HPA axis shutdown due to impaired GR functionality or deficient GR addressing due to insufficient cortisol stress responses.

A study in alexithymia sufferers suggests that - as an alternative to deficits in interhemispheric transfer - cortical inhibition may also be a cause. The study describes magnetic stimulation of the motor cortex area for the muscles of one hand by an electromyogram, measuring the motor response of one hand as well as the inhibitory response of the other hand. This showed an increased flow of information between the brain hemispheres.

One study concluded that alexithymia may be the result of repressing an undesirable fact (in this case, the existence of diabetes).²⁴

According to our impression, alexithymic disturbances of the perception of (especially positive) emotions, which are more frequently reported in ADHD, especially in ADHD-HI and ADHD-C) could be the consequence of a persistent rationalization. A typical symptom of ADHD is an aversion to relaxation and mindfulness techniques such as yoga, meditation, and the like. According to our hypothesis, in combination with the also typical symptom of thought circling, this leads to an increased cognitive, analytical perception, while relaxed emotional perception cannot be allowed. Only a few positive emotions can break through this armor, e.g., pleasure/sex. Negative emotions predominate, because according to the inner “logic” of stress, these are conducive to survival, since 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 study results. Alexithymia correlates with negative emotions and a tendency to avoidance behavior as coping.⁴¹
Alexithymia further correlates with increased levels of rationalization.⁴²

In addition, the image that ADHD cognition is too focused on thinking processes and too little on emotional perception is already being applied in therapies.

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

3.1.2.2.3. Alexithymia testing¶

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

• Difficulty in identifying feelings
  • Alexithymia means having difficulties to perceive one’s own feelings and their physiological concomitants in an inadequate way. In extreme cases, the ability to adequately classify emotional and accompanying physiological changes is missing
• Difficulty 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 possible solutions to problematic situations.

3.1.2.2.4. Alexithymia treatment¶

Cognitive behavioral therapy in alcohol abusers with alexithymia significantly reduced alexithymia symptoms within 3 months. The reduction was greater in women than in men.⁴³

3.2. Dysphoria with inactivity¶

3.2.1. Dysphoria with inactivity (self-esteem and depression)¶

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

3.2.2. Self-esteem in ADHD - lower than appropriate for symptoms¶

To us, the self-image of many ADHD sufferers seems impaired to an extent that is no longer at all appropriate to the existing symptoms and the behavioral characteristics caused by them. It often seems as if the self-esteem that is 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 symptom situation and behavior.

Put another way:
What if an ADHD sufferer (with a solid bundle of symptoms that clearly meets or exceeds the diagnostic criteria) went through the world cheerfully and humorously, met his symptoms with a loving self-irony, and liked himself? If he also managed to leave the responsibility for his symptoms with himself and not assign it to others? Would the person then still have ADHD at all, although the symptoms objectively disturb or reduce the quality of social, educational or professional functioning? Would the affected person really have a disorder if it did not bother him or her (with existing capacity for insight)? Can a diagnosis really be given without subjective suffering on the part of the affected person?
If, on the other hand, there is subjective suffering, it is unquestionable that a disorder should be diagnosed.
And what is the contribution of suffering that makes the symptoms so undoubtedly a 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 is one of the most distressing and combative symptoms of ADHD.
In addition, dysphoria often leads to an inability to recover when inactive (especially in ADHD-HI and ADHD-C), which contributes to an inability to adequately relieve stress levels, which inherently exacerbates ADHD symptoms.

3.2.3. Self-esteem enhancing medication¶

ADHD medications also reduce dysphoria during periods of inactivity, although to varying degrees. Therefore, it is disadvantageous to give stimulants only for the activity phases of the day. Unfortunately, we see it time and again that children are medicated only during school hours and adults only for work hours (or even only part of them), e.g., by a single dose of half-day-retardant MPH (e.g., Medikinet or Ritalin adult). Such treatment pretends that the affected person no longer has ADHD in the afternoon. Dosing into the early evening, on the other hand, with appropriate caution to avoid sleep problems, can help improve emotional symptoms outside of activity time. And these are, in particular, dysphoria during inactivity as well as rejection sensitivity (in the relationship area, which is also mostly lived in the evening). Suitable all-day coverage can be achieved by two doses of half-day retarded MPH (where the second dose is often lower than the first) or one dose of Elvanse, and following in time by low doses of unretarded MPH for the evening. It should be noted that about 15% of affected individuals are fast metabolizers, thus requiring up to twice as many single doses.
Further, it should be taken into account that stimulants (MPH and AMP) dampen the limbic system, which dampens emotional dysregulation but at the same time has an overall weakened emotion sensation as an undesirable side effect, whereas atomoxetine and guanfacine do not have this disadvantage and, moreover, act as mirror preparations throughout the day. To avoid the higher side effects (compared to stimulants) of the latter two agents and to improve drive, which is much more weakly promoted by ATX and guanfacine, a combination medication should be considered, in which atomoxetine at half the dose (compared to a sole medication) can lay a healthy foundation on which half the dose of MPH or AMP (compared to a sole medication) can improve drive and executive functions during the day. For more in-depth discussion, see Barkley.¹⁰

3.2.4. Dysphoria in inactivity and depression¶

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

3.3. Impatience¶

For this purpose, Barkley, among others.¹⁰

Not being able to wait is a well-known emotional ADHD symptom. It manifests itself, among other things, in driving too fast, talking in between and similar behaviors.

3.4. Frustration Intolerance¶

Low frustration tolerance is a known emotional ADHD symptom.

3.5. Irritability¶

ADHD sufferers are often easily irritable. This is particularly evident in ADHD-HI and ADHD-C, who act out stress externally due to the subtype and have deteriorated impulse control.

3.6. Rejection Sensitivity¶

In addition to more difficult emotion regulation, increased reaction to negative stimuli has been reported in ADHD sufferers.⁴⁴

Largely unnoticed in the literature so far is the hypersensitivity to actual or perceived rejection reported by many of the ADHD patients we interviewed. In our ADxS.org online symptom test, Rejection Sensitivity shows up as a similarly strong indication of ADHD as impulsivity, gross or fine motor problems, or inner restlessness. (as of June 2020, n = 1889)

A very high number of these affected persons reported that the rejection sensitivity decreased significantly under stimulants. Individual sufferers (about 10%) reported that MPH increased RS, and even switching to another MPH preparation showed differences.

More on this topic on the page ⇒ Rejection Sensitivity: sensitivity to rejection and criticism as a specific ADHD symptom.

3.7. Rapid excitability (i.e. excitement)¶

4. Emotional dysregulation in ADHD: symptom or comorbidity?¶

Although emotional dysregulation occurs in many mental disorders, i.e. it is not very ADHD-specific, we assume that emotional dysregulation (especially rejection sensitivity) is an original symptom of ADHD - if no other mental disorders exist - just as emotional dysregulation in depression is a symptom of depression. If depression heals, emotional dysregulation also disappears. There is no known disorder in which emotional dysregulation occurs comorbidly, but persists when the disorder subsides.
The specific abnormalities of emotion recognition in ADHD are also a specific feature of ADHD and not a comorbidity.

In contrast, in a study with n = 102 children, emotional problems alone correlated with emotional lability, with no difference whether ADHD was present or not. In ADHD sufferers, emotional lability only led to additional behavioral problems compared to non-affected individuals.⁴⁵

Two larger studies found only moderate to weak correlations between ADHD leading symptoms and mood symptoms,⁴⁶⁴⁷ whereas one smaller study found a strong correlation between cognitive and emotional problems in ADHD.⁴⁸

Specific emotion regulation problems cause ADHD to indirectly increase the frequency of suicidal ideation in comorbidly depressed individuals.⁴⁹

One study concluded that emotional dysregulation was the symptom linking ADHD and gambling addiction.⁵⁰

A study of 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.⁵¹

5. Impact of emotional dysregulation on the quality of life of ADHD sufferers¶

Emotional dysregulation causes much more serious limitations in the quality of life of ADHD sufferers than hyperactivity or inattention. The negative impact on life satisfaction and self-esteem is considerably greater.⁵²

6. The importance of emotions in ADHD¶

Conscious and unconscious emotions play a supporting role in the core ADHD problem of motivation and self-regulation.
Emotions have three important roles in ADHD symptomatology.

6.1. Motivation / drive / self-activation¶

Deficits in self-activation can only partly be explained by the disorder of reward evaluation - the further away a reward is to be expected, the lower the drive. This phenomenon is massively amplified in ADHD sufferers (devaluation of distant rewards).

6.2. Self-regulation¶

Intense emotions alone do not pose a problem if the affected person has sufficient skills to recapture and adequately stabilize their emotions.
In ADHD, frustration or other emotions often cannot be adequately processed and regulated. The result is

• Impulse overreactions (typical of ADHD-HI and ADHD-C)
• Internal blockades (typical for ADHD-I)

6.3. Emotion recognition and processing¶

In addition, many ADHD sufferers have significant difficulty recognizing and controlling the expression of their emotions.⁵³
Similarly, in ADHD (as in autism), there appears to be a worsened recognition of others’ emotions, with impaired stimulus processing at a different level of processing.⁵⁴⁵⁵⁵⁶
Emotional dysregulation in ADHD may result from deficits in the recognition and/or attribution of emotional stimuli.²

7. Emotional reactions as an ADHD early indicator in infants¶

Specific emotional responses occur in children of parents with ADHD as early as 6 months of age.⁵⁷

8. Neurophysiological correlates of emotional dysregulation¶

See the article on this topic ⇒ Neurophysiological correlates of emotional dysregulation In the section ⇒ Neurophysiological correlates of ADHD symptoms in the section ⇒ Neurological aspects.

9. Emotional Dysregulation Treatment¶

9.1. Medication¶

Emotional dysregulation, according to our impression, benefits from drug treatment somewhat less clearly than other symptoms of ADHD. Here, a particularly sensitive medication setting is required.

Stimulants (e.g., methylphenidate) have been shown not only to improve attention and reduce hyperactivity and impulsivity, but also to improve emotional self-regulation, which may be at least partially a consequence of reduced impulsivity.⁵⁸
Barkley explained in a lecture,⁵⁹⁶⁰ that stimulants can dampen emotions by inhibiting the limbic system, which is not affected in ADHD per se. The higher the dosage, the more the limbic system (including the amygdala) is inhibited, he said. This naturally reduces affect. An individually too high stimulant dosage can therefore lead to impaired emotional experience, which occurs in about 20% of patients treated with stimulants.
In this context, Barkley refers to the increasingly frequent use of combination medication (stimulants and atomoxetine or stimulants and guanfacine) for this reason, in order to accumulate the respective positive effects and to spread and thus reduce the side effects, which are usually located in different areas. Atomoxetine, unlike stimulants, does not affect the limbic system and therefore does not affect emotional sensation. Atomoxetine activates the ACC and frontal lobe, directly affecting executive functions. Stimulants improve attention cognition, executive functions, and working memory. They are less useful for improving emotion regulation.
In our view, a dampening effect of stimulants on the limbic system would then be particularly helpful in the case of greatly exaggerated impulsivity or anxiety, whereas affected persons who are more emotionally balanced should dose stimulants rather cautiously and reduce stimulants at the latest when their emotional sensation is impaired and, if necessary, augment them with other agents or switch completely to other agents.

A strikingly high number of ADHD sufferers reported that their existing rejection sensitivity decreased significantly under stimulants. Individuals (about 10%) reported that MPH increased RS, with a change to another MPH preparation already showing differences.

Comorbid anxiety disorders, depression, and aggression may be exacerbated by stimulants, as anxiety and moods are regulated by dopaminergic activity of the ventromedial prefrontal cortex in conjunction with the limbic system. In these cases, norepinephrine reuptake inhibitors or α2A-adrenergic agonists are recommended instead.⁶¹
One (quite small) study found no short-term change in state anxiety with a single dose of MPH, but did find evidence of possible long-term worsening.⁶²
Amphetamine medications have been shown to have better effects on mood in ADHD.

According to one (very small, n = 26) study, memantine (given in addition to stimulants) should further improve emotional executive functions and self-regulatory functions.⁶³

9.2. Therapeutic treatment¶

Mindfulness training is able to improve the balance between thinking and feeling, which is shifted towards thinking in ADHD-typical alexithymia (lack of emotion).

Exercises such as those done with trauma patients, who also often suffer from a lack of feeling, can improve the perception of feelings.

The 5-4-3-2-1 exercise⁶⁴

1. Sit quietly and breathe consciously.
2. Look around you and name 5 things you see.
3. Now name 5 things that you hear. If there are fewer, name them several times.
4. Now close your eyes. Name 5 things that you feel.
5. Repeat the exercise with 4 things instead of 5, then with 3, then with 2 and again with 1 thing.

Other sources:

Smart but Stuck: Emotions in Teens and Adults with ADHD; Thomas E. Brown (Jossey-Bass/Wiley, 2014).