Emotion dysregulation involves difficulties in modulating emotional responses appropriately. Signs include intense, rapidly shifting emotions, irritability, and anger outbursts.
In ADHD, emotion dysregulation is associated with impulsivity and deficits in executive functioning, leading to challenges in managing emotions effectively.
While not a core diagnostic criterion, research suggests that emotion dysregulation is a prevalent feature of ADHD that contributes to impairment in multiple domains, warranting further investigation into its nature, underlying mechanisms, and treatment implications.
Soler-Gutiérrez, A. M., Pérez-González, J. C., & Mayas, J. (2023). Evidence of emotion dysregulation as a core symptom of adult ADHD: A systematic review. Plos one, 18(1), e0280131. https://doi.org/10.1371/journal.pone.0280131
Key Points
- Adults with ADHD consistently show greater emotion dysregulation compared to controls across various measures, with medium to large effect sizes.
- Emotion dysregulation in adults with ADHD is associated with greater symptom severity, executive functioning deficits, psychiatric comorbidities, and impairment.
- Adults with ADHD tend to use more maladaptive emotion regulation strategies like emotional suppression compared to healthy controls.
- Neuroimaging studies found abnormal activation patterns in brain regions involved in emotion regulation in adults with ADHD compared to controls.
- While informative, the existing research has limitations including small sample sizes, heterogeneity in measures used, and lack of accounting for comorbidities.
Rationale
Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity that persists into adulthood in many cases (American Psychiatric Association, 2013).
Although not part of the core diagnostic criteria, recent evidence suggests that emotion dysregulation is a prevalent feature of ADHD that contributes to impairment (Shaw et al., 2014).
Most research to date has focused on emotion dysregulation in children with ADHD (Bunford et al., 2015; Christiansen et al., 2019).
However, difficulties with emotion regulation persist into adulthood (Hirsch et al., 2018). This systematic review aimed to synthesize the current evidence on the nature, neurobiology, and clinical implications of emotion dysregulation in adults with ADHD.
Method
The authors conducted a systematic review following PRISMA guidelines. They searched PsycInfo, Medline, Eric, PsycArticle, Psicodoc, and Scopus databases for empirical studies published in English that included adults diagnosed with ADHD and measured emotion regulation.
22 studies met inclusion criteria and were reviewed.
Sample
The reviewed studies included adults aged 18+ diagnosed with ADHD according to DSM-IV or DSM-5 criteria. Sample sizes ranged widely. Most participants were recruited from clinical settings.
There was heterogeneity in terms of gender distribution, ADHD subtypes, medication status, and psychiatric comorbidities.
Measures
A variety of measures were used to assess ADHD symptoms and emotion regulation across studies.
ADHD measures included clinical interviews such as the Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID) and the Diagnostic Interview for ADHD in adults (DIVA 2.0), as well as self-report rating scales like the Adult ADHD Self-Report Scale (ASRS-v1.1) and the Conners’ Adult ADHD Rating Scales (CAARS).
Emotion regulation was measured using self-report questionnaires assessing various facets of emotional functioning, including the Difficulties in Emotion Regulation Scale (DERS) for emotional control, the Cognitive Emotion Regulation Questionnaire (CERQ) for cognitive emotion regulation strategies, and the Emotion Reactivity Scale (ERS) for emotional reactivity and lability.
Results
Adults with ADHD consistently showed greater emotion dysregulation compared to healthy controls, with effect sizes in the medium to large range (d=0.31-2.27).
Emotion dysregulation was associated with ADHD symptom severity, executive dysfunction, and functional impairment. Adults with ADHD tended to use more maladaptive emotion regulation strategies like emotional suppression.
A few neuroimaging studies found abnormal activation patterns in prefrontal-limbic circuits involved in emotion regulation in ADHD adults compared to controls.
Insight
This systematic review provides evidence that many adults with ADHD struggle with regulating their emotions effectively, above and beyond the impact of core ADHD symptoms.
The findings suggest that emotion dysregulation is an important source of difficulty that should be assessed and targeted in treatment.
The neuroimaging results, while preliminary, point to differences in the neural circuitry underlying emotional processing and regulation in ADHD that warrant further investigation.
More research is needed to understand the developmental trajectory of emotion dysregulation in ADHD and how it interacts with core symptoms and comorbidities over time.
Examining emotion regulation could lead to more comprehensive models of ADHD and interventions that better address the full range of difficulties patients experience.
Strengths
This review had several methodological strengths, including:
- Comprehensive systematic review following PRISMA guidelines
- Included only studies of adults with ADHD diagnosed using DSM criteria
- Examined associations of emotion dysregulation with ADHD symptoms, comorbidities, and functional outcomes
- Reviewed neuroimaging findings on neural correlates of emotion dysregulation in ADHD
Limitations
Despite strengths, this review also came with several limitations, including:
- Substantial heterogeneity across studies in sample characteristics (gender balance, ADHD subtypes, comorbidities, medication status) and measures used
- Small sample sizes in many studies
- Cross-sectional designs preclude causal inferences
- Lack of consistency in accounting for comorbid psychiatric disorders that are independently associated with emotion dysregulation
- Emotion dysregulation measured only by self-report in most studies
Implications
The results highlight the importance of assessing and treating emotion dysregulation in adults with ADHD.
Pharmacological and psychosocial interventions targeting emotion regulation in ADHD appear promising but require further evaluation in controlled trials.
Accounting for emotion dysregulation could improve diagnostic accuracy and treatment outcomes.
At a theoretical level, the findings suggest that influential models of ADHD focusing solely on cognitive deficits like executive dysfunction are likely insufficient to explain the full range of symptoms and impairments.
The field should move towards more integrative models incorporating emotional and motivational processes.
References
Primary reference
Soler-Gutiérrez, A. M., Pérez-González, J. C., & Mayas, J. (2023). Evidence of emotion dysregulation as a core symptom of adult ADHD: A systematic review. Plos one, 18(1), e0280131. https://doi.org/10.1371/journal.pone.0280131
Other references
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Bunford, N., Evans, S. W., & Wymbs, F. (2015). ADHD and emotion dysregulation among children and adolescents. Clinical Child and Family Psychology Review, 18(3), 185-217. https://doi.org/10.1007/s10567-015-0187-5
Christiansen, H., Hirsch, O., Albrecht, B., & Chavanon, M. L. (2019). Attention-deficit/hyperactivity disorder (ADHD) and emotion regulation over the life span. Current Psychiatry Reports, 21(3), 1-11. https://doi.org/10.1007/s11920-019-1003-6
Hirsch, O., Chavanon, M., Riechmann, E., & Christiansen, H. (2018). Emotional dysregulation is a primary symptom in adult Attention-Deficit/Hyperactivity Disorder (ADHD). Journal of affective disorders, 232, 41-47. https://doi.org/10.1016/j.jad.2018.02.007
Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014). Emotion dysregulation in attention deficit hyperactivity disorder. American Journal of Psychiatry, 171(3), 276-293. https://doi.org/10.1176/appi.ajp.2013.13070966
Keep Learning
Here are some reflective questions related to this study that could prompt further discussion:
- How might emotional impulsivity and deficient emotional self-regulation help explain some of the interpersonal difficulties and risky behaviors common in ADHD?
- What are some adaptive emotion regulation strategies that could be taught to adults with ADHD? How would you tailor them to address the specific emotional difficulties seen in this population?
- How do you think the neural systems involved in emotion regulation interact with and/or overlap with the attentional and cognitive control networks implicated in ADHD? What are the clinical implications of this?
- Why do you think there has been less research on emotional symptoms compared to cognitive symptoms of ADHD historically? Do you think this is changing, and if so, why now?
