Emotional impulsivity and deficient emotional self-regulation might be core symptoms of ADHD
A large proportion of children with attention-deficit/hyperactivity disorder (ADHD) exhibit notable emotion-related problems (or “emotional symptoms”)1.
These emotional symptoms seem to associate with poor quality of life, impaired social adjustment and reduced marital status2,3.
Furthermore, children with ADHD and emotional symptoms are more ly to have hyperactivity/impulsive symptoms that continue into early adulthood than those who do not present with these problems4.
Addressing the underlying emotional mechanisms in affected patients could, therefore, have a marked impact on quality of life. Whether these emotional symptoms should be considered integral to ADHD (and thus incorporated into the diagnostic nomenclature)1 or rather as an associated trait5, however, is hotly debated.
In 2019, Stephen Faraone and colleagues compiled a Practitioner Review for the Journal of Child Psychology and Psychiatry that aimed to clarify the nature of emotional symptoms in ADHD.
The researchers first identified that a large number of terms are used to describe the role of emotional symptoms observed in ADHD, which could lead to clinical confusion.
Such terms include emotional lability (EL), emotional reactivity, emotional impulsivity (EI), emotional instability, emotional dysregulation, deficient emotional self-regulation (DESR), distress tolerance, frustration discomfort and irritability.
They then evaluated how the emotional symptoms in ADHD differ from those observed in other mood disorders. Here, they found that EI and DESR might be sufficiently specific for ADHD to function as diagnostic criteria, while irritability should not be considered a symptom of ADHD.
Poignantly, the researchers point out that impulsive and poorly regulated cognition and behaviours are already in the diagnostic criteria for ADHD, yet corresponding impulsive and poorly regulated emotions are not.
The fact that only a subset of patients with ADHD exhibit emotional dysregulation and that another subset of individuals without ADHD can also present with emotional dysregulation, however, is a challenge to address before contemplating changes to the diagnostic criteria. Faraone et al.
assert that more accurate identification and description of EI and DESR would ly benefit those with ADHD as well as those with other psychiatric disorders.
The researchers reiterate that few symptoms in psychiatry are fully specific, and that this fact should be considered when deciding whether emotional symptoms should form part of the core disorder in ADHD.
Going forward, they explain that improvements to available treatments to effectively manage EI and DESR are now needed. They also recommend that a new measurement tool or assessment instrument is created that can capture the multi-dimensional nature of emotional symptoms in ADHD.
A useful tool would be able to identify emotional symptoms in young people with ADHD and better monitor any change in emotions with treatment.
Faraone, S.V., Rostain, A.L., Blader, J., Busch, B., Childress, A.C., Connor, D.F. & Newcorn, J.H. (2019), Practitioner Review: Emotional dysregulation in attention-deficit/hyperactivity disorder – implications for clinical recognition and intervention. J. Child Psychol. Psychiatr. 60: 133-150. doi: 10.111/jcpp.12899.
Emotional impulsivity (EI): Impulsivity is broadly defined in the DSM-V as actions that are poorly conceived, prematurely expressed, unnecessarily risky, and inappropriate to the situation. EI specifically was defined by Barkley in 20151 as difficulties with emotion generation that is highly impulsive.
Deficient emotional self-regulation: Defined by Barkley in 20151 as difficulties with the self-regulatory functions that effectively manage emotional experience to rein in behaviour from accelerating to problematic degrees.
1Barkley, R.A. et al. (2015), Emotional dysregulation is a core component of ADHD. In R.A. Barkley (Ed.), Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th edn). New York: Guilford Press.
2Anastopoulos, et al. (2011), Self-regulation of emotion, functional impairment, and comorbidity among children with AD/HD. J. Atten. Disord. 15: 583–592. doi: 10.1177/1087054710370567.
Study: Many With ADHD Can’t Control Emotions
From the WebMD Archives
May 6, 2011 — More than half of people with attention deficit hyperactivity disorder (ADHD) also have trouble regulating their emotions, and that difficulty may be passed through families, a new study shows.
Researchers are calling this cluster of symptoms deficient emotional self-regulation (DESR). It involves quick bursts of outsized anger, frustration, impatience, or excitability in response to everyday events.
“Any sort of reflexive, emotionally laden reaction that would not be politic or thoughtful or helpful,” says study researcher Craig B. H. Surman, MD. Surman is an instructor in psychiatry in the Massachusetts General Hospital Pediatric Psychopharmacology and Adult ADHD Program.
“It’s not just people with mental health challenges that have issues regulating their emotions. Everyone does to some extent, but hopefully, in most cases it’s when people are really maxed out or strained or stressed,” Surman says.
“Folks who have deficient emotional self-regulation, we feel, don’t have inhibitory capacity to censor emotional reactions even when they’re not under these kinds of stresses.”
What’s more, it appears that this inappropriate emotional reactivity appears to be shared among siblings, though researchers aren’t sure if genetics or a family environment is the reason.
“Is it a neurobiological thing in these families, or a learned thing?” Surman asks.
For the study, researchers recruited 83 people: 23 with ADHD alone, 27 with ADHD plus DESR, and 33 people with neither condition for comparison. Researchers then enrolled 128 siblings of each of the participants.
Clinicians who were kept in the dark about which group participants belonged to evaluated each person in the study to independently confirm their diagnosis and to measure any DESR symptoms.
People with ADHD were considered to have DESR if they also reported emotional-control symptoms that were worse than those reported by 95% of a large comparison group of people without ADHD.
More than half of those with ADHD enrolled in the study (55%) were also emotionally reactive.
As expected, ADHD was more common in siblings of the original participants with ADHD than in siblings of the comparison group. Previous studies have suggested that ADHD may run in families.
The surprising thing to researchers was that ADHD and DESR appeared to only co-occur in siblings of original participants with both sets of challenges.
“I think that what we’ve demonstrated is that there’s a subset of people who have attention deficit hyperactivity disorder who can’t control their emotional reactions, also,” Surman says.
Because mental health conditions ADHD, depression, and generalized anxiety disorder often occur together, the researchers also asked participants about symptoms and signs that might indicate that another mental illness could account for the emotional volatility they were feeling.
“We found you can individually remove any of the major mental health conditions that we inventoried and people still are reporting these kinds of irritable, emotional overreactions,” Surman says.
The study is published in the American Journal of Psychiatry.
Though researchers are still trying to understand the role of different brain structures in ADHD, one fold of tissue in the middle of the brain, called the cingulate gyrus, appears to be playing a big role.
“It’s so tied to key regulatory systems for behavior and attention and also emotion that it’s highly implicated as a ly place of some sort of issue for ADHD,” Surman says.
Scans that look at the activity of the brain as it is working, called functional magnetic resonance imaging (fMRI) scans, have also shown that the activity of the cingulate gyrus in the brains of ADHD patients appears to be lower compared to people without ADHD.
When those same patients are given stimulant medications, the activity of the cingulate gyrus appears to normalize.
In addition to medications, cognitive behavioral approaches to therapy may help.
A paper published last year in The Journal of the American Medical Association, which Surman co-authored, found that two-thirds of patients with ADHD who got 12 weekly counseling sessions of cognitive behavioral therapy report at least a 30% reduction of their symptoms, compared to one-third of a comparison group that was taught relaxation techniques.
“I think there’s a lot of hope if people know why they’re doing what they’re doing,” Surman says.
Surman, C. American Journal of Psychiatry, online, April 15, 2011.
Safren, S. The Journal of the American Medical Association, Aug. 25, 2010.
News release, Massachusetts General Hospital.
Craig B. H. Surman, MD, instructor in psychiatry, Massachusetts General Hospital Pediatric Psychopharmacology and Adult ADHD Program, Cambridge, Mass.
© 2011 WebMD, LLC. All rights reserved.
Do You Have Deficient Emotional Self-Regulation (DESR)?
Getty / Steve Peixotto Photography
Deficient emotional self-regulation (DESR) is not among the defining criteria for a diagnosis of attention deficit disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). However, of the 6.
1 million children who live with ADHD in the United States, it's suggested that about half may also have DESR.
Regardless, it remains unclear whether deficient emotional self-regulation is a symptom of ADHD or a related condition.
Deficient emotional self-regulation refers to the inability to regulate physiological arousal caused by overwhelming emotions. This term was defined in 2015 by Russell Barkley as part of a debate about whether DESR should be an integral part of a diagnosis of ADHD or an associated trait.
Deficient emotional self-regulation has also been known as other related terms such as the following concepts:
- emotional lability
- emotional impulsivity
- emotional dysregulation
- frustration discomfort
- emotional reactivity
- emotional instability
- poor distress tolerance
People with ADHD who are also living with DESR generally have a poor ability to inhibit emotional reactions that are proportion to the situation. In other words, if you are living with DESR, you may react in the same way that someone else who is under extreme stress or strain would to a normal situation.
While DESR is not recognized in the DSM-5 as a criterion for ADHD, emotional impulsivity is defined as actions that are the following:
- poorly conceived
- prematurely expressed
- unnecessarily risky
- inappropriate to the situation
In order to better understand DESR, it's important to understand the concept of executive functioning. While DESR is not included in the diagnostic criteria for ADHD, it can have serious negative effects on the daily functioning of those who struggle. In fact, DESR can worsen other ADHD symptoms.
Executive function (EF) is what underlies the capacity for self-regulation. If you think about your mind as a group of individuals, then executive function is your brain's ability to corral that group of individuals to coordinate together and get things done.
In other words, instead of being scattered and aimless, and jumping from one thing to the next, executive function allows you to focus on what's most important, shift tasks easily when it's required, and keep the bigger picture in mind.
In general, executive function makes it much easier to respond to the demands of daily life; but in individuals with ADHD, executive function is often poor.
What's more, previously, the capacity to regulate emotions was thought to be one type of executive function. In other words, the ability to rein in negative emotions or to not let your emotions overwhelm you was thought to be a part of executive function.
To help you understand, here are some of the other abilities that are generally grouped under executive functions:
- ability to process information and stay alert
- ability to not get stuck and switch tasks
- ability to start a task and get organized
- ability to use working memory and access your memories
- ability to regulate actions and monitor yourself
However, it has been argued that the ability to regulate emotions does not belong on this list; rather, emotion regulation is a thread running through all of the above processes. And when it fails, the whole system fails. This explains why having DESR can cause so many impairments in different areas of one's life.
When you feel overwhelmed by your emotions, that makes it harder to focus on other cognitions such as staying with a task or making an appropriate choice for the situation that you are in.
What looks a lack of willpower is actually a flood of emotion that is so overwhelming it makes it virtually impossible to stay the course and be productive. And instead, it leads to procrastination, the inability to focus on long-term rewards, and even a struggle to manage excitement and intense interest in new things.
If you or someone you know is struggling with DESR, it's not your imagination that it is the hardest part of living with ADHD; given the effects in all areas of your life, this is completely understandable.
Let's take a step back for a moment and outline the precise experiences that you might be having if you live with DESR. The symptoms of deficient emotional self-regulation are as follows:
- low frustration tolerance
- emotional impulsivity
- mood lability
- quick bursts of disproportionate anger and frustration
- excitability in the face of everyday events
- snapping at small disappointments
In addition to the immediate symptoms of DESR, there are also longer-term impacts and indirect effects on the lives of those who struggle.
A study conducted with 206 adults with ADHD and 123 without ADHD in 2011 and published in the American Journal of Psychiatry indicated that people living with ADHD who also live with deficient emotional self-regulation experience more impairment in daily life. Below are some issues you may face if you have DESR:
- greater risk of never being married or being divorced
- higher risk of car accidents or arrests
- overall lower quality of life
- poorer social adjustment
In general, you may also experience feelings of fear, shame, anger, and hopelessness at your ability to manage your emotions, and as a result, many different areas of your life.
What causes deficient emotional self-regulation? In a study of 23 people with ADHD, 27 with ADHD combined with DESR, and 33 without neither, along with their siblings, it was shown that there was a familial link between ADHD and DESR.This suggests that there is a genetic component to DESR among those with ADHD. In other words, DESR is not just a learned behavior; it may run in families due to a genetic component.
What can you do to get help if you are living with DESR? The two main treatment options are medication or therapy.
Stimulant medication normally prescribed for ADHD may also help you to manage deficient emotional self-regulation. However, not everyone does well with medication in terms of how well it works, side effects, and overlap with other medications that you might already be taking.
It's important to discuss all these issues with your doctor if you are considering taking medication to manage DESR. Medication can be helpful when used correctly and monitored to ensure that side effects are minimized and that dosage is optimal.
Therapy such as cognitive-behavioral therapy (CBT) or mindfulness-based techniques can be helpful to allow you to develop better emotional self-regulation.
Through these types of therapies, you would be training your brain to respond in different ways to triggers and learning new coping skills to manage emotions when they become overwhelming. Therapy can also be combined with medication so that you experience optimal effects of both treatments.
If you have ADHD and also believe you are living with DESR, know that you are not alone and that there are coping methods that you can employ on your own to manage daily life. Ideas include practicing daily meditation to engage in a practice of mindfulness, getting regular exercise to help modulate your emotions, and watching the foods that you eat that may contribute to highs and lows.
Beyond this basic layer of coping, it is important to speak to your doctor or a mental health professional if you are truly struggling on a daily basis.
Not everyone with ADHD will also be living with DESR. Given that DESR is still not a recognized criteria for the diagnosis of ADHD, additional research is needed before we will have definitive answers as to the best treatment options for those with both ADHD and DESR.
In the meantime, the best thing you can do is to communicate with your health professional so that he or she is aware of the symptoms and struggles you are facing. It is only through this awareness that better treatment options can be made available.
Finally, if the person with DESR is someone whom you know or a family member, try to remember to show patience as they work through these issues. Your support during times of difficulty will be more helpful than anything else, despite how hard it may be in the moment to offer.
If you find yourself struggling to cope emotionally yourself, remember to take breaks as needed and perhaps reach out to a support group for families who will understand and relate to the issues you are facing.