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Emotional dysregulation is an original symptom of ADHD.1234567891011121314151617181920 Wender named emotional volatility as a symptom of ADHD as early as 1971. Barkley refers to this as deficient emotional self-regulation (DESR). Studies found emotional dysregulation in 25% to 45% of children with ADHD and in 34% to 70% of adults with ADHD .213222324252627282930
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.25 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.31 Two larger studies found moderate to weak correlations between ADHD leading symptoms and mood symptoms,3233 one smaller study found a strong correlation between cognitive and emotional problems in ADHD.34 One study concluded that emotional dysregulation was linked between ADHD and gambling addiction.35 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.36
Barkley had suggested including emotional dysregulation in the DSM-5 symptom list of ADHD.29 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.43738 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.27
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 perception of one’s own emotions). Dysphoria on 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.39 Specific emotion regulation problems mean that ADHD indirectly increases the frequency of suicidal thoughts in comorbidly depressed persons with ADHD.40
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 frequently 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.41 Neurophysiological correlates have not yet been found.27
The severity of ADHD symptoms correlates with more negative emotions.42
Emotional dysregulation occurs more frequently in ADHD (with hyperactivity), in women with ADHD and correlates with greater symptom severity.27
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 al43
A screening test is currently being developed.44 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.45 In our experience, atomoxetine is even more effective for emotional dysregulation than stimulants. If necessary, combination medication can be helpful.
Emotion regulation refers to the processes responsible for monitoring, evaluating and modifying emotional experiences and/or expressions in order to achieve one’s goals. Emotional dysregulation, on the other hand, is a failure to regulate emotions that leads to emotional experiences or expressions that interfere with appropriate goal-directed activity. Regulation affects not only the individual emotions experienced, but also the emotion dynamics, including intensity, fluctuation range and temporal characteristics, such as rate of rise or recovery, consistency and lability of emotions.44
Mood swings, aggression disorders, anxiety disorders and depression or depression-related symptoms are the most frequently mentioned types of emotional dysregulation.
How much can an emotion 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
E.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 model46 with mental disorders and found the most frequent correlations to be:47
Dysphoric temperament: association with symptoms of ADHD (dysphoria with inactivity)
Volatile temperament: association with symptoms of ADHD (mood swings)
Melancholic temperament: association with severe depressive symptoms
Cyclothymic temperament: correlation primarily with symptoms of borderline personality
Euphoric temperament: positive correlation with manic symptoms
Euthymic temperament (euthymic: cheerful, cheerful): 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 the emotional traits of temperament revealed that high will, low anger, low sensitivity and high control are traits that are not related to psychopathology.
An interesting concept is the description of emotional dysregulation as an emotional partial performance disorder48 in addition to the model of cognitive partial performance disorders such as reading and spelling difficulties, dyslexia etc., when “Disorders of affect quality and regulation … occur as a largely singular and narrowly circumscribed disorder, with otherwise normal cognitive and psychological functions … in conjunction with typical cognitive patterns (e.g.: paranoid PS: “Everyone is against me”, dependent PS: “I can’t do it alone”, histrionic PS: “I have 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.25
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.
ADHD is still far too often misdiagnosed as depression.
See in detail: ⇒ Depression and dysphoria in ADHD (from the perspective of differential diagnosis).
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.
10.2.1.1. Irritability / emotional outbursts as an ADHD symptom¶
Irritability is a common (comorbid) symptom of ADHD.1549 Another apt description is “marked irritability with frequent but brief outbursts of anger”.5051
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,5253 as are anger and rage.53
Irritability is a typical symptom of impending burnout.54
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 people with ADHD who do not suffer from a comorbid ODD or behavioral disorder).55 Aggression 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.56 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.55 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.
With regard to the overly conflict-shy behavior of persons with ADHD, conflict avoidance seems to be well explained by Rejection Sensitivity. ⇒Rejection Sensitivity - fear of rejection and criticism as a specific ADHD symptom.
In our impression, however, this does not primarily serve a defense of autonomy in the sense of a motive-driven (conscious or unconscious) reaction, but is the consequence of an inner blockade in the face of too many stimuli and opportunities (which are perceived as stress) in the form of a neurophysiological consequence of an excessive noradrenaline level, which deactivates the PFC.
According to the data from our ADxS symptom test (as of June 2020, n = 1889), Rejection Sensitivity correlates most strongly with Frustration Intolerance (0.56) as well as Aggression and Impatience (0.53 each). In the DSM/ICD/Wender-Utah scales, Rejection Sensitivity correlates most strongly with the Wender-Utah scale of Emotional Dysregulation (0.47).
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.
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.50
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.5859
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.
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.
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.
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.65 A general article on alexithymia worth reading was published in 2009 in Die Zeit.66
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, emotional coldness, etc., the flatter the cortisol response to the TSST in children with ADHD.67 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.6869 Furthermore, a close connection between callous unemotional traits and impulsivity in ADHD70 and with irritability and aggression71 was described.
In addition, many people with ADHD have considerable difficulty recognizing and controlling the expression of their own emotions.72
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.73
Normally, alexithymia has a prevalence of 10% (men: 11.1%, women: 8.9%).74 The prevalence in ADHD is therefore slightly more than doubled. Alexithymia also occurs more frequently in combination with other disorders than alone, e.g.
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.79 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.80
10.3.2.2.1. Differentiation of alexithymia from similar disorders¶
Alexithymia is separate from callous-unemotional traits and the split-brain problem.
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.81
Cold aggression is associated with reduced emotionality (callous unemotional traits, reduced empathy).82
Cortisol and testosterone levels are elevated in callous-unemotional traits.83
Low dietary magnesium intake is thought to correlate with callous-unemotional traits.84
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.85
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).86Alexithymia is therefore part of the split-brain problem.
The following presentation is largely based on the compilation by Naundorf74, 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.87 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.88
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).
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.89
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.90
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).74
Similar representation of affect avoidance in schizotypal disorders
The description of affect avoidance in schizotypal disorders (there as a consequence of depersonalization anxiety) is strongly reminiscent of the description of emotional poverty as a protective reaction against unpleasant / over-intense emotional perceptions.
It is described that the alienation from oneself (de-personalization) that exists in schizotypal disorders also leads to alienation from the human and factual environment (de-realization), which is very stressful for people with ADHD and which they try to avoid.
“The fear of such alienation phenomena leads people with schizotypal symptoms in particular to avoid situations in which something like this could be triggered, particularly irritating, embarrassing or distressing, but especially interpersonal situations in which pronounced emotions can be expected. People with ADHD will therefore try to avoid upsetting experiences.
Experts call this “affect avoidance” (affect = emotion, mood, in common parlance a rather uncontrolled surge of emotion with corresponding consequences). This avoidance of affect is observed in schizophrenics in particular and is quickly interpreted negatively without further knowledge of the patient and their condition, namely as a lack or loss of emotional responsiveness and interpersonal vibrancy (general accusation: narrow-minded, “sausage-like”). The person concerned then appears to be emotionally poor to emotionally cold, unloving, indifferent, apathetic, sometimes even cold-hearted, shameless or brutal.
Depending on the person, this may well be the case, but in the majority of cases it is probably not, especially not in the long term, because the negative consequences in the partnership, family, neighborhood, circle of friends and at work are obvious.
Furthermore, schizotypal patients have a biological disposition that is based on a properly practiced “safety distancing”. This serves to protect them from emotional flooding and thus insecurity in everyday life. This is because they have a kind of “filter disorder” - similar to, if not quite as pronounced as in schizophrenics. This means that they are unable to evaluate and categorize thoughts and feelings as effectively and, above all, sort out what is not essential for them. They are therefore in constant danger of being “flooded”. As a result, they are constantly at the mercy of negative feelings and quickly become distressed. So they build up a kind of “mental wall” around themselves to avoid this excess of stress that cannot be sorted out and thus ultimately a breakdown due to a lack of sensibly stored and only purposefully used reserves of strength.
Unfortunately, this active sorting out also leads to avoidance and thus to a deficit of emotional experiences, and thus in the long term to interpersonal, social and sometimes also professional insecurity, which fuels the expected vicious circle even more. After all, if you do not “train” yourself daily to correctly assess your experiences emotionally, to evaluate them concretely and thus to organize them and keep them available for the future, you will end up lacking that routine in the “interpersonal emotional balance” that every healthy person can practice and use on their own initiative and without much thought.
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.91 Alexithymia also correlates with an increased level of rationalization.92
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.
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.
Cognitive behavioral therapy for alcohol addicts with alexithymia significantly reduced alexithymia symptoms within 3 months. The reduction was greater in women than in men.96
Frustration intolerance is a recognized ADHD symptom in children, which tends to be more noticeable in adults as a deterioration in self-control.97 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.499899
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.54 Burnouts regularly result from too much stress for too long and therefore from an unmanageable stress situation.
10.5.1. Self-perception disorders as an ADHD symptom¶
Self-perception disorders are described as a common symptom of ADHD.100101
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¶
10.5.2.2. 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.
Anhedonia is a core characteristic of depression and describes a reduction in the number and strength of positive and joyful reactions.
In survivor guilt syndrome (a form of PTSD), anhedonia refers to the persistent inability to enjoy distractions. The latter is strongly reminiscent of the symptom of inability to relax and enjoy, which is typical of ADHD-HI. However, the symptom of anhedonia in ADHD correlates much more strongly with the ADHD-I subtype than with the hyperactive ADHD-HI subtypes
Anhedonia is observed in other disorders such as schizophrenia (negative symptoms), schizoid, schizotypal, anxious-avoidant or dissocial personality disorders, psychoses, addictions and psychosomatoses.
It is assumed that alexithymia always triggers anhedonia, while anhedonia may or may not trigger alexithymia.102 In any case, there seems to be a correlation between anhedonia and alexithymia in mental disorders.103
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.104
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.
ADHD is subject to a devaluation of more distant rewards (reward discounting): Rewards that are further away are less interesting for people with ADHD than for non-affected people. Therefore, persons with ADHD are only as motivated as non-affected people when rewards are immediately available. This is the counter-effect of hyperfocusing: people with ADHD can very well concentrate on something once they have started an activity that gives them satisfaction, because the reward that is then immediately available keeps the reinforcement center active. However, this interest is much harder to achieve due to the lower number of dopamine D2 and D3 receptors in the striatum.105
This latent lack of interest in the absence of reward while performing uninteresting activities and the impaired ability to start an interesting activity (only the maintenance of an interesting activity once started is promoted by the corresponding release of dopamine) could correspond to the symptom of inner emptiness (during inactivity) described by many people with ADHD. The feeling of inner emptiness and dysphoria during inactivity seem to be closely related.
This symptom is not serious enough to be considered a contributing factor for ADHD.
In a test group of n = 82 girls aged 9-12 years, the n = 42 people with ADHD overestimated their social skills significantly more than non-affected people compared to external assessments (teachers, parents and third-party observers). If oppositional defiant behavior was added, this increased even further, as did reduced depression symptoms. Overconfidence only correlated with the tendency of people with ADHD to respond in the direction of Social desirability (socially desirable reporting bias). In persons with ADHD, overestimation of social competence was linked to the degree of imbalance. Overconfidence decreased with increasing balance, while it increased with balance in non-affected individuals.
We interpret this, especially due to the bias towards social desirability, as an effect of ADHD-typical rejection sensitivity.
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.50
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).106107
Animal studies showed that the MAO-A inhibitor moclobemide prevented the development of anhedonia under stress108 and that the SSRI escitalopram was able to reduce stress-induced anhedonia, whereby escitalopram normalized the reduced gene expression level for BDNF in the hippocampus, but not the reduced gene expression level of the D2 receptor gene in the striatum.109
People with ADHD have pronounced self-esteem problems.110
A comprehensive description of self-esteem problems in ADHD can be found at adhspedia.de.111
The severity of ADHD symptoms correlates with self-esteem, life satisfaction and depression traits.
There is a clear connection between112
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 they also managed to leave the responsibility for their symptoms with themselves 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 does not bother them (if they have the ability to understand)? 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.
With a combination of ADHD-HI and Conduct Disorder (CD) or aggressive behavior or Oppositional Defiant Disorder (ODD), self-esteem is significantly lower than in ADHD-HI alone or non-affected individuals.113
ADHD treatment (medication and non-medication) improves self-esteem and social behavior.114
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.115
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 (around 10%) reported that MPH increased RS, although even switching to a different 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 immediate effects of clonidine and guanfacine.
The fact that children with ADHD reacted more sensitively to punishment than people without ADHD,116 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.117 Rejection sensitivity also correlated with a flattened alpha-amylase stress response and more negative affect in healthy adolescents.118
10.6.1.1. Rejection sensitivity / Offensiveness and stress¶
Increased sickliness is a typical symptom of the final stage of burnout54, an atypical depression.119 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.120121122 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.123
Stress appears to be a mediator that links rejection sensitivity and depression.124
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.125
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.
Functional (healthy levels of) 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.
There are also other disorders with a faulty self-perception, e.g. anorexia, which involves a body schema disorder.
Anorexia is associated with abnormalities in ventral and dorsal areas of the brain (including the insula and striatum) as well as abnormalities in the serotonin and dopamine balance.126
The striatum and the neurotransmitters dopamine and serotonin are also involved in the development of ADHD symptoms. Nevertheless, anorexia is rarely a comorbidity of ADHD.
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. However, dosing into the early evening - with appropriate caution to avoid sleep problems - can help to improve emotional symptoms outside of activity times. 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. In order 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.29
ADHD is often accompanied by increased anxiety.132133
Anxiety in ADHD appears to be strongly moderated by executive problems134
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.
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).
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.136137
Anxiety depends on the stress phenotype. Anxiety is primarily observed in people who internalize stress (ADHD-I). If such symptoms, which only occur with 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.
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
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.140
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.
