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Emotional Instability: A Core Symptom of ADHD?

A new report claims that emotional instability should be listed as a core symptom of ADHD in the DSM, instead of just hyperactivity and inattention.

Emotional dysregulation — or the inability to properly modulate and regulate emotions — is often seen in people with ADHD, starting in childhood and lasting well into adulthood. However, it isn’t listed as a symptom of ADHD in the DSM-V, which has increasingly focused on hyperactivity, impulsivity, and inattention. New research — and a new report based on long-term studies of ADHD — aims to change that.

The report, presented by Philip Asherson, Ph.D., at the Fifth World Congress on Attention Deficit, posits that while emotional instability is not unique to people with ADHD, it presents a “unique source of impairment in these patients,” and should be treated as a core symptom of the disorder — particularly because it responds so well to treatment.

Emotional dysregulation used to be considered a core symptom of ADHD, Asherson noted. However, as physicians (and the DSM) started to concentrate more on hyperactivity and inattention, emotional symptoms were phased out of diagnostic protocol. This is bad news for ADHD patients, Dr. Asherson says, since emotional difficulties contribute extensively to impairments in home life, school settings, and careers.

To support his theory that emotional instability is a core part of ADHD — and that it can be treated — Asherson and his team examined prisoners with ADHD, placing some of them on methylphenidate and assessing their improvement after 12 weeks. For the vast majority of the prisoners, there was significant improvement on all aspects of the Conners Adult ADHD Rating Scale, which covers symptoms of inattention and hyperactivity.

Asherson’s team also measured emotional symptoms using the Emotional Dysregulation Scale of the Wender-Reimherr Interview for Adult ADHD. After 12 weeks of taking methylphenidate — with no additional medication or therapy strategies — the prisoners all showed significant improvement on emotional symptoms as well, indicating that emotional dysregulation responds to standard ADHD treatment as well as hyperactivity and inattention symptoms do.

Asherson acknowledges that emotional dysregulation is not unique to ADHD — in fact, it’s common to many mental health disorders. But its prevalence in ADHD patients can give doctors an additional piece of the puzzle when attempting to tease out a complex diagnosis.

“As a clinician, and particularly in adult psychiatry, where people are less familiar with ADHD, if they see mood instability, they’ll often be thinking [mood disorders] or personality disorder,” Asherson said. “They forget that ADHD can also cause it.”

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  1. It will come as no surprise to a lot of researchers if emotional dysregulation can be seen as a core feature of ADHD. Bi-facor theory would actually predict that ADHD and borderline personality disorder would share most core features.

  2. From the information gathered mainly through ADDitude, I see no difference between the symptoms of ADD and BPD, but it seems the average psychiatrist does not recognize this resemblance and does not convey the correct information to the parents/carers or to the patient himself. ADD and ADHD are still thought of as a children’s problem, mainly disturbing the teacher’s control of the class and solving the problem by stuffing the child with a molecule identical to the cocaine molecule! So research re treatment and identification of the seriousness of this chronic/sometimes fatal disease is very superficial.

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