In most discussions about ADHD, the issues are related to distraction, forgetfulness and organization. One of the most disruptive – and least discussed – symptoms for millions of adults with ADHD is not related to paying attention. It’s about emotion.
Emotional dys-regulation in ADHD adults: difficulty in the intensity, duration and expression of emotional reactions. It’s feeling emotions stronger than they should be, having a hard time getting back to a calm baseline after a trigger, and sometimes doing or saying things at a time when your emotions are so overwhelming you regret it later.
If you’ve ever been told that you’re ‘too sensitive,’ ‘overreacting’ or ‘impossible to talk to when you’re upset’ – and you have ADHD – then this article is for you. The symptoms that you’re feeling are real, and have a name; they have a neurological explanation and there are real strategies to help.
What Is Emotional Dysregulation in ADHD Adults?
Emotional dysregulation is not just feeling full of emotion. We all have strong emotions at times. For adults with ADHD, the threshold and speed of emotional responses, along with the rate of recovery, differ.
Emotional Dysregulation has been proposed by Dr. Russell Barkley, a prominent ADHD expert, to be a primary component of ADHD, rather than a secondary issue. In his model, the same executive dysfunction characteristic of the ADHD that affects attention and impulse control also affects the regulation of emotional responses.
Emotional dysregulation that for ADHD adults looks like:
- A minor issue in the workplace causing a cascade of shame that wreaks havoc on the day
- Unexpected change of plans that leads to an exaggerated state of anger
- Having been hurt by an incidental remark that few could hear, care for, or understand
- Crying, shutting off, or snapping at loved ones without being able to get it across why
- Frequent but short periods of frustration, excitement, or anxiety that come and go quickly
They can’t be called weaknesses of character. They are manifestations of a brain that is responding to emotional stimuli in a manner (and perhaps at a faster rate) that exceeds the capacity of the regulatory systems.
The Neuroscience Behind ADHD and Emotional Regulation
Understanding the prevalence of emotional dysregulation in ADHD can be helpful if one considers the workings within the brain.
Executive function is in the control of the prefrontal cortex, which is the area of the brain involved in emotional regulation. It helps temper emotions from the amygdala, the brain’s emotional alarm system, puts emotions into perspective, delays responses, and instead of simply responding, selects responses.
ADHD is characterized by hypo-activity in the prefrontal cortex, with disruption of dopamine signaling that is known to support prefrontal cortex activity. This produces a kind of emotional alert on full and a volume down control on the Cortex.
That’s why ADHD emotional dysregulation has nothing to do with wanting to overreact. The regulatory brake in the brain is not kicking in quickly enough to stop the emotional avalanche before it’s coming at him/her.
There is also evidence that ADHD is associated with diminished activity in the anterior cingulate cortex, which is responsible for detecting errors and conflict monitoring – that is, ADHD adults have poor error detection and monitoring of conflict.
What Emotional Dysregulation Looks Like in Adult ADHD: Common Signs
Identifying some of the emotional signs and symptoms of ADHD as an adult is the first step in helping to solve them. The following are the patterns that are often observed in medical practice:
Rejection Sensitive Dysphoria (RSD)
Rejection sensitive dysphoria is likely the most important and unrecognized emotional out-of-control behavior associated with ADHD. RSD was first noted by Dr. William Dodson as an extreme sensitivity to perceived or received rejection, criticism, failure, and/or teasing.
Adults with RSD may experience:
- Unexpected, intense feeling of hurt resulting from real or imagined criticism
- Extended fear of failure leading to avoidance of new tasks
- Actions or behaviors done for another person so that they will not reject.
- Taking neutral feedback as criticism
- Sudden, but severe, emotional outbursts that appear on the outside as mood disorders.
RSD episodes can pass off very quickly, sometimes in a few hours, and may be hard for witnesses to understand, and for the person having them. Bipolar disorder is not the same, but sometimes mistaken for them.
Low Frustration Tolerance
People with ADHD tend to get more and more frustrated when tasks are not accomplished quickly. Small problems – time on the internet, a lost item, an unanticipated task – can create a degree of irritation that appears, at the time, utterly excessive.
This is not immaturity, it is a low frustration tolerance in ADHD. It is a similar executive function deficiency to the difficulty with sustained effort. Small annoyances are able to overload the prefrontal cortex quicker when it is already overwhelmed by the demands of managing attention.
Emotional Impulsivity
Just as with ADHD, emotional impulsivity is acting before the regulating system has time to react – responding before thinking. This shows up as:
- Snapping at other people before you realize what you’ve done
- Sending an email or text that you later regret
- Crying when you were not trying for it to be taken as such
- Loud or prolonged laughter in social situations
- Expressing enthusiasm to the point of intimidating others
Mood Shifts and Emotional Lability
One symptom of ADHD emotional dysregulation can be rapid, unpredictable mood changes. It is not uncommon for adults to feel irritated, angry, or embarrassed at a moment’s notice, over nothing in particular. The emotional instability (lability) in ADHD differs from that of bipolar disorder, and the lability is shorter in duration and more typically follows environmental cues.
Shame Spirals
One of the deep emotional scars of ADHD is often a reservoir of shame. When you feel this way for years, that can make it so you are more prone to feelings of emotional out-of-controlness. One unforgettable word of shame can trigger a cascade of past and future, resulting in a reaction that feels like an out-of-proportion response to the moment – but is actually an out-of-proportion response to the years of shame.
How Emotional Dysregulation Affects Adult Life
ADHD and emotional regulation issues have an impact on every facet of adult functioning:
Relationships: Emotional impulsivity and RSD can have a tremendous impact on love relationships. They may be seen as manipulative, aggressive and immature by partners that don’t know and understand what ADHD is. For adults with ADHD, avoiding dating relationships may be a way to avoid rejection.
Workplace performance: Fear of failure or sensitivity to criticism may result in poor performance, avoidance of feedback, and failure to recover from error. When emotional responses are directed in a hurtful or frustrated way, it can also harm a working relationship.
Mental health: Adult ADHD has been shown to have significantly elevated rates of anxiety and depression – emotional dysregulation is a major contributing factor. Being ‘too much’, misunderstood, and unable to control responses can drain emotional reserves and exacerbate mental health problems.
Self-esteem: If emotions are out of control, many adults with ADHD start believing the issue is their personal traits or their self, and not their brain. One of the worst things about emotional dysregulation not being dealt with is this false conclusion.
Practical Strategies for Managing ADHD Emotional Dysregulation
The purpose of emotional regulation strategies for ADHD adults is not to make them feel less, but to help create distance between trigger & response. These are what helps:
1. Name It to Tame It
Guiding emotion labels – putting them in words, either spoken or written – activates the PFC and lowers the activity of the amygdala. If you feel anger rising, try to take a break and label your emotions as such: “I’m getting hot here, this is shame, not danger. This is not toxic positivity, rather it is neurologically-based and effective.
2. Build a Personal Early Warning System
Most people who have ADHD have physical warning signs before they flood emotionally, such as a tight chest, tense jaw or feeling hot in the face. Knowing what to look for before it gets to the crisis stage allows you the chance to intervene. Use a therapist to plan your escalation process and make suitable exit plans.
3. Create a ‘Pause Protocol’
Before reacting to something emotionally charged, whether it be a thought-provoking email or a partner’s gripe or a difficult circumstance, you take at least 10 minutes to calm down. This one step can eliminate many of the regretted reactions. The 24-hour time delay before reacting to the perceived criticism is crucial for RSD triggers.
4. DBT Skills for Emotional Regulation
Dialectical Behavior Therapy (DBT) has been developed specifically for borderline personality disorder and strong evidence of it being successfully used to address emotional dysregulation in ADHD. Specific skills that directly translate to skills appropriate for ADHD include:
- TIPP: Temperature (cold water on the face to quickly diminish emotional intensity), Intense exercise, Paced breathing, Progressive muscle relaxation
- Opposite action: Willingly doing the opposite of what you feel (do not send the heated message; reach out instead)
- Check the facts: Making sure your emotional interpretation of a situation is grounded in the facts
5. Medication Management
Stimulant medications help with emotional dysregulation in ADHD adults by improving prefrontal cortex function. Evidence also indicates that stimulants decrease emotional impulsivity as well as attentional symptoms. Antihistamines and CNS drugs such as guanfacine (Intuniv) and clonidine have been specifically linked to decreased emotional reactivity, and sometimes work concurrently with stimulants in this regard.
Talk with your prescribing clinician if your ADHD is not being treated for emotional issues, as you may need to change your protocol.
6. Therapy Tailored to ADHD
CBT for ADHD (Cognitive Behavioral Therapy) targets processing of emotions and thoughts that sustain emotional dysregulation (shame narratives, catastrophic thinking, avoidance). It is crucial to use a therapist with some knowledge of ADHD because a traditional CBT approach will lack the neurological component.
Complementing therapy, ADHD coaching can help with actual application of regulation strategies in the here and now.
7. Protect the Basics
Emotional dysregulation in adults with ADHD is greatly exacerbated by sleep deprivation, hunger, and overstimulation. The ADHD brain does not have as much buffer in one place, and when needs are not met, it’s gone. Poor sleep, not regular feeding, and sensory load are basic and essential components of emotional regulation – not some add-on extras.
8. Communicate Your ADHD to Key People in Your Life
This can be one of the least used, but most effective strategies: to teach the people around you what emotional dysregulation is like from the inside. When resources are shared, couples attend therapy together with an ADHD therapist, or when there is a direct conversation and information about what helps during escalation, it can greatly limit relationship damage and secondary shame.
You Are Not ‘Too Much’
If you have struggled in relationships, in the workplace, and have been dealing with years of self-criticism, please hear this: You are not broken, dramatic or difficult. You are living in a neurological reality which most around you cannot see.
The ADHD brain is very sensitive, very reactive, and recovers slower than it should. That’s not a character indictment, it’s merely a fact. It’s a description of an executive function problem – a problem that can be counteracted through appropriate support, strategy and understanding.
Meaningful change in emotional dysregulation is possible with accurate diagnosis, appropriate treatment, and behaviors that are designed according to your brain’s wiring.
Frequently Asked Questions: Emotional Dysregulation and ADHD Adults
Q: Is emotional dysregulation an official symptom of ADHD?
It does not appear in the DSM-5 criteria for ADHD, which is a major area of disagreement amongst clinicians. Recent studies, though, including those of Dr. Russell Barkley and Dr. William Dodson, have confirmed that emotional dysregulation is a primary, rather than secondary, problem associated with ADHD. It is a common practice for many clinicians to evaluate and manage it as a component of ADHD management.
Q: How is ADHD emotional dysregulation different from bipolar disorder?
There are two major distinctions: trigger and duration. Episodes of emotional behavior associated with ADHD are often short-lived (minutes to hours) and directly linked to specific triggering events such as a sense of rejection or frustration. Mood episodes are bipolar and occur with days to weeks and are not as dependent on identifiable triggers. Both can occur in the same person and diagnosis is crucial.
Q: What is rejection sensitive dysphoria and is it always part of ADHD?
Rejection sensitive dysphoria is a heightened emotional reaction to experiencing or anticipating a rejection, criticism or failure. Research indicates that as many as 99% of adults with ADHD have some degree of RSD, though in varying intensities. Not a formal diagnostic category yet it is gaining momentum in the field of ADHD Clinics.
Q: Can emotional dysregulation in ADHD adults improve without medication?
Yes, but many times the medication makes things happen quicker. Use of therapy, particularly DBT and CBT (CBT adapted for ADHD) and lifestyle and behavioral strategies can result in significant improvements in emotional regulation. For many adults, however, medication will open up enough of the neurological barrier that other methods will be much more effective.
Q: Why do I feel so ashamed after an emotional outburst, even when I didn’t mean it?
Every ADHD adult experiences shame after emotional dysregulation episodes; it is the difference between that time and the way that you value the world. Importantly, shame can be the next dysregulation – and then it’s a cycle. One of the reasons working with an ADHD-informed therapist is so valuable is the fact that to break the shame cycle is as important as learning how to regulate their skills.
Q: Is emotional dysregulation more common in women with ADHD?
Women are more likely than men to suffer high intensity emotional dysregulation (and RSD in particular) and emotional symptoms may be a main indication for women to seek diagnosis later in life, research suggests. Women who suffer from ADHD are also at higher risk to be misdiagnosed with anxiety disorder or depression prior to their ADHD diagnosis.
Knowing about emotional dysregulation is only the first step. We offer all our patients evidence-informed and compassionate care at Dr. John Shershow’s office, supporting adults with ADHD, emotional dysregulation, and all the complex mental health issues that come with neurodivergence.