Emotional Instability a Core Feature of ADHD
Emotional dysregulation should be considered a core aspect of ADHD because it is commonly seen in patients, including those without comorbidities, and responds to treatment, new research shows.
Presenting data from a study in adult prisoners alongside a review of the literature, Philip Asherson, MD, PhD, professor of molecular psychiatry at King’s College London, in the United Kingdom, told delegates attending the 5th World Congress on Attention Deficit Hyperactivity Disorder (ADHD) that although emotional lability is not unique to ADHD, it is a unique source of impairment in these patients.
Consequently, it should always be considered in the diagnosis of patients presenting with chronic emotional or mood instability, said Dr Asherson.
Dr Asherson noted that “traditional” diagnostic criteria for ADHD included emotional lability. However, this domain, which includes mood instability and affective lability, became separated out as clinicians concentrated on hyperactivity, impulsivity, and inattention.
This may not reflect the true picture of ADHD, he continued, because the severity of emotional instability surely contributes to impairments related to home life, occupation, education, criminal activity, driving, and financial outcomes.
ADHD Is Often Mistaken for Other Conditions
A number of other health problems, such as anxiety, depression, and certain types of learning disabilities, have symptoms that are similar to those of ADHD. Other mental disorders, such as mood disorder, personality disorder, or OCD, may also be misdiagnosed as ADHD.
In some cases, children’s circumstances may cause them to behave in ways that can be misinterpreted as ADHD. As a result, doctors must determine whether or not a sudden change or stressor in children’s lives - such as the death of a family member or divorce - is affecting their behavior.
To determine whether emotional lability is a “third dimension” of ADHD, however, it would need to be demonstrated that treatment can have an impact on lability, that there are case-control differences in lability, that it demonstrably contributes to impairment, and that it shares genetic factors with the other dimensions.
Better Focus, Improved Mood
In an attempt to answer some of these questions, Dr Asherson launched the CIAO project, which is an open-label study of methylphenidate (multiple brands) in adult offenders with ADHD.
Of 1922 male prisoners aged 18 to 30 years, 19.3% met the DSM-5 criteria for ADHD, and 40% were treated with methylphenidate. For these patients, the dose was up-titrated during a 4-week period and was then maintained at a stable dose for 8 weeks.
During 12 weeks, there were significant improvements on the Inattention/Memory Problems and Hyperactivity/Restlessness subscales of the Conners’ Adult ADHD Rating Scales (P < .0001 for both), indicating that treatment was effective.
When the team repeated the assessments using the Emotional Dysregulation Scale of the Wender-Reimherr Interview for Adult ADHD, there were again significant improvements in scores on all domains (P < .0001 for all baseline changes to week 5).
Dr Asherson explained that prisoners were better able to focus and were less restless and that their mood was more stable. This translated into a significant reduction in the total number of critical incidents between baseline and week 12 (P < .001) and a significant increase in the number of positive reports (P < .03).
ADHD Is Associated With Short-Term Memory Problems
Although they do not have problems with long-term memories, people with ADHD may have impaired short-term - or working - memory, research shows. As a result, they may have difficulty remembering assignments or completing tasks that require focus or concentration.
A 2012 review published in Clinical Psychology Review found that children with ADHD have statistically significant, large magnitude working memory problems compared to similar children who did not have ADHD.
Further analysis revealed that, even after accounting for changes in inattention and hyperactivity due to treatment, improvements in emotional dysregulation was independently associated with reductions in the number of adjudications against prisoners (P
< .0001).
These findings, which were collated in February of this year, have led to the study being refunded and converted to a randomized, controlled trial to examine the effects of methylphenidate on emotional dysregulation.
Confirmatory Findings
Dr Asherson told delegates that his findings reflect those of several previous studies in adults, as well as in children and adolescents. Crucially, there have also been a number of investigations, including twin, genetic, and neurobiological studies, that have demonstrated that emotional lability is a core feature of ADHD.
He nevertheless pointed out that despite the common genetic influences, more work needs to be done to untangle the connection between ADHD and emotional dysregulation, particularly because the latter is not unique to ADHD.
For example, there are two potential models: that the same neural processes lead to both ADHD and emotional dysregulation, which would imply, for example, a role for executive control; and that different neural processes lead to ADHD and emotional symptoms, such as via amygdala dysfunction.
Speaking to Medscape Medical News after the session, Dr Asherson said that, in a way, emotional instability is “particularly poor” at signaling which mental health problem a patient has, but that does not mean it is not an aspect of ADHD.
“Within that context, for people with ADHD who are emotionally unstable, the evidence is that there’s a good treatment response of stimulants and atomoxetine [Strattera, Eli Lilly and Company] on those emotional symptoms in people who have ADHD,” he added.