ADHD: An Emotional Rollercoaster
Malvika Iyer is a Neuroscience Researcher at BrainSightAI. Here is her analysis of the neuroscientific evidence behind ADHD and emotional dysregulation.
Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental impairment that hampers the brain's ability to chalk out, focus, and perform executive functions. Though the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) states inattention, impulsivity, and hyperactivity as the main symptoms of ADHD, these symptoms and their severity vary from person to person (sometimes even from situation to situation). This makes the diagnosis of ADHD itself a multi-step process.
The DSM-5 classifies ADHD into three types, called presentations. These are:
Predominantly hyperactive: Characterized by fidgety behavior, restlessness, etc.
Predominantly inattentive: Characterized by inattention, forgetfulness, and often 'zoning out' of conversations, and
Combined: Presenting both inattentive and impulsive behaviors.
Due to a lack of awareness, hyperactive children may often come across as 'misbehaving' or 'spoilt' kids, while inattentive children get labeled 'lazy' and 'lacking interest.' The lack of interest is now attributed to a low concentration of dopamine receptors, thus suppressing the brain's reward system. As a result, an ADHD brain's motivation levels differ so drastically from a neurotypical brain that a task that seems boring to a non-ADHD brain looks so dull to the ADHD brain that it refuses to do it (regardless of the importance of the task).
Although ADHD is one of the most researched conditions, we still need widespread awareness. Many people still doubt the existence of ADHD. That said, in places with increasing understanding and acceptance, there is a significant increase in the number of self-reported cases of ADHD. The DSM-5 has a self-report checklist that is available online, and anyone who suspects they might have ADHD can take that test and then proceed to consult a psychiatrist.
Prevalence of ADHD:
ADHD impacts the lives of about 11% of children and 5% of adults in the USA. However, the percentage of adults is almost half that of children (although around 85% of the children with ADHD are at risk of having it in adulthood, too) because ADHD in adults is currently underreported. This could be because, in most cases, the manifestation of ADHD changes as it progresses from childhood to adulthood. For example, something externally visible, like fidgeting, is internalized as anxiety.
To make things worse, ADHD in adults often comes with comorbidities like anxiety attacks, depression, mood disorders, and substance abuse. As a result, people with ADHD get treated for the comorbid conditions without knowing the underlying cause, i.e., ADHD. This renders the treatment ineffective.
The Emotional Mess:
ADHD is like having a Ferrari engine for a brain with bicycle brakes. Strengthen the brakes, and you have a champion.
Dr. Edward Hallowell, Psychiatrist
One crucial feature that affects adults with ADHD is emotional dysregulation, a term used to describe poorly regulated emotions, different from the usual/expected emotions in a given situation. People with ADHD tend to 'feel' more, resulting in impulsive reactions projected as bouts of immense anger, sadness, frustration, and other negative emotions. Often, the ability to 'self-soothe,' downregulate unwanted/harsh emotions, and reconsider healthier emotional responses that are better in the long run, is also reduced immensely. This shouldn't be confused with a lack of knowledge or understanding.
For example, a person with ADHD would know that a specific impulsive action can cost them their job, yet they would end up doing it. This is because a part of the anterior cingulate cortex (ACC), which stops the neurotypical brain from making impulsive decisions, the consequences of which could be highly detrimental in the future, is inactive in an ADHD brain. fMRI imaging studies have shown a complete absence of activity in that region of the ACC; this can cause Emotional Impulsiveness (EI), leading to rash, impulsive decisions that might land someone with ADHD in an undesirable situation. People with ADHD are also more prone to alexithymia, the inability to recognize one's emotions.
Deficient Emotional Self-Regulation (DESR) is a relatively new term to describe the issues caused by EI associated with a lack of emotional self-regulation. DESR and EI are essentially manifestations of emotional dysregulation. Statistical evidence has shown that many cases of people with ADHD show trouble with EI and DESR. Yet, surprisingly, the DSM-5 still does not consider DESR a possible pointer to underlying ADHD. However, most psychiatrists believe that regardless of whether or not it appears in the DSM-5 (or the next DSM), DESR should be an indicator for ADHD, and people reporting it should undergo screening for ADHD.
Dopamine in the picture:
There is a cascade called the reward cascade. This involves serotonin release, which in turn stimulates enkephalin at the level of the hypothalamus, which in turn inhibits GABA at the substania nigra, which in turn fine-tunes the amount of dopamine released at the nucleus accumbens or "reward site." This pathway is activated while performing any task. As a result, a memory associated with the dopamine release felt after performing the job is formed; hence, there is an increased motivation to perform the same task repeatedly, leading to habit formation.
Dopamine activity on the ACC is crucial for several activities: learning, effort-based decision-making, emotional assessment, and emotional regulation. This learning also includes emotional, emotion-related, observational, and experiential learning.
This pathway is hampered in ADHD for two reasons:
Mutation in dopamine receptors renders them less effective than in non-ADHD (neurotypical) brains; and
A faster mechanism for dopamine reuptake, thereby giving less time for dopamine to act on the desired site
As a result, dopamine is not adequately concentrated for the required time, even if it is adequately released. Because of this, in addition to hampering all activities mentioned above, the lack of dopamine leads to less motivation to perform any task. Furthermore, since dopamine also releases when a pleasurable activity is performed, the lack of dopamine may drive an ADHD brain to derive pleasure from different sources like substance abuse, alcohol, etc.; these may become habit-forming and create more unrest in the already difficult life of ADHDers.
Managing ADHD & the emotional rollercoaster:
Though not curable, there are many ways to manage ADHD effectively. Practicing mindfulness meditation is one of the most effective ways. The key is to check your emotions deliberately, be mindful of your emotional state, and try and understand why you feel what you feel. There are emotional wheels that help us figure out and describe what we think, rather than loosely telling a feeling (Say, "I feel like I want to cry a lot" vs. "I feel emotionally distraught"). These are a great help in dealing with alexithymia.
Exercising, being in the company of nature, and cognitive behavioral therapy (CBT) have also proven highly effective in managing emotions without medication. CBT is often explicitly crafted per the needs of individuals with ADHD. In case CBT doesn't work out, stimulant medication is prescribed. Usually, combining all these techniques works well to make ADHD manageable and life easier.
About ADHD and emotion
Adult ADHD and emotional dysregulation
ADHD self-report checklist https://www.hcp.med.harvard.edu/ncs/ftpdir/adhd/18Q_ASRS_English.pdf
Dr. Barkley's talk on ACC
About CBT and exercise