ADHD and Emotions: What the DSM-5 Doesn't Tell Us

Allison* arrives at the office discouraged and a bit confused.

“How did your appointment with the new psychiatrist go?”

“Um, not great,” she says. “He met with me for about 20 minutes and thinks I have some kinda ‘light bipolar disorder’ and gave me a prescription for a mood stabilizer.”

I share her discouragement and try my best to temper my irritation. I’ve been down this road before.

Allison has struggled for years with disorganization, difficulty staying committed to tasks, and failing to follow-through on projects.

Despite a successful consulting career, she feels like a failure and unable to live up to her potential. Recently her engagement broke off when her fiancé learned of a second derogatory mark against Allison’s credit score for failure to pay her bills on time and $5,000 worth of back taxes and penalties for failing to file taxes on time. Childhood teachers called her a “space cadet” who could do so much better if she just “applied herself.”

As a clinical psychologist, I’ve gone through an extensive diagnostic evaluation process with Allison. That process includes hours of clinical interviews, administration of numerous standardized assessment questionnaires, and interviewing (with her permission) her ex-fiancé.

That rigorous diagnostic process did not identify bipolar disorder (a mental health condition that results in clear, atypical, and notable shifts in mood, energy, and activity levels that cycle over several days, weeks, or months).

Instead, our evaluation concluded that Allison has adult Attention Deficit Hyperactivity Disorder (ADHD), a far more common disorder (studies suggest that ADHD is approximately four to five times as common as bipolar disorder and, if not diagnosed in childhood, is substantially likely to go unrecognized in adulthood).

But Allison, like many individuals with ADHD, also has really strong emotions. She describes herself as impatient and “gets a bit angry sometimes.” She has been criticized as “too sensitive” by others, tends to feel overwhelmed by life, but also tends to get very easily excited by new ideas and new relationships.

“Many cases of ADHD in adults are not being accurately assessed,” said Frederick W. Reimherr, M.D., in an interview with Healio Psychiatry.

Reimherr and his colleagues have been studying adults with ADHD in Utah since the 1970s. One of their main conclusions? “Many patients with ADHD have emotional symptoms that are not part of the DSM criteria for the disorder,” they write in a recent publication in The Journal of Clinical Psychiatry.

These conclusions have been replicated not just by Reimherr and his colleagues but by other researchers as well, including Russell Barkley who titled a chapter in his textbook, Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis & Treatment: “Emotional Dysregulation is a Core Component of ADHD.”

Across eight double-blind adult ADHD clinical trials encompassing 1,490 patients, a presentation of ADHD with emotional dysregulation symptoms was present in as many as 25 to 73 percent of participants. Furthermore, previous studies have shown that emotional dysregulation symptoms in adults with ADHD have been shown to significantly respond to both methylphenidate and atomoxetine, medications that are traditionally used in the treatment and management of ADHD.

Yet, emotional symptoms are nowhere to be found in diagnostic criteria for the disorder, leaving adults like Allison and many others with delays and obstacles to receiving effective treatments. “The improvement in these emotional dysregulation symptoms with medications shown to be effective in treating ADHD supports the inclusion of these symptoms in the diagnostic criteria,” Reimherr said.

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*Identity disguised and fictionalized.