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01-12-2020 | Attention Deficit Hyperactivity Disorder | Research article

Emotion dysregulation in adults with attention deficit hyperactivity disorder: a meta-analysis

Authors: Ashkan Beheshti, Mira-Lynn Chavanon, Hanna Christiansen

Published in: BMC Psychiatry | Issue 1/2020

Abstract

Background

Emotional symptoms are increasingly considered a core feature of attention deficit/hyperactivity disorder (ADHD). We aimed to quantify the evidence of emotional dysregulation and its respective facets in individuals with adult ADHD compared to healthy controls using meta-analysis.

Methods

Two electronic databases (PubMed, PsycINFO) were reviewed to identify studies. Studies were eligible for inclusion that had reports on any measure of emotion (dys) regulation in adults (> 18 years of age) in clinically diagnosed patients with ADHD as well as healthy control participants. We included a total of 13 studies (N = 2535) to assess (1) the standardized mean difference in emotion dysregulation (ED) as a general factor and its specific facets (i.e., emotional lability, negative emotional responses, and emotion recognition) between adults with ADHD and healthy controls; and (2) the association between ADHD symptom severity and ED.

Results

Compared to healthy controls, adults with ADHD revealed significantly higher levels of general ED (Hedges’ g = 1.17, p < 0.001; Hedges’ g is the adjusted effect size). With regard to intermediate dimensions of ED, emotional lability exhibited the strongest weighted effect (Hedges’ g = 1.20, CI [0.57, 1.83], p < 0.001). Furthermore, symptom severity and general ED correlated significantly (r = 0.54, p < 0.001). Regarding intermediate dimensions of ED, negative emotional responses correlated closely with ADHD symptom severity (r = 0.63, p < 0.001) and emotional lability (r = 0.52, p < 0.001).

Conclusions

Our findings support ED symptoms as a core feature of ADHD’s psychopathology. With respect to dimensions of ED, emotional lability, and negative emotional responses play a more definitive role in the psychopathology of adults with ADHD. Due to insufficient statistical reports in the included studies, we could not perform meta-regressions to control the role of moderator variables.

Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®): American psychiatric pub; 2013.

Barkley RA. Differential diagnosis of adults with ADHD: the role of executive function and self-regulation. J Clin Psychiatry. 2010;71:e17.CrossRefPubMed

Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler O, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163:716–23. https://doi.org/10.1176/ajp.2006.163.4.716.CrossRefPubMedPubMedCentral

Retz W, Stieglitz R-D, Corbisiero S, Retz-Junginger P, Rösler M. Emotional dysregulation in adult ADHD: what is the empirical evidence? Expert Rev Neurother. 2012;12:1241–51. https://doi.org/10.1586/ern.12.109.CrossRefPubMed

Barkley RA, Murphy KR, Fischer M. Adult ADHD: What the science says. New York: Guilford; 2008.

Bunford N, Dawson AE, Evans SW, Ray AR, Langberg JM, Owens JS, et al. The Difficulties in Emotion Regulation Scale–Parent Report: A Psychometric Investigation Examining Adolescents With and Without ADHD. Assessment. 2018:1073191118792307.

Corbisiero S, Stieglitz R-D, Retz W, Rösler M. Is emotional dysregulation part of the psychopathology of ADHD in adults? ADHD Atten Defic Hyperact Disord. 2013;5:83–92.CrossRefPubMed

Skirrow C, Asherson P. Emotional lability, comorbidity and impairment in adults with attention-deficit hyperactivity disorder. J Affect Disord. 2013;147:80–6. https://doi.org/10.1016/j.jad.2012.10.011.CrossRefPubMed

Graziano PA, Garcia A. Attention-deficit hyperactivity disorder and children's emotion dysregulation: a meta-analysis. Clin Psychol Rev. 2016;46:106–23. https://doi.org/10.1016/j.cpr.2016.04.011.CrossRefPubMed

10.

Martel MM. Research review: a new perspective on attention-deficit/hyperactivity disorder: emotion dysregulation and trait models. J Child Psychol Psychiatry. 2009;50:1042–51. https://doi.org/10.1111/j.1469-7610.2009.02105.x.CrossRefPubMed

11.

Ramsay JR, Rostain AL. Adult ADHD research: current status and future directions. J Atten Disord. 2008;11:624–7. https://doi.org/10.1177/1087054708314590.CrossRefPubMed

12.

Skirrow C, Ebner-Priemer U, Reinhard I, Malliaris Y, Kuntsi J, Asherson P. Everyday emotional experience of adults with attention deficit hyperactivity disorder: evidence for reactive and endogenous emotional lability. Psychol Med. 2014;44:3571–83. https://doi.org/10.1017/S0033291714001032.CrossRefPubMed

13.

Hirsch O, Chavanon M, Riechmann E, Christiansen H. Emotional dysregulation is a primary symptom in adult attention-deficit/hyperactivity disorder (ADHD). J Affect Disord. 2018;232:41–7. https://doi.org/10.1016/j.jad.2018.02.007.CrossRefPubMed

14.

Wender PH. Attention-deficit hyperactivity disorder in adults. Psychiatr Clin N Am. 1995;21(4):761–74.CrossRef

15.

Kring AM, Sloan DM. Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment: Guilford Press; 2009.

16.

Shushakova A, Ohrmann P, Pedersen A. Exploring deficient emotion regulation in adult ADHD: electrophysiological evidence. Eur Arch Psychiatry Clin Neurosci. 2018;268:359–71. https://doi.org/10.1007/s00406-017-0826-6.CrossRefPubMed

17.

Faraone SV, Rostain AL, Blader J, Busch B, Childress AC, Connor DF, Newcorn JH. Practitioner review: emotional dysregulation in attention-deficit/hyperactivity disorder - implications for clinical recognition and intervention. J Child Psychol Psychiatry. 2018. https://doi.org/10.1111/jcpp.12899.

18.

Hoxhaj E, Sadohara C, Borel P, D'Amelio R, Sobanski E, Müller H, et al. Mindfulness vs psychoeducation in adult ADHD: a randomized controlled trial. Eur Arch Psychiatry Clin Neurosci. 2018;268:321–35. https://doi.org/10.1007/s00406-018-0868-4.CrossRefPubMed

19.

Shaw P, Stringaris A, Nigg J, Leibenluft E. Emotion dysregulation in attention deficit hyperactivity disorder. Am J Psychiatry. 2014;171:276–93. https://doi.org/10.1176/appi.ajp.2013.13070966.CrossRefPubMedPubMedCentral

20.

Cole PM, Martin SE, Dennis TA. Emotion regulation as a scientific construct: methodological challenges and directions for child development research. Child Dev. 2004;75:317–33.CrossRefPubMed

21.

Izard CE. Emotion theory and research: highlights, unanswered questions, and emerging issues. Annu Rev Psychol. 2009;60:1–25. https://doi.org/10.1146/annurev.psych.60.110707.163539.CrossRefPubMedPubMedCentral

22.

Ryckaert C, Kuntsi J, Asherson P. Emotional dysregulation and ADHD. In: Oxford Textbook of Attention Deficit Hyperactivity Disorder (Oxford Library of Psychology), vol. 103; 2018.

23.

Buck R. Mood and emotion: a comparison of five contemporary views. Psychol Inq. 1990;1:330–6.CrossRef

24.

Gross JJ, Thompson R. Emotion Regulation: Conceptual Foundations. Handbook of Emotion Regulation; 2007.

25.

Werner K, Gross JJ. Emotion regulation and psychopathology: A conceptual framework. In: Kring AM, Sloan DM, editors. Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment: The Guilford Press; 2009. p. 13–37.

26.

Helfer B, Cooper RE, Bozhilova N, Maltezos S, Kuntsi J, Asherson P. The effects of emotional lability, mind wandering and sleep quality on ADHD symptom severity in adults with ADHD. European Psychiatry. 2019;55:45–51.CrossRefPubMed

27.

Schweren L, Hoekstra P, van Lieshout M, Oosterlaan J, Lambregts-Rommelse N, Buitelaar J, et al. Long-term effects of stimulant treatment on ADHD symptoms, social–emotional functioning, and cognition. Psychol Med. 2019;49(2):217–23.CrossRefPubMed

28.

Asherson P. ADHD across the lifespan. Medicine. 2016;44:683–6.CrossRef

29.

Fayyad J, Sampson NA, Hwang I, Adamowski T, Aguilar-Gaxiola S, Al-Hamzawi A, et al. The descriptive epidemiology of DSM-IV adult ADHD in the World Health Organization world mental health surveys. Atten Defic Hyperact Disord. 2017;9:47–65. https://doi.org/10.1007/s12402-016-0208-3.CrossRefPubMed

30.

Thomas R, Sanders S, Doust J, Beller E, Glasziou P. Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics. 2015;135:e994–1001. https://doi.org/10.1542/peds.2014-3482.CrossRefPubMed

31.

Moher D. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151:264. https://doi.org/10.7326/0003-4819-151-4-200908180-00135.CrossRefPubMed

32.

Sonuga-Barke EJ, Brandeis D, Cortese S, Daley D, Ferrin M, Holtmann M, et al. Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. Am J Psychiatr. 2013;170(3):275–89.CrossRefPubMed

33.

Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions. Oxford: Cochrane Collaboration; 2011.

34.

Glass GV, McGaw B, Smith ML. Meta-Analysis in Social Research. Beverly Hills: Sage Publications; 1981.

35.

Turner HM, Bernard RM. Calculating and synthesizing effect sizes. Contemp Issues Commun Sci Disord. 2006;33:42–55.CrossRef

36.

Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60. https://doi.org/10.1136/bmj.327.7414.557.

37.

Bisch J, Kreifelts B, Bretscher J, Wildgruber D, Fallgatter A, Ethofer T. Emotion perception in adult attention-deficit hyperactivity disorder. J Neural Transm. 2016;123:961–70.CrossRefPubMed

38.

Corbisiero S, Mörstedt B, Bitto H, Stieglitz R-D. Emotional Dysregulation in adults with attention-deficit/hyperactivity disorder–validity, predictability, severity, and comorbidity. J Clin Psychol. 2017;73:99–112.CrossRefPubMed

39.

Irastorza LJ. Questions about adult ADHD patients: dimensional diagnosis, emotion Dysregulation, Competences and Empathy. Acta Psychopathol. 2016. https://doi.org/10.4172/2469-6676.100069.

40.

Miller M, Hanford RB, Fassbender C, Duke M, Schweitzer JB. Affect recognition in adults with ADHD. J Atten Disord. 2011;15:452–60. https://doi.org/10.1177/1087054710368636.CrossRefPubMed

41.

Mitchell JT, Robertson CD, Anastopolous AD, Nelson-Gray RO, Kollins SH. Emotion Dysregulation and emotional impulsivity among adults with attention-deficit/hyperactivity disorder: results of a preliminary study. J Psychopathol Behav Assess. 2012;34:510–9. https://doi.org/10.1007/s10862-012-9297-2.CrossRef

42.

Rapport LJ, Friedman SR, Tzelepis A, van Voorhis A. “Experienced emotion and affect recognition in adult attention-deficit hyperactivity disorder”: Correction to Rapport et al. (2002). Neuropsychology. 2002;16:369. https://doi.org/10.1037/0894-4105.16.3.369.CrossRef

43.

Rüfenacht E, Euler S, Prada P, Nicastro R, Dieben K, Hasler R, et al. Emotion dysregulation in adults suffering from attention deficit hyperactivity disorder (ADHD), a comparison with borderline personality disorder (BPD). Borderline Personal Disord Emot Dysregul. 2019;6(1). https://doi.org/10.1186/s40479-019-0108-1.

44.

Surman CBH, Biederman J, Spencer T, Miller CA, Petty CR, Faraone SV. Neuropsychological deficits are not predictive of deficient emotional self-regulation in adults with ADHD. J Atten Disord. 2015;19:1046–53. https://doi.org/10.1177/1087054713476548.CrossRefPubMed

45.

Richard-Lepouriel H, Etain B, Hasler R, Bellivier F, Gard S, Kahn J-P, et al. Similarities between emotional dysregulation in adults suffering from ADHD and bipolar patients. J Affect Disord. 2016;198:230–6. https://doi.org/10.1016/j.jad.2016.03.047.CrossRefPubMed

46.

Cavelti M, Corbisiero S, Bitto H, Moerstedt B, Newark P, Faschina S, et al. A comparison of self-reported emotional regulation skills in adults with attention-deficit/hyperactivity disorder and borderline personality disorder. J Atten Disord. 2017;23(12):1087054717698814.

47.

Bodalski EA, Knouse LE, & Kovalev D. Adult ADHD, Emotion Dysregulation, and Functional Outcomes: Examining the Role of Emotion Regulation Strategies. J Psychopathol Behav Assess, 2018;41(1):81–92.

48.

Reimherr FW, Marchant BK, Strong RE, Hedges DW, Adler L, Spencer TJ, et al. Emotional dysregulation in adult ADHD and response to atomoxetine. Biol Psychiatry. 2005;58:125–31. https://doi.org/10.1016/j.biopsych.2005.04.040.CrossRefPubMed

49.

Irastorza LJ, Bellon JM. Adult ADHD Patients: Emotional Dysregulation and Personality Dimensions. Age. 2016;34:10–5.

50.

Rapport LJ, Friedman SL, Tzelepis A, Van Voorhis A. Experienced emotion and affect recognition in adult attention-deficit hyperactivity disorder. Neuropsychology. 2002;16(1):102.CrossRefPubMed

51.

Barkley RA. Behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of ADHD. Psychol Bull. 1997;121:65.CrossRefPubMed

52.

Nowicki S, Duke MP. Individual differences in the nonverbal communication of affect: the diagnostic analysis of nonverbal accuracy scale. J Nonverbal Behav. 1994;18(1):9–35.CrossRef

53.

Larsen RJ, Diener E. A multitrait-multimethod examination of affect structure: Hedonic level and emotional intensity. Pers Individ Diff. 1985;6(5):631–6.CrossRef

54.

Oliver MN, Simons JS. The affective lability scales: Development of a short-form measure. Pers Individ Diff. 2004;37(6):1279–88.CrossRef

55.

Schutte NS, Malouff JM, Hall LE, Haggerty DJ, Cooper JT, Golden CJ, Dornheim L. Development and validation of a measure of emotional intelligence. Personal Individ Differ. 1998;25(2):167–77.CrossRef

56.

Nock MK, Wedig MM, Holmberg EB, Hooley JM. The emotion reactivity scale: development, evaluation, and relation to self-injurious thoughts and behaviors. Behav Ther. 2008;39(2):107–16.CrossRefPubMed

57.

Gross JJ. Emotion regulation: taking stock and moving forward. Emotion. 2013;13(3):359.CrossRefPubMed

58.

Kring AM. Handbook of emotions: emotion disturbances as transdiagnostic processes in psychopathology. 2nd ed. New York: Guilford Press; 2008.

59.

Kring AM. The future of emotion research in the study of psychopathology. Emot Rev. 2010;2:225–8. https://doi.org/10.1177/1754073910361986.CrossRef

60.

Barkley RA, Murphy KR, Fischer M. ADHD in adults: What the science says: Guilford Press; 2010.

61.

Evren B, Evren C, Dalbudak E, Topcu M, Kutlu N. Relationship of internet addiction severity with probable ADHD and difficulties in emotion regulation among young adults. Psychiatry Res. 2018;269:494–500.CrossRefPubMed

62.

Polanczyk GV, Willcutt EG, Salum GA, Kieling C, Rohde LA. ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis. Int J Epidemiol. 2014;43:434–42. https://doi.org/10.1093/ije/dyt261.CrossRefPubMedPubMedCentral

63.

Simon V, Czobor P, Bálint S, Mészáros A, Bitter I. Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis. Br J Psychiatry. 2009;194:204–11. https://doi.org/10.1192/bjp.bp.107.048827.CrossRefPubMed

64.

Barkley RA. Distinguishing sluggish cognitive tempo from ADHD in children and adolescents: executive functioning, impairment, and comorbidity. J Clin Child Adolesc Psychol. 2013;42(2):161–73.CrossRefPubMed

65.

Posner J, Kass E, Hulvershorn L. Using stimulants to treat ADHD-related emotional lability. Curr Psychiatry Rep. 2014;16(10):478.CrossRefPubMedPubMedCentral

66.

Rowles BM, Findling RL. Review of pharmacotherapy options for the treatment of attention-deficit/hyperactivity disorder (ADHD) and ADHD-like symptoms in children and adolescents with developmental disorders. Dev Disabil Res Rev. 2010;16:273–82. https://doi.org/10.1002/ddrr.120.CrossRefPubMed

67.

Daughton JM, Kratochvil CJ. Review of ADHD pharmacotherapies: advantages, disadvantages, and clinical pearls. J Am Acad Child Adolesc Psychiatry. 2009;48:240–8. https://doi.org/10.1097/CHI.0b013e318197748f.CrossRefPubMed

68.

Peyre H, Speranza M, Cortese S, Wohl M, Purper-Ouakil D. Do ADHD children with and without child behavior checklist–dysregulation profile have different clinical characteristics, cognitive features, and treatment outcomes? J Atten Disord. 2015;19(1):63–71.CrossRefPubMed

69.

Rösler M, Retz W, Fischer R, Ose C, Alm B, Deckert J, et al. Twenty-four-week treatment with extended release methylphenidate improves emotional symptoms in adult ADHD. World J Biol Psychiatry. 2010;11(5):709–18.CrossRefPubMed

70.

Cole P, Weibel S, Nicastro R, Hasler R, Dayer A, Aubry JM, et al. CBT/DBT skills training for adults with attention deficit hyperactivity disorder (ADHD). Psychiatr Danub. 2016;28(Suppl 1):103–7.PubMed

71.

Lenzi F, Cortese S, Harris J, Masi G. Pharmacotherapy of emotional dysregulation in adults with ADHD: a systematic review and meta-analysis. Neurosci Biobehav Rev. 2018;84:359–67. https://doi.org/10.1016/j.neubiorev.2018.08.010.CrossRefPubMed

72.

Moukhtarian TR, Cooper RE, Vassos E, Moran P, Asherson P. Effects of stimulants and atomoxetine on emotional lability in adults: a systematic review and meta-analysis. Eur Psychiatry. 2017;44:198–207. https://doi.org/10.1016/j.eurpsy.2017.05.021.CrossRefPubMed

73.

Hesslinger B, van Tebartz EL, Nyberg E, Dykierek P, Richter H, Berner M, Ebert D. Psychotherapy of attention deficit hyperactivity disorder in adults--a pilot study using a structured skills training program. Eur Arch Psychiatry Clin Neurosci. 2002;252:177–84. https://doi.org/10.1007/s00406-002-0379-0.CrossRefPubMed

74.

Philipsen A, Graf E, van Tebartz EL, Jans T, Warnke A, Hesslinger B, et al. Evaluation of the efficacy and effectiveness of a structured disorder tailored psychotherapy in ADHD in adults: study protocol of a randomized controlled multicentre trial. ADHD Atten Defic Hyperact Disord. 2010;2:203–12. https://doi.org/10.1007/s12402-010-0046-7.CrossRefPubMed

75.

Boonstra AM, Oosterlaan J, Sergeant JA, Buitelaar JK. Executive functioning in adult ADHD: a meta-analytic review. Psychol Med. 2005;35:1097–108.CrossRefPubMed

76.

Bridgett DJ, Walker ME. Intellectual functioning in adults with ADHD: a meta-analytic examination of full scale IQ differences between adults with and without ADHD. Psychol Assess. 2006;18:1.CrossRefPubMed

77.

Gershon J. A meta-analytic review of gender differences in ADHD. J Atten Disord. 2002;5:143–54. https://doi.org/10.1177/108705470200500302.CrossRefPubMed

78.

Hirsch O, Chavanon M, Christiansen H. Emotional dysregulation subgroups in patients with adult attention-deficit/hyperactivity disorder (ADHD): a cluster analytic approach. Sci Rep. 2019. https://doi.org/10.1038/s41598-019-42018-y.

Title: Emotion dysregulation in adults with attention deficit hyperactivity disorder: a meta-analysis
Authors: Ashkan Beheshti
Mira-Lynn Chavanon
Hanna Christiansen
Publication date: 01-12-2020
Publisher: BioMed Central
Keywords: Attention Deficit Hyperactivity Disorder
Attention Deficit Hyperactivity Disorder
Published in: BMC Psychiatry / Issue 1/2020
Electronic ISSN: 1471-244X
DOI: https://doi.org/10.1186/s12888-020-2442-7

2024 ASCO Annual Meeting

Springer Medicine

Emotion dysregulation in adults with attention deficit hyperactivity disorder: a meta-analysis

Abstract

Background

Methods

Results

Conclusions

2024 ASCO Annual Meeting

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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