Research Recap with Skye: Emotional Dysregulation and ADHD

0:05 Welcome to Hacking Your ADHD. I'm your host, William Curb, and I have ADHD. On this podcast, I dig into the tools, tactics, and best practices to help you work with your ADHD brain. Today, I'm joined by Skye Waterson for our research recap series. In this series, we take a look at a single research paper and dive into what the paper says, how it was conducted, and try and find any practical takeaways.

0:27 In this episode, we're going to be discussing a paper called "Evidence of Emotion Dysregulation as a Core Symptom of Adult ADHD: A Systematic Review." And just to give a bit of a background here, when Skye and I were discussing topics to look into for future episodes, rejection sensitive dysphoria was one that seemed like it might be really interesting and to see what's, like, actually out there.

0:49 And in a way, it was interesting because there's just not a whole lot of research on the topic. So instead, we came up with this paper, which asks whether emotion dysregulation should be considered a core fourth symptom of adult ADHD alongside traditional things like inattention, impulsivity, and hyperactivity.

1:08 And just to get l- started, let's try and get a quick definition of what we're talking about with emotional dysregulation and of course with rejection sensitive dysphoria. You wanna hit that one, Skye? Yeah, 100%. So we know that ADHD is associated with executive functioning deficits. this is, the core part of the DSM diagnosis.

1:30 But when we're looking at emotional regulation, so we'll say emotional regulation first, this is a particular piece of interest. Okay, so emotional dysregulation. There's actually a different paper, which is c- from, 2019 by Thompson, um, which ca- talks about emotional dysregulation as a theme in search of a definition.

1:55 And basically how they described it is patterns of emotional experience or expression that interfere with goal-directed activity, which is obviously very relevant for ADHD. so looking at how people do that specifically and how, how ADHD may affect emotional dysregulation, specifically was the purpose of this paper Yeah.

2:22 And it's because, So the important part for me here is, 'cause it's important to both get the definition, but it's the reason behind looking at this is the number of people I know that are like, "Yes, emotional, I have trouble with my emotions, and it is because of my ADHD." But we don't just have the research behind it because measuring emotion is very hard.

2:49 that comes up in this paper, in an interesting way because this ended up being a, narrative structured systematic review rather than a meta-analysis because of the, heterogeneity of the number of studies that they were able to get. So they got 22 studies through their methodology, but they're just like, "These are just too similar," or, "These two are too dissimilar.

3:12 There's, nothing is quite the same, so it's hard to group things properly." like if you look at, they had 12 different scales of how people measured emotions across 22 studies, which is, wild to think about that, how you would tr- even, compare those properly with a meta-analysis, which is why they didn't.

3:36 Yeah, 100%. And so yeah, it's definitely, I think the, idea of emotional dysregulation and I think the idea of RSD as a part of that is maybe on the more cutting edge of the research into, ADHD currently. And, it also is worth noting that, because this comes up a lot, their criteria were that you had to be diagnosed with ADHD following the DSM or later criteria.

4:07 So if you did not have a clinical diagnosis, so it was just about symptoms or probable ADHD, you were not included in these papers, which is relevant because I think a lot of papers, and we see this a lot, will focus more on symptomology than on diagnosis. And but you could see why in this case it was really important to focus on the diagnosis itself.

4:29 Yeah. And it was also, because this is looking specifically at adult ADHD, also cut out a lot of papers because in general, ADHD is more often studied in children Exactly. Exactly. So we ended up having, three sections. So we had the features of emotional, regulation in people with ADHD. Then we had studies that looked at the neurological and psychophysiological activity during the performance on emotional regulation in ADHD.

5:03 And then there was a third section on interventions. and they were divided into these, from these 22 papers. So with the emotional regulation features, those were 10 studies Yeah, and that's where we're gonna get the most overlap and the most data we can, properly compare, but a lot of the data is just incompatible because of either what was controlled for, what was, a lot of the studies didn't, look at gender, which, has a big effect on, how your ADHD plays into your ability to regulate your emotions Yeah, 100%.

5:51 And, I, will say what they did find was that ADHD groups had consistently lower emotional regulation scores than control groups, m- ranging from a medium to very large effect sizes. So we did see, they did see what they expected to see in this paper, which was emotional dysregulation is higher in people who have ADHD Yeah.

6:18 And they found that, most people that w- are, dealing with this are using these maladaptive strategies to, suppressing their emotions to deal with their emotional outbursts and stuff, which has this terrible cyclical cycle of making you have worse mental health and having more emotional problems. Yeah.

6:40 I thought that was really r- for me, that was maybe my most interesting part of this whole paper Yeah. okay, and it's one of those things where of course if you don't know about your ADHD and the emotional side of it, you're gonna be trying to suppre- your main strategy is suppressing 'cause you're like, "I don't wanna be different. I don't wanna be a problem."

7:02 Yeah. And this reminded me of masking as well. Like, you know, suppressing and masking could be argued to be similar things, um, because you are in some ways, yeah, being taught to s- to, to just, like, not have the problem, to mask the problem. And when you think about it like that, you can see why this is a strategy that has been used, because it's probably a strategy on some level that has been encouraged, because it's just easier for everybody Oh, at least it feels that way.

7:34 Oh yeah, yeah. Easier for everybody in the moment Yeah, it's one of those things where you're like, if I don't bring up, just shove all this stuff down, it's gonna make everything better." And it usually, the- that's not a good long-term strategy No, no. it's not usually. Although, okay, this is a bit sideways, but I do remember back in the day, I, studied relationships, and they found there was two kinds of relationships.

8:03 There was the relationships where things got brought to the surface and then you argued about and resolved that way, and then there were actually people who didn't, and they just kinda sat on it. And as long as both people agreed that was what we were gonna do, that seemed to be okay. Yeah. and I think that's a little bit different than just being like, I'm not g- I'm just not gonna feel this feeling," versus, "I'm going to be a little bit more introspective about why I'm feeling this feeling and how it's affecting my relationship." Because, there have been times where, like I get very upset with something, and at the time it feels so important and I'm like, "This is an issue."

8:44 And if I'm like, "I'm gonna not react to this right now, I'm gonna let myself think about it," and then 10 minutes later, half an hour later, I'm like, "You know what? I'm glad I didn't go off because that wasn't… It's not as important as it felt at the time And that is one of the things about emotional dysregulation, is that with ADHD and emotional dysregulation, impulsivity is an effect.

9:07 And we see that, and we see that, how that works with ADHD. And, um, and it does mean that we can be, quote, "hot-headed." You know? We can, we can have that hot-headed, assumption. And so, yeah, then how we manage that is what we're looking at. Yeah. I've definitely had that, it In therapy I've talked about this, where it, feels like it's zero to a hu- 100, but it's usually like I'm like silently boiling over inside.

9:36 That's the suppressing the emotion. And so then it's 90 to 100, but I didn't notice the 90. and so I think that's an important distinction there, 'cause if you are suppressing your emotion, yeah, that is how it can feel. It's oh, I'm just… I hit my boiling point and I can't Yeah, 100%. Should we dive into a little bit then of the, um, neurological and psychophysiological activity related to ADHD?

10:08 So this was f- you know, they had, um, in terms of brain activity, they had four studies that were conducted with adults diagnosed with ADHD. and they were looking at emotional regulation strategies in adults with and without ADHD using event-related potentials. So this is where we get into the neuroscience of it all, and I have to say, it's been a bit of a while since I've learned about event-related potentials.

10:33 But what they were essentially finding was that there were differences in people who had ADHD and people who didn't. You know, it was a significant, group effect that, um, the frontal amplitudes of the late positive potential, so when we're seeing the brainwaves, were higher in ADHD adults without medication compared to the control group.

10:57 Um, and this kind of related to a conversation that they did have later on where they were like, "We don't know if," and there is a question mark around whether medication is affecting emotional dysregulation in ADHD as well. so what they did see was like medication was improving, the emotional dysregulation symptoms across the board, but what they didn't have with the data from all the studies if participants were medicated or not when they were doing the assessments Yeah.

11:31 Yeah. And this was the, um… You know, they had a few, I think they d- definitely had a few papers where that was the case, 'cause they were able to look at this brain, you know, systems in people without medication compared to a control group. But again, we're talking about three studies. Like, this is not…

11:49 Even though this has this l- the sort of, you know, trappings of a meta-analysis, it is very much narrative. It is, it is a discussion about a group of papers, not an overall sense of it, because there's just so much, there's so many gaps in this whole conversation. I mean, I really think this episode is about how much we don't know about emotional dysregulation at this point Yeah.

12:14 that was one of the interesting things was the title of the paper versus the discussion of the paper, in the title it's like, "Evidence of emotional dysregulation as a core symptom of adult ADHD." And it's oh, this is clickbait title of oh yeah, that's there. And then the discussion of they're like, yeah, there's a lot of stuff we need to know.

12:36 of stuff that is not quite there yet. And this-- they, they are completely transparent about how they, there just wasn't enough data to, support a lot of conclusions yet because they're like, "Yeah, we have 22 studies. We can't even do a meta-analysis Yeah, 100%. It was interesting then if we'd go to emotional regulation outcomes in ADHD and treatment, they just had there just four studies.

13:05 so they were looking at, um, mindfulness as part of it, and they did find some, some benefits, um, to mindfulness, and we may have even talked about these studies as well, when it came to, ADHD. So there was a little bit of a sense, you know, this is a very short section, before they came into the discussion Yeah.

13:28 And it's… Yeah, it makes sense with, Yeah, mindfulness has generally been shown to be great for, controlling that impulsivity piece, which is a big piece of emotional regulation Mm-hmm. Yeah. Yeah, definitely. So overall, they kind of… The discussion, I found the discussion maybe the best part of the whole paper, 'cause I feel like they really brought it all together.

13:54 They wanted to unify all available data related to emotional dysregulation, and what they found when they looked at those three hypothesis, uh, hypotheses that they were looking at, is that, you know, when adults with or without ADHD are compared, ADHD group have constantly lower emotional regulation scores than controls.

14:19 and then when we look at the second hypothesis, they found that, yes, ADHD people were more likely to use non-adaptive strategies, so they tended to blame themselves, catastrophize, blame others, and like, ugh, God, you're reading my diary here, ruminate. Um, and, um, and, obviously the suppression strategy that we talked about here versus, like, reappraisal.

14:44 And then the final, um, the final hypotheses Yeah, so their final thing, they were looking at, differences in brain activity with people without ADHD, or with and without ADHD. And, they were finding that, when participants were able to layer on these strategies of, how to reappraise what's going on, that they were able to see differences But, but yeah, the emotional dysregulation piece, uh, kind of disappears and it becomes more, uh, doesn't disappear, but you have significant dis- differences in the cortical activation of both groups where you, when you are doing these things where you're not doing these rumination tasks and things where you have other strategies in place, you see a significant difference in

15:37 how you, are processing your emotions. And I think that is, that's true across the board whether you have ADHD or not, and I think it's especially true if you have ADHD and you're, and you have built up a strategy of these things that are not helpful and hurt you in the long run. So if you're able to relearn these tasks where oh yeah, I'm learning how to look at my emotions and no, not just suppress them.

16:04 I'm doing things like, reevaluating how I'm feeling and why I'm feeling it. It makes a big difference in how you're able to keep your emotions, I don't like to say in check, but, live with your emotions in ways that are healthy Yeah. Ride the wave, as they say. and I think that's a helpful note sort of to, to end on in that this, you know, we went hunting for RSD.

16:32 We found this paper kind of saying, "Hey, look, we have a lot of research that needs to be done into this area. I know that it feels like it's been done because it feels so true, but actually in reality, the research isn't there." But what we do have does indicate that, yes, this is correct, and also that there are strategies that we can use that will help with this reduction of emotional dysregulation, um, and potentially RSD as well.

17:00 Yeah. And I do think it's worth noting here too that these strategies that we're talking about often imply that RSD is something that we bring upon ourselves becau- not on purpose, not trying to blame the victim here, but something that be- from what we've learned through, you know, countless corrections and everything, we learned this is how we deal with our emotions.

17:29 And that might be a more core piece of what RSD is and why some people just don't deal with those issues because they didn't build those terrible strategies for themselves.