Emotional Dysregulation and ADHD

“My wife is the Jekyll & Hyde of New York.  She can go from lovely to livid in seconds. Sometimes I think our three-year-old has greater frustration tolerance than she does.” — Jack, New York.

Jack’s wife has ADD/ADHD. The traditional view of ADD/ADHD as a problem of attention and focus has broadened in the last decade to include significant challenges in emotional functioning.  In his book, ADHD and the Nature of Self-Control, Dr. Russell Barkley, a leading researcher in the field of ADD/ADHD, suggests that a better description for ADD/ADHD is as a “Self-Regulation Disorder.”  He offers that the main problem in individuals with ADHD is one of self-control, and that issues of attention are secondary to larger difficulties in self-regulation.

Dr. Barkley theorizes that as children develop, their behavior is less influenced by external forces (e.g., fear of parental punishment) and more directed by internal codes of conduct learned from family, peers, and society.  The essence of adult self-control is controlling one’s behavior and emotions based on this internal set of rules and standards. This is why most of us don’t shotlift, hang up on our parents, or smash a glass when we’re angry. An internal voice tells us this is inappropriate behavior.

For individuals with ADD/ADHD, the formation of these internal standards may be well-developed, but accessing this information quickly may be problematic, leading to a breakdown in self-regulation.  Putting it another way, those with ADD/ADHD know what to do, but have a hard time actually doing it.  It is almost as if the internal voice of reason is too weak to be heard.

Dr. Barkley gives this example:  Getting reprimanded by a superior at work tends to evoke a strong emotional response.  A major difference between people with ADD/ADHD and others is in their ability to regulate themselves during that event. Most people have more control over their impulses and immediate reactions, which buys them a few seconds to think about a healthy response.  If you have ADD/ADHD, you’re more likely to lash out, create a scene, and immediately express intense emotions.  The emotions you feel are naturally appropriate. However, the way you act on them is not.

One major reason for this lack of emotional control has to do with the internal wiring of the ADD/ADHD brain.  Someone with ADD/ADHD has difficulty communicating to themselves a desired set of actions; e.g., “Don’t yell at the boss.” Dr. Barkley calls this process of self-talk the “internalization of speech.”

Imagine a pathway between the frontal lobe of the brain and the mammalian brain, the part of our brain where action and raw emotions reside. For most of us, this pathway is a four lane highway, recently paved and accessible to even the largest trucks. Information flows freely and is managed in a generally adaptive manner.  Most importantly, we have the ability to move at will, maneuver freely between lanes, and make choices quickly and safely.

For those with ADD/ADHD, this pathway is like a two-lane highway packed with cars. The traffic is overwhelming the route and is not allowing helpful information to get through.  There may often be a feeling of being stuck with no choices.  Since the pathway is blocked, the only way forward is on a loud motorcycle, cutting dangerously through traffic to get to the front. This is what it’s like with ADD/ADHD;  you’re moving through too quickly on the less desirable path and infuriating people all around you.

Another analogy is  the ‘bad executive’.  Imagine a terrible boss who has helpful information but withholds it from his or her employees. This concept of the frontal portion of our brain as an executive, not communicating effectively to the rest of the brain, is why Dr. Barkley and others refer to ADD/ADHD as EFDD: Executive Function Deficit Disorder. The executive system of self-control and productive decision-making is lacking.

Emotional Disregulation | ADHD

For individuals with ADD/ADHD, experiencing this poor emotional self-control and low frustration tolerance is painful, with even simple mundane tasks turning ugly and ending in emotional outbursts.

Here are a few of the quotes gathered from clients at the Sachs Center. Names and places have been changed to protect identity.

“Every single time I call customer service for any company, I just lose it.  I can actually feel the blood pressure increase and heat rising in my body but there doesn’t seem like anything I can do to stop it. It’s like a train heading towards a cliff with no way to stop.” – Johnfrom Queens, NY.

“She gets angry very quickly. When I want to talk something out, she can’t control herself from raising her voice, saying mean things and blaming me.  No matter how nice I try to speak to her, there is no stepping outside herself.  It’s like trying to feed a wild animal. Get too close and you might lose an arm or leg.” – Mark from Brooklyn, NY

Being aware of and in control of one’s emotions is arguably the hallmark of psychological health. For men and women with ADD/ADHD, this is a daily struggle. At time, even the slightest hiccup can cause the top to blow and explode all over co-workers, loved ones, or even the kind woman at the bank. (One diagnostic question often asked at the Sachs Center is: “Do you lose your temper often with bank tellers and customer service representatives?”)

It’s not just anger that individuals with ADD/ADHD have a hard time managing.  Sadness, fear, and shame can also be felt with greater intensity and depth, leading to problems in life and relationships.

“For those of us with ADD, a mild criticism can be devastating, leading us to obsess over it for weeks.  A movie with a sad ending can bring me down for days.   I remember weeping and weeping at my son’s graduation from college. The intensity of the feelings can get the best of me.” – Jane from Newark, NJ.

It is not surprising that some adults with ADD/ADHD come to the Sachs Center thinking they are actually suffering from Bipolar Disorder.  ADD/ADHD can be confused with Bipolar Disorder, as both involve emotional dis-regulation. The difference between Bipolar Disorder and ADD/ADHD is in the timing of these emotional outbursts.  For individuals with Bipolar Disorder, their intense emotional states are not always related to a particular event, and often appear out of the blue. Bipolar mood swings can last for days.   For individuals with ADD/ADHD, however, the emotional reactivity is often directly related to an event or interaction, and usually doesn’t last very long.

Similar with Bipolar Disorder, Borderline Personality Disorder (BPD) can also be misdiagnosed as ADD/ADHD. Like Bipolar Disorder, both ADD/ADHD and BPD involve heightened states of emotional dis-regulation.  However, the emotional outbursts of an ADD/ADHD individual are generally related to low frustration-tolerance, while those of an individual with BPD are based on feelings of rejection and/or abandonment.    For more on Borderline Personality Disorder, check out the book I Hate You, Don’t Leave Me: Understanding the Borderline Personality, by Jerold J. Kreisman and Hal Strauss.

Individuals with ADD/ADHD often also have co-morbid conditions —both ADD/ADHD and another psychological challenge or disorder.  It is quite common for adults with ADD/ADHD to have Anxiety and/or Depression, and both should be treated as separate probelms.    A thorough assessment by a trained clinician is necessary to determine an accurate diagnosis.

You might assume that if you have ADD/ADHD you’re destined to be an emotional mess. Or since you have ADD/ADHD, you’re entitled to major meltdowns. Research shows that with concerted effort, change can happen.  With support, you can learn to regulate your emotions and manage your frustration.

Here are a few tips that we recommend at the Sachs Center, designed to improve your emotional functioning.

Deep Breathing:  Learn this mantra:  “Don’t act out, breath out.”  When frustrated or angry, begin to count back from ten while taking deep breaths.  Repeat a calm word or phrase while counting, such as “relax” or “take it easy.” In fact, since the ADD/ADHD mind often seeks rapid change in thought, the shift of attention to counting and breathing should help the impulse pass as quickly as it appeared.  Ask your partner or a trusted friend to remind you to count to ten when they notice you are getting heated.

Find A Hobby:  Instead of allowing this excess energy to express itself inappropriately in emotional interactions, channel it into a hobby.  In one case, a man who had struggled with ADD/ADHD his whole life became a marathoner.  He eventually organized a charity marathon for a local food bank.  It worked wonders for his marriage because he had an outlet for his abundant energy. The sense of self-efficacy that comes from succeeding at a new challenge will increase self-esteem and reduce the chronic frustration that those with ADD/ADHD often feel.

Walking: A daily walk can greatly reduce your feelings of frustration and impact your overall emotional health. Research also shows that the benefits of a daily walk can be as great as running or weight training. And best of all—it’s free.

Walk and Talk:  Individuals with ADD/ADHD like to move, and sitting on the couch hashing out feelings may make you feel trapped –which could lead to an unhelpful emotional reaction.  Suggest a walk outside. This will get you moving and minimize direct eye contact (often threatening to guys with ADD/ADHD).   Another benefit: You can’t check your phone as much when you’re walking.

Learn Your Triggers: By exploring and learning about what the physical triggers are for your maladaptive emotions, you can better understand when an unregulated emotion may arise. For example: Do you lose it when talking with customer service reps on the phone? Or does waiting in line at the bank drive you crazy?  When we learn our triggers, we can better deal with them. One solution may be to ask your partner to make the customer service calls and do the banking.

Encourage Praise:  While it may be a chicken-and-egg question, some of your rude, uncaring, and emotionally inappropriate behavior may not be completely off base.  You may be responding to the way your partner overreacts to your ADD/ADHD symptoms. Take a good look at their responses to your behavior. Ask them to substitute positive reinforcement for nagging.  Encourage them to let you know when you’re doing well at managing your emotions so that you feel successful and continue to work on yourself.

Be Careful with Speech:  Avoid words like “NEVER” or “ALWAYS” when talking about yourself or your loved ones. Expressions like “You’re always complaining!” or “I never get to do what I want!” can never be true 100 % of the time, so why state that as a fact? These words also serve to end the conversation, putting your partner in a bunker from which they’re likely to feel defensive and/or argumentative. Choose to be solution-focused and just state the facts. “You nag me sometimes when I forget to do something. This makes me feel small and unloved. Can you help me out by giving me a simple nonjudgmental cue to remember the task?”

Use Humor:  Make up a light-hearted “miscommunication” song or phrase–or some similar strategy–that you can use when something rubs you the wrong way. One couple uses the word “ouch” to suggest that something said or did landed in a painful way. Another teased her husband when he got too angry, calling him “King Kong.” This was his favorite movie so he couldn’t help but laugh at the connection. Or simply agree that you will both learn to laugh at certain situations, and then discuss and correct them in a pleasant, tension-free atmosphere later on.

Understand the Impact:  Intended or unintended, your dis-regulated self has an impact on the loved ones in your life.  Take responsibility for your actions. Own your mistakes and set about on a path of change.

Meditation:  Research shows that daily meditation practice can decrease unhealthy emotional responses and improve focus and concentration.  To learn how to meditate, see: Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness by Jon Kabat-Zinn.

With awareness, practice, and support, self-regulation is possible.  For additional assistance, find a therapist, coach, or psychiatrist in your area who specializes in Adult ADD/ADHD.