Despite not being part of the official diagnostic criteria, one third of adolescents and adults with ADHD report about their emotional instability as their main impairment. The emotional instability includes flash tempers, low frustration tolerance, and feeling easily overwhelmed by emotions. Individuals with ADHD also struggle with empathy. They may appear cold and aloof while being very sensitive to rejection and criticism.
The absence of emotions in ADHD diagnostic criteria is attributed to the difficulty of measuring them objectively. As the research focuses on observable behaviours the symptoms should be visible and countable. However, emotions are not always present and not easy to be quantified.
Major Types of Emotional Instability in ADHD
There are three major types of emotional problems associated with ADHD. This includes over-reaction, shame/guilt and emotional regulation issues sensititve to rejection. The first two are commonly associated with a number of other psychiatric conditions. However, the rejection sensitivity seems to be associated exclusively with ADHD.
Over-Reaction
People with ADHD live intense, passionate lives. If they are not interested in something, it is not on their radar screen. They only engage deeply with subjects that genuinely interest them. People with ADHD tend to over-react to things that others may consider minor. This hyperarousal can lead to constant mental agitation, making it hard for ADHD individuals to experience inner peace.
Shame and Guilt
Children with ADHD often receive a significant number of critical or corrective messages during their upbringing, affecting their self-esteem and emotional well-being. This can result in feelings of inadequacy and incompetence, ultimately impacting their self-esteem.
Rejection-Sensitive Dysphoria (RSD)
The RSD appears to be the emotional condition found only with ADHD. Rejection Sensitive Dysphoria (RSD) involves extreme emotional sensitivity and pain triggered by perceived rejection, teasing, criticism, or disappointments. The emotional pain is described as unbearable and can lead to depression or externalized rage. RSD is often misdiagnosed as social phobia but is distinct in its nature.
ADHD individuals may become people-pleasers, or withdraw from chalanges to avoid potential rejection or failure. These coping mechanisms comes at a high personal cost preventing them from higher achivements and leading to disatisfaction.
Treatment of Rejection-Sensitive Dysphoria (RSD)
Treatment for RSD and emotional difficulties associated with ADHD is challenging due to its genetic and neurological nature. Since RSD is genetic and neurological, psychotherapies have been found to have little benefit.
Rejection-Sensitive Dysphoria Treatment with Alpha-Agonists
Psychotherapies have limited benefits, but certain medications like alpha-agonists (Guanfacine and Clonidine) can provide relief for some individuals. Guanfacine and Clonidine are FDA-approved for the treatment of ADHD, especially for the treatment of hyperactivity. Unfortunately, only one out of three people treted with Guanfacine get a robust benefit; the rest just get mild sedation. But for the lucky ones, the change is nothing short of life changing and freeing. Most report that the benefits to their quality of life are much greater with an alpha-agonist than they experienced with stimulant medication. Side effects are dry mouth, mild sedation, and more frequent dizziness if the person stands up too quickly.
RSD Treatment with MAOIs
Additionally, Monoamine Oxidase Inhibitors (MAOIs), particularly tranylcypromine, have been found to be effective for both the attention/impulsivity component of ADHD and RSD. However, these medications require dietary restrictions and caution when combined with other drugs, making them only suitable for specific cases under professional guidance.