Emotional Dysregulation in Adult ADHD Esther Sobanski, MD London, 22nd April 2016

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1 Emotional Dysregulation in Adult ADHD Esther Sobanski, MD London, 22nd April 2016 Department of Psychiatry and Psychotherapy Central Institute of Mental Health Director Prof. Dr. Andreas Meyer-Lindenberg Mannheim, Germany

2 Schedule Theory of Emotion Differential Diagnosis of Emotional Dysregulation in ADHD Non-pharmacological Treatment of Emotional Dysregulation in Adult ADHD

3 Theory of Emotion

4 Definition: What is emotion biologically? A. Automatically displayed body reaction autonomous nervous system heart rate bowel action level of muscle tension in response to a stimulus situation/ object/ person / thought B. Individual interpretation of the body reaction learning history

5 Definition: Four components of emotion Somatic component - Physiological arousal / muscel tonus Valence - Positive / Negative Cognitive component - Thoughts / Interpretation Behavioral component - Flight / Advance / Freeze

6 Intensity of Emotion: Arousal and Valence of Emotion Valence Arousal

7 Basic Emotions (Stavemann, 2001) Fear Sadness Anger Concern Regret Discontent Disgust Embarresmment Neutral Intensity Satisfaction Disheartenment Symphathy Happiness Dispair Love

8 Worldwide Understanding of Basic Emotions Japan Brasil Chile Argentinia USA Happiness Fear Surprise Anger Disgust Sadness % right

9 Basic emotions Which emotions do you identify: Happiness? Sadness? Anger? Disgust? Suprise? Fear?

10 Differential Diagnosis of Emotional Dysregulation in Adult ADHD

11 Steps of differential diagnosis 1. Clinical characteristics of emotional dysregulation in adult ADHD 2. Which differential diagnoses are relevant for discrimination of emotional dysregulation? 3. How to discriminate?

12 Emotional Lability (Conners) Irritability Low frustration tolerance Temper tantrums Mood swings Affective interference (Brown) Irritability Low frustration tolerance Wender Utah Criteria Reduced temper control Hot temper, temper tantrums Low frustration tolerance Irritability Affective lability Mood swings Dysphoric mood Emotional over-reactivity Reduced stress resistance Feeling overwhelmed 1) What you are looking for? Clinical characteristics emotional dysregulation in ADHD Persistent/ chronic / lifelong pattern of Increased affective reactivity. Increased intensity of (negative) emotions. Increased mood /emotional fluctuations. Intensity and frequency inappropriate.

13 Drug screen Time course Medical history EEG Neuropsychological testing Thyroid hormones Time course Medical / Neurological conditions Substance Use Disorders Inattention Hyperacticty Posttraumatic Stress Disorder Intrusive symptoms Dissociative symptoms Nightmares Time Cours 2) POSSIBLE DIFFERENTIAL DIAGNOESES Affect Somatic symptoms Time course Inattention Prodromal Schizophrenia Affective disorders Inattention Inattention Affective Symptoms Inattention Impulsivity Hyperacticty Affective symptoms Affective symptoms Flattend / inappropriate affect Delusions Time Course Inattention Hyperactivity Affective symptoms ADHD Personality Disorders Borderline PD Sleep disorders Inattention Affective symptoms Parasuicides Stress-related dissociative / paranoid symptoms Time course Excessive daytime sleepiness Snoring Dysaesthesia Anxiety disorders Affect Vegetative Symptoms Time course

14 DD ADHD vs. Major Depressive Episode ADHD Major Depressive Episode Phenomenology Enduring depressed mood Emotional dysregulation Psychomotor agitation Diminished ability to think or concentrate DD: Somatic symptoms; Loss of appetite, weight & libido DD: Circadian pattern of symptoms Loss of energy, markedly diminished interest Feelings of worthlessness or guilt Sleep disturbances Hyperactivity Impaired stress tolerance Inattentiveness DD: Impulsivity Diminished self-esteem Sleep disturbances Time pattern DD: Distinct episode Lifelong condition Problematic: Dysthymia vs. ADHD inattentive type Depressive episode: Cognitive distorsion of biography

15 DD ADHD vs. Bipolar Disorder Bipolar disorder Cyclothymia Mood lability Irritability Psychomotor agitation DD: Elated mood DD: Inflated self-esteem or grandiosity DD: Flight of ideas Distractibility Impulsivity Talkative Decreased need for sleep DD: Distinct onset Phenomenology Time pattern ADHD Mood lability Irritability and hot temper Hyperactivity Inattention Impulsivity Logorrhoic Sleep problems Lifelong condition

16 DD ADHD vs. Generalized Anxiety Disorder Generalized anxiety disorder Phenomenology Pervasive anxiety Overarousal Psychomotor agitation Impaired attention DD: Constant worries DD: Vegetative symptoms palpitations, tachycardia, dizziness, transpiration ADHD Emotional dysregulation/ Overarousal Hyperactivity Inattention DD: Impulsivity Time pattern DD: Distinct Onset Lifelong condition

17 DD ADHD vs. Prodromal Schizophrenia Schizophrenia Prodromal phase ADHD Phenomenology Affective lability Mood lability Irritability, aggression Irritability, hot temper DD: Flattened, inappropriate affect Psychomotor agitation DD: Delusions DD: Hallucinations DD: Bizarre behavior Disorganized speech & behavior DD: Distinct onset Mostly in adolescence / young adulthood Time pattern Hyperactivity Disorganisation Lifelong condition Starts in childhood

18 DD ADHD vs. Borderline Personality Disorder BPD Phenomenology Affective instability Inappropriate, intense anger DD: paranoid ideation, dissociative symptoms impulsivity DD: parasuicidal behavior DD: chronic feelings of emptiness DD: inability of being alone DD: efforts to avoid loss DD: Begins in adolescence; Chronic course Time pattern ADHD Mood lability Irritability and hot temper DD: hyperactivity inattentiveness impulsivity DD: disorganisation Chronic lifelong disorder Starts in childhood

19 How to differentiate? Adult ADHD differential diagnoses Phenomenology characteristic disorder specific symptoms Course of illness / Time pattern / Onset Mood - Emotion Family history Medical assessment Neuropsychological testing

20 Self-rating scales assessing emotional dysregulation in adult ADHD

21 Psychotherapy / Non-pharmacological Interventions for Emotional Dysregulation in Adult ADHD

22 Stepped care approach 1) ADHD: Yes 2) Comorbidity/associated symptoms: yes or no? 3) Multimodal treatment Treatment hierarchy Residual emotional symptoms with functional relevance Handbook for attention deficit hyperactivity disorder in adults UK Adult ADHD Network

23 Psychoeducation is the first step

24 Indication of Psychotherapy Expert consensus of the panel In combination with pharmacotherapy In motivated adults Specific indication E. g. residual symptoms when treated with pharmacology

25 Personal comment Psychoeducation Often sufficient ro reduce feelings of guilt /shame or partnership problems resulting from ADHD symptoms Psychotherapy Adjustment disorder After diagnosis of ADHD adult patients often experience intense sadness of lost years of life because getting diagnosed so lately. Chronic dysfunctional emotional regulation Overarousal, impared emotion regulation Reduced self-esteem Distorted cognition towards failure

26 Multimodal treatment: Non-pharmacological interventions Treatment of comorbid disorders Occupational rehabilitation Psychotherapy Sports Psychoeducation Pharmacotherapy DGPPN Expert Guidelines NICE Guidelines Evidence Based Guidelines 2009, Canadian Guidelines CADDRA European Consesus Statement 2010 BMC Psychiatry 2010

27 Aquired impairment by learning history over the lifespan

28 Cognitive behavioral therapy works on emotional dysregulation in adult ADHD Metacognitive therapy 2012

29 Philipsen et al., 2007

30 Mindfulness Buddhist meditation technique Rooted back 2500 years Third wave of behavior therapy Mindfulness-Based Stress Reduction (J. Kabat-Zinn, 1982) Mental training: To observe inner experiences Thoughts Feelings Body sensations Without being identified ( Letting go ) Without acting Proposed neurobiological mechanism: Default networks: Mind wandering Prefrontal cortex: Behavior control, effortful attention Amygdala. Salience

31 Mindfulness

Neural mechanisms of mindfulness meditation Effortful attention regulation during meditation. Panel (A) provides a schematic representation of the meditation process.

32 Neural mechanisms of mindfulness meditation Effortful attention regulation during meditation. Panel (A) provides a schematic representation of the meditation process. The inner circle outlines the phenomenological layer, presenting the typical sequence (clockwise) a meditator will go through. The middle circle relates the attentional processes that lie underneath, while the outer circle represents the different brain networks that are involved in carrying out these functions. The different attentional processes and the brain networks are represented as partially overlapping to indicate that in many instances more than one process/network is involved. Panel (B) outlines the main brain areas involved in each of the five networks.

33 Effects on attention and hyperactivity JAD 2016

34 Mindfulness meditation training in adults and adolescents with ADHD: Results on emotional symptoms <.02 Zylowksa et al., 2008

35 2015

37 Thank you for your attention

3/9/2017. A module within the 8 hour Responding to Crisis Course. Our purpose

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