Similarities between emotional dysregulation in adults suffering from ADHD and bipolar patients

Adults with both bipolar disorder and ADHD

ADHD and bipolar disorder (BP) commonly coexist, and both share key symptoms, depending on affective state and emotional dysregulation. The overlap poses diagnostic challenges and may lead to underdiagnoses. Comorbid cases exhibit worsened symptom burden, increased psychiatric morbidity, admissions, and suicide attempts. Treating BP before ADHD is recommended. Stimulant use combined with mood stabilisers may be effective and relatively safe; however, this review finds that well-designed randomised controlled studies in the area is warranted.

The Brief Emotion Dysregulation Scale: Development, Preliminary Validation, and Recommendations for Use

Emotion dysregulation is a multi-faceted, transdiagnostic construct, and its assessment is crucial for characterizing its role in the development, maintenance, and treatment of psychiatric problems. We developed the Brief Emotion Dysregulation Scale (BEDS) to capture four components of emotion dysregulation: sensitivity, lability, reactivity, and consequences. We examined factor structure and construct validity in four independent samples of college students (N = 1,485). We elected to treat consequences as a separate index of problems associated with emotion dysregulation. Exploratory and confirmatory factor analyses did not support the reactivity subscale and instead supported a well-fitting two-factor solution for sensitivity and lability. Multi-group analyses demonstrated strong factorial invariance by gender. The resulting 12-item BEDS includes sensitivity and lability subscales and a separate consequences scale to indicate associated problems. Convergent correlations suggested good construct validity. This provides preliminary support for the BEDS as a brief transdiagnostic screening tool for emotion dysregulation and associated consequences.

Inflammation and emotion regulation: a narrative review of evidence and mechanisms in emotion dysregulation disorders

Emotion dysregulation (ED) describes a difficulty with the modulation of which emotions are felt, as well as when and how these emotions are experienced or expressed. It is a focal overarching symptom in many severe and prevalent neuropsychiatric diseases, including bipolar disorders (BD), attention deficit/hyperactivity disorder (ADHD), and borderline personality disorder (BPD). In all these disorders, ED can manifest through symptoms of depression, anxiety, or affective lability. Considering the many symptomatic similarities between BD, ADHD, and BPD, a transdiagnostic approach is a promising lens of investigation. Mounting evidence supports the role of peripheral inflammatory markers and stress in the multifactorial aetiology and physiopathology of BD, ADHD, and BPD. Of note, neural circuits that regulate emotions appear particularly vulnerable to inflammatory insults and peripheral inflammation, which can impact the neuroimmune milieu of the central nervous system. Thus far, few studies have examined the link between ED and inflammation in BD, ADHD, and BPD. To our knowledge, no specific work has provided a critical comparison of the results from these disorders. To fill this gap in the literature, we review the known associations and mechanisms linking ED and inflammation in general, and clinically, in BD, ADHD, and BD. Our narrative review begins with an examination of the routes linking ED and inflammation, followed by a discussion of disorder-specific results accounting for methodological limitations and relevant confounding factors. Finally, we critically discuss both correspondences and discrepancies in the results and comment on potential vulnerability markers and promising therapeutic interventions.

Retrospective diagnosis of childhood ADHD using the Wender Utah Rating Scale

OBJECTIVE

An external validation of the Wender Utah Rating Scale (WURS) against a clinical assessment is lacking, especially for French-speaking populations.

METHOD

Participants completed three subsets of the WURS-61 and were assessed for ADHD using the DIVA 2.0 semi-structured interview. Exploratory factor analyses were performed. Logistic regression models and Receiver-Operating Curves were used to determine the cut-off scores that predicted childhood ADHD with best accuracy.

RESULTS

One hundred three adults were included. Three factors were extracted for the WURS-25 and WURS-K, and four for the WURS-29. Cut-off scores are 44, 24 and 42, respectively. When considering DSM-5 rather than DSM-IV criteria, these values changed to 44, 36 and 44, respectively. More than 83% of the participants had been correctly classified.

CONCLUSION

All three subsets of the WURS-61 retrospectively predict the presence of ADHD in childhood. This result might prove to be useful in screening and research procedures.

Identifying different patterns of emotion dysregulation in adult ADHD

BACKGROUND

Emotion dysregulation (ED) is a core intrinsic feature of adult presenting Attention Deficit Hyperactivity Disorder (ADHD). However, the clinical expressions of ED are diverse and several questionnaires have been used to measure ED in adults with ADHD. Thus, to date, the characteristics of ED in adult ADHD remain poorly defined. The objective of this study is to identify the different patterns of ED in adults with ADHD.

METHODS

A large sample of 460 newly diagnosed adults with ADHD were recruited. Patients completed a total of 20 self-reported questionnaires. Measures consisted in the several facets of ED, but also other clinical features of adult ADHD such as racing thoughts. A factor analysis with the principal component extraction method was performed to define the symptomatic clusters. A mono-dimensional clustering was then conducted to assess whether participants presented or not with each symptomatic cluster.

RESULTS

The factor analysis yielded a 5 factor-solution, including "emotional instability", "impulsivity", "overactivation", "inattention/disorganization" and "sleep problems". ED was part of two out of five clusters and concerned 67.52% of our sample. Among those patients, the combined ADHD presentation was the most prevalent. Emotional instability and impulsivity were significantly predicted by childhood maltreatment. The ED and the "sleep problems" factors contributed significantly to the patients' functional impairment.

CONCLUSIONS

ED in ADHD is characterized along emotional instability and emotional impulsivity, and significantly contributes to functional impairment. However, beyond impairing symptoms, adult ADHD may also be characterized by functional strengths such as creativity.

Psychopathological Dissection of Bipolar Disorder and ADHD: Focussing on Racing Thoughts and Verbal Fluency

In the present study, we propose a review and a synthesis of the work of our group about the phenomenology and the cognitive mechanisms of racing thoughts in bipolar disorder (BD) and ADHD. Contrary to the mainstream idea according to which racing thoughts are pathognomonic of BD, our work suggests that racing thoughts are enhanced in ADHD compared to hypomanic episodes of BD, whereas in euthymic episodes of BD self-reported racing thoughts are similar to the rates reported by healthy controls. Using verbal fluency tasks, we found many similarities between bipolar and ADHD subjects with one clear difference: lexical search strategy in hypomania is based on phonemic similarities rather than semantic-relatedness. However, this distinction observed in this cognitive task is certainly difficult to grasp during a clinical interview aiming to differentiate mild hypomania from combined ADHD presentation. The main landmark to distinguish them remains the episodic nature of bipolar disorders as opposed to the lifelong presentation of ADHD symptoms, a dichotomous view that is not so clear-cut in clinical practice.

Emotional dysregulation as trans-nosographic psychopathological dimension in adulthood: A systematic review

Introduction

Emotional dysregulation (ED) is characterized by inappropriate emotional reactions related to environmental or cognitive stimuli. In most recent years, increasing interest has been devoted to its definition and detection across mental disorders for its detrimental role progressively highlighted in both neurodevelopment and adult mental disorders, with implications on the severity of clinical manifestations. The aim of this systematic review was to evaluate and gather the scientific evidence about ED in adult psychiatric population to elucidate the concept of ED as trans-nosographic entity.

Methods

The electronics databases PubMed, Scopus and Web of Science was reviewed to identify studies in accordance with the PRISMA guidelines; at the end of the selection process a total of 29 studies (N = 709; N = 658; N = 1,425) was included. All studies included assessed the presence of ED symptoms, by means of a validate scale in adult (>18 years of age), in clinically diagnosed patients as well as healthy control participants.

Results

Our results suggest ED as a trans-diagnostic factor across multiple mental disorders, such as bipolar disorder, attention deficit hyperactivity disorder, autism spectrum disorder, personality disorders; a better definition of this concept could be helpful to interpret and clarify many clinical cases and improve their diagnostic and therapeutic management.

Attention deficit/hyperactivity disorder in adults: A case study

Attention-Deficit/Hyperactivity Disorder (ADHD) is often misdiagnosed or mistreated in adults because it is often thought of as a childhood problem. If a child is diagnosed and treated for the disorder, it often persists into adulthood. In adult ADHD, the symptoms may be comorbid or mimic other conditions making diagnosis and treatment difficult. Adults with ADHD require an in-depth assessment for proper diagnosis and treatment. The presentation and treatment of adults with ADHD can be complex and often requires interdisciplinary care. Mental health and non-mental health providers often overlook the disorder or feel uncomfortable treating adults with ADHD. The purpose of this manuscript is to discuss the diagnosis and management of adults with ADHD.

Two Facets of Emotion Dysregulation Are Core Symptomatic Domains in Adult ADHD: Results from the SR-WRAADDS, a Broad Symptom Self-Report Questionnaire

OBJECTIVES

Emotional dysregulation (ED) in adult ADHD is frequent but definition and tools for its evaluation are not consensual. Our aim was to determine the core ADHD symptomatic domains via the Self-Reported Wender-Reimherr Adult Attention Deficit Disorder Scale (SR-WRAADDS) following its validation in a large clinical sample of adults with ADHD and controls.

METHOD

Three hundred sixty-nine adult patients with ADHD and 251 healthy participants completed the SR-WRAADDS and questionnaires about ADHD, depression, and ED. We analyzed the psychometric properties of the SR-WRAADDS and a factor analysis yielded symptomatic domains.

RESULTS

The SR-WRAADDS has good reliability. The 30 symptoms were best organized in a four-factor solution: attention/disorganization, hyperactivity/restlessness, impulsivity/emotional outbursts, and emotional lability.

CONCLUSIONS

The symptomatic structure of the SR-WRAADDS includes two distinct dimensions related to ED: "impulsivity/emotional outbursts" and "emotional lability." The SR-WRAADDS is a reliable and clinically useful tool that assesses all ADHD symptom domains, including facets of ED.

Does central executive training and/or inhibitory control training improve emotion regulation for children with attention-deficit/hyperactivity disorder? A randomized controlled trial

INTRODUCTION

Approximately 48-54% of children with attention-deficit/hyperactivity disorder (ADHD) have impairing difficulties with emotion regulation, and these difficulties are not ameliorated by first-line ADHD treatments. Working memory and inhibitory control represent promising intervention targets given their functional, if not causal, links with ADHD-related emotion dysregulation.

METHODS

This preregistered randomized controlled trial tested whether two digital therapeutic training protocols that have been previously shown to improve working memory (Central Executive Training [CET]) and inhibitory control (Inhibitory Control Training [ICT]) can improve emotion regulation in a sample of 94 children with ADHD aged 8-13 years (M = 10.22, SD = 1.43; 76% White/non-Hispanic; 29 girls).

RESULTS

Results of Bayesian mixed model ANOVAs indicated both treatment groups demonstrated significant decreases in emotion dysregulation relative to pre-treatment at immediate post-treatment (parent report; d = 1.25, BF₁₀ = 8.04 × 10¹³, p < 0.001), at 1-2 months after completing treatment (teacher report; d = 0.99, BF₁₀ = 1.22 × 10⁶, p < 0.001), and at 2-4-months follow-up (parent report; d = 1.22, BF₁₀ = 1.15 × 10¹⁴, p < 0.001). Contrary to our hypotheses, the CET and ICT groups demonstrated equivalent reductions in emotion dysregulation and maintenance of effects. Exploratory analyses revealed that results were robust to control for informant expectancies, ADHD medication status/changes, in-person vs. at-home treatment, child age, and time from treatment completion to post-treatment ratings.

DISCUSSION

To determine whether working memory and inhibitory control are causally linked with ADHD-related emotion dysregulation, future studies should include active control conditions that do not train executive functions prior to making decisions about the clinical utility of CET/ICT for the treatment of emotion dysregulation in ADHD.

CLINICAL TRIAL REGISTRATION

[https://clinicaltrials.gov/], identifier [NCT03324464].

Executive Functioning and Emotion Regulation in Children with and without ADHD

Difficulties with emotion regulation affect the majority of youth with attention-deficit/hyperactivity disorder (ADHD) and predict greater functional impairment than ADHD symptoms alone. Deficits in executive functioning are also present for most children with ADHD, and have been linked with emotion regulation difficulties in both clinical and neurotypical populations throughout development. The current study was the first to assess all three core executive functions (working memory, inhibitory control, set shifting) simultaneously in a clinically-diverse sample of children with and without ADHD and common comorbidities and investigate the extent to which they uniquely predict emotion dysregulation. A sample of 151 children ages 8-13 years (M = 10.36, SD = 1.52; 52 girls; 70.2% White/Non-Hispanic) were assessed using a criterion battery of executive functioning tasks, teacher-reported ADHD symptoms, and parent-reported emotion regulation. Results of the bias-corrected, bootstrapped conditional effects path model revealed that better-developed working memory predicted better emotion regulation (β = 0.23) and fewer ADHD symptoms (β = -0.21 to -0.37), that ADHD symptoms (β = -0.18 to -0.20) independently predicted emotion dysregulation, and that working memory exerted indirect effects on emotion regulation through both inattention and hyperactivity/impulsivity (β = 0.04-0.07). Sensitivity analyses indicated that these effects were generally robust to control for age, sex, executive function interrelations, and inclusion/exclusion of children with co-occurring ASD. These findings underscore the importance of working memory (relative to inhibitory control and set shifting) and its relations with ADHD symptoms for understanding children's emotion regulation skills, and may help explain the limited efficacy of first-line ADHD treatments, which do not target working memory, for improving emotion regulation skills.

Development of bipolar disorder in patients with attention-deficit/hyperactivity disorder: A systematic review and meta-analysis of prospective studies

BACKGROUND

Increasing attention has been recently paid to precursors of bipolar disorder (BD). Symptoms of attention-deficit/hyperactivity disorder (ADHD) have been reported among the most common prodromes of BD. The aim of this study was to estimate the risk of BD in youths affected by ADHD based on prospective studies.

METHODS

A systematic review was conducted according to the PRISMA guidelines. A meta-analysis of single proportions was performed to compute the overall occurrence of BD in ADHD individuals. Binary outcome data were used to calculate risk estimates of BD occurrence in ADHD subjects versus Healthy Controls (HC).

RESULTS

An overall proportion of BD occurrence of 10.01% (95%-confidence interval [CI]: 6.47%-15.19%; I² = 82.0%) was found among 1248 patients with ADHD over 10 prospective studies. A slightly higher proportion was found when excluding one study based on jack-knife sensitivity analysis (11.96%, 95%-CI: 9.15%-15.49%; I² = 54.1%) and in three offspring studies (12.87%, 95%-CI: 8.91%-18.23%). BD occurrence was not significantly associated with mean follow-up duration (p-value = 0.2118). A greater risk of BD occurrence in ADHD versus HC from six studies was found (risk ratio: 8.97, 95%-CI: 4.26-18.87, p-value < 0.0001).

LIMITATIONS

Few prospective studies have been retrieved in our search and most were not specifically aimed at assessing BD in followed-up ADHD patients.

CONCLUSIONS

Greater clinical attention should be paid to ADHD as an early precursor of BD since a substantial proportion of ADHD patients is expected to be diagnosed with BD during the developmental age.

An Examination of Relations Among Working Memory, ADHD Symptoms, and Emotion Regulation

Emotion regulation difficulties are present in many, if not most, children with attention-deficit/hyperactivity disorder (ADHD) and confer risk for a host of adverse outcomes. Little is known, however, regarding the neurocognitive and behavioral mechanisms that underlie these difficulties. A well-characterized, clinically evaluated sample of 145 children ages 8-13 years (M = 10.33, SD = 1.47; 55 girls; 69% White/non-Hispanic) were administered multiple, counterbalanced working memory tests and assessed for emotion dysregulation and ADHD symptoms via multiple-informant reports. Bias-corrected, bootstrapped conditional effects modeling indicated that underdeveloped working memory exerted significant direct effects on emotion regulation in all tested models as well as indirect effects on emotion regulation via parent-reported hyperactive/impulsive symptoms (95% CIs excluded zero). Interestingly, hyperactive/impulsive symptoms also predicted emotion dysregulation when controlling for the influence of working memory. Inattention failed to predict emotion regulation difficulties in all tested models (all 95% CIs included zero). This pattern of results replicated across parent and teacher models and were robust to control for mono-informant bias, age, and gender. These findings suggest that emotion dysregulation in ADHD reflects, in part, both a direct outcome of underdeveloped working memory and an affective outcome of hyperactive and/or impulsive symptomatology, both attributable to and independent of the role of underlying working memory deficits.

Childhood Maltreatment in Bipolar Disorders

In this chapter, we will focus on childhood maltreatment and its role in the vulnerability to BD.We will review how childhood maltreatment and trauma not only predispose to the development of BD but also to a more unstable, pernicious, and severe clinical expression of the disorder. This environmental risk factor is suggested to be part of a multiple hit model of vulnerability, involving not only early stressors (prenatal and postnatal ones) but also interactions with the genetic background of individuals and with other stressors occurring later in life. We will also review how childhood maltreatment and trauma may modify the brain functioning and circuits and alter some biological pathways in BD, hence leading to psychopathology. Finally, we will briefly discuss the implications for clinical practice and treatment.

An emotional-response model of bipolar disorders integrating recent findings on amygdala circuits

Because of our classification system limitations for defining psychiatric disorders and understanding their physiopathology, a new research area based on dimensions has emerged. It consists of exploring domains derived from fundamental behavioral components linked to neurobiological systems. Emotional processing is among the most affected dimensions in bipolar disorders (BD), but is excluded from the definition criteria. The purpose of this review is to synthesize the emotional responses disruption during the different phases of BD, using intensity and valence as the two key characteristics of emotions. We integrate those emotional disruptions into an original, emotion-based model contrasting with the current diagnostic frame built on mood. Emotional processing is underpinned by cortico-limbic circuits involving the amygdala. Recent publications showed the crucial role of the amygdala in emotional processes triggered by stimuli of negative, but also positive valence. We show how these neuroscience data can provide physiological basis for emotional disturbances observed in BD. We conclude with translational perspectives to improve the current knowledge about neural substrates underlying altered emotional responses characterizing BD.

Parsing the effects of comorbid adult ADHD and substance misuse on affective lability in bipolar disorder

INTRODUCTION

Attentional deficits, substance misuse, and affective lability are all common features among adults with bipolar disorder, but little research has attempted to parse their inter-relationships.

METHODS

Using standardized scales and semi-structured interviews, we evaluated adult ADHD features and affective lability in 113 dually-diagnosed mood/substance use disorder inpatients (mean age 32.6 years, 63% female) drawn from one private suburban academically affiliated inpatient treatment program.

RESULTS

24% of bipolar subjects had above-threshold ADHD screens. Affective Lability Scale (ALS) total and subscores were significantly associated with ADHD scores (univariate r's ranging from 0.38-0.63). ALS total and most subscale scores were significantly higher among bipolar subjects having above- (versus below-) threshold ADHD ratings. Linear regressions to predict affective lability revealed significant partial correlations between bipolar diagnoses and ALS total, depression, elation, and anger subscores, while controlling for significant effects from ADHD comorbidity. Inclusion of current substances of abuse did not change goodness-of-fit.

LIMITATIONS

Subjects were drawn from a single private institution, potentially limiting generalizability.

CONCLUSIONS

Comorbid ADHD appears to moderate multiple domains of affective lability in bipolar disorder inpatients, independent of current substance misuse.

Evidence against emotion inference deficits in children with ADHD

Inconsistent evidence suggests that pediatric attention deficit/hyperactivity disorder (ADHD) may be associated with impairments in the ability to use context clues to infer the emotion states of others. However, the evidence base for these impairments is comprised of data from laboratory-based tests of emotion inference that may be confounded by demands on nonaffective cognitive processes that have been linked with ADHD. The current study builds on our previous study of facial affect recognition to address this limitation and investigate a potential mechanism underlying children's ability to infer emotion state from context clues. To do so, we used a fully crossed, counterbalanced experimental design that systematically manipulated emotion inference and working memory demands in 77 carefully phenotyped children ages 8-13 (M_age = 10.46, SD = 1.54; 66% Caucasian/Non-Hispanic; 42% female) with ADHD (n = 42) and without ADHD (n = 35). Results of Bayesian mixed-model ANOVAs indicated that using context clues to infer the emotion state of others competed for neurocognitive resources with the processes involved in rehearsing/maintaining information within working memory (BF₁₀ = 1.57 × 10¹⁹, d = 0.72). Importantly, there was significant evidence against the critical Group × Condition interaction for response times (BF₀₁ = 4.93), and no significant evidence for this interaction for accuracy (BF₀₁ = 2.40). In other words, children with ADHD do not infer emotions more slowly than children without ADHD (d = 0.13), and their small magnitude impairment in accuracy (d = 0.30) was attributable to their generally less accurate performance on choice-response tasks (i.e., across both emotion and control conditions). Taken together, the evidence indicates that emotion inference abilities are likely unimpaired in pediatric ADHD and that working memory is implicated in the ability to infer emotion from context for all children-not just children with ADHD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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

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.

ADHD with Comorbid Bipolar Disorders: A Systematic Review of Neurobiological, Clinical and Pharmacological Aspects Across the Lifespan

BACKGROUND

Attention deficit hyperactivity (ADHD) disorder is a neurodevelopmental disorder characterized by inattention, hyperactivity, disruptive behaviour, and impulsivity. Despite considered typical of children for a long time, the persistence of ADHD symptoms in adulthood gained increasing interest during the last decades. Indeed, its diagnosis, albeit controversial, is rarely carried out even because ADHD is often comorbid with several other psychiatric diosrders, in particular with bipolar disorders (BDs), a condition that complicates the clinical picture, assessment and treatment.

AIMS

The aim of this paper was to systematically review the scientific literature on the neurobiological, clinical features and current pharmacological management of ADHD comorbid with BDs across the entire lifespan, with a major focus on the adulthood.

DISCUSSION

The pharmacology of ADHD-BD in adults is still empirical and influenced by the individual experience of the clinicians. Stimulants are endowed of a prompt efficacy and safety, whilst non-stimulants are useful when a substance abuse history is detected, although they require some weeks in order to be fully effective. In any case, an in-depth diagnostic and clinical evaluation of the single individual is mandatory.

CONCLUSION

The comorbidity of ADHD with BD is still a controversial matter, as it is the notion of adult ADHD as a distinct nosological category. Indeed, some findings highlighted the presence of common neurobiological mechanisms and overlapping clinical features, although disagreement does exist. In any case, while expecting to disentangle this crucial question, a correct management of this comorbidity is essential, which requires the co-administration of mood stabilizers. Further controlled clinical studies in large samples of adult ADHD-BD patients appear extremely urgent in order to better define possible therapeutic guidelines, as well as alternative approaches for this potentially invalidating condition.

Cyclothymic temperament: Associations with ADHD, other psychopathology, and medical morbidity in the general population

BACKGROUND

Cyclothymic temperament (CT) is an affective disposition often preceding bipolar disorder (BD), and is the most common affective temperament in patients with BD. In depressed patients, CT is a predictor for developing a bipolar course. In a clinical sample of adults with BD and attention deficit hyperactivity disorder (ADHD), CT was associated with higher loads of psychiatric symptoms, somatic comorbidity, impairment, and higher morbidity among first-degree relatives. We aimed to investigate the morbidity and occupational functioning of persons with CT in the general population.

METHODS

Randomly recruited Norwegian adults (n = 721) were assessed with a 21-item cyclothymic subscale from the TEMPS Autoquestionnaire. Self-reported data were collected on psychiatric symptoms, comorbidity, educational and occupational level, and known family morbidity.

RESULTS

Thirteen percent had CT associated with an increased prevalence of ADHD, BD, high scores on the Mood Disorder Questionnaire (MDQ), and childhood and adulthood ADHD symptoms. CT was found in 75% (p < .001) of the bipolar participants, and in 68% (p < .001) of those with a positive MDQ score. CT was associated with more anxiety/depression, substance and alcohol problems, lower educational and occupational levels, and having a first-degree relative with anxiety/depression, alcohol problems, ADHD, and BD.

LIMITATIONS

The CT subscale alone might include overlapping features with cyclothymic, anxious, irritable, and depressed temperaments, thus increasing the prevalence estimate of CT.

CONCLUSIONS

CT is a strong predictor of occupational failure and associated with more psychiatric impairment in the participants and their families. CT should be assessed in both mood disorder and ADHD patients.

Practical considerations for the evaluation and management of Attention Deficit Hyperactivity Disorder (ADHD) in adults

Attention deficit with or without hyperactivity disorder (ADHD) is one of the most frequent neuropsychiatric disorders, and affects 2-4% of adults. In contrast with many European countries, the identification and management of adult ADHD remains underdeveloped in France, and a subject of controversy. This review provides a practical update on current knowledge about ADHD in adults for French-speaking professionals who have to detect or manage adult patients with ADHD. ADHD is classified as a neurodevelopmental disorder in the recent update of the international diagnostic classification. While symptoms and impairment due to ADHD are frequently severe during childhood, they often evolve as children grow older, with frequent persistent disabilities in adulthood. In adulthood, the clinical presentation, as in childhood, involves the symptom triad of inattention, hyperactivity and impulsivity. However, differences are noted: hyperactivity is more often internalized, symptoms of inattention may be masked by anxiety symptoms or obsessive-like compensation strategies. ADHD is often diagnosed during childhood, but it is not rare for the diagnosis to be made later. Failure to recognise symptoms resulting in misdiagnosis, or alternatively well-developed compensation factors could be two underlying reasons for the long delay until diagnosis. Other symptoms, such as emotional deregulation or executive function-related symptoms are also usually observed in adults. In addition, in adults, ADHD is often associated with other psychiatric disorders (in 80% of cases); this makes the diagnosis even more difficult. These disorders encompass a broad spectrum, from mood disorders (unipolar or bipolar), to anxiety disorders, and other neurodevelopmental disorders and personality disorders, especially borderline and antisocial personality disorder. Substance-use disorders are very common, either as a consequence of impulsivity and emotional dysregulation or as an attempt at self-treatment. Sleep disorders, especially restless leg syndrome and hypersomnolence, could share common pathophysiological mechanisms with ADHD. ADHD and comorbidity-related symptoms are responsible for serious functional impairment, in various domains, leading to academic, social, vocational, and familial consequences. The impact on other psychiatric disorders as an aggravating factor should also be considered. The considerable disability and the poorer quality of life among adults with ADHD warrant optimal evaluation and management. The diagnostic procedure for ADHD among adults should be systematic. Once the positive diagnosis is made, the evaluation enables characterisation of the levels of severity and impairment at individual level. A full examination should also assess medical conditions associated with ADHD, to provide personalized care. In recent years, a growing number of assessment tools have been translated and validated in French providing a wide range of structured interviews and standardized self-report questionnaires for the evaluation of core and associated ADHD symptoms, comorbidities and functional impairment. The treatment of ADHD in adults is multimodal, and aims to relieve the symptoms, limit the burden of the disease, and manage comorbidities. The most relevant and validated psychological approaches are psycho-education, cognitive-behavioural therapy and "third wave therapies" with a specific focus on emotional regulation. Cognitive remediation and neurofeedback are promising strategies still under evaluation. Medications, especially psychostimulants, are effective for alleviating ADHD symptoms with a large effect size. Their safety and tolerance are satisfactory, although their long-term clinical benefit is still under discussion. In France, methylphenidate is the only stimulant available for the treatment of ADHD. Unfortunately, there is no authorization for its use among adults except in continuation after adolescence. Hence the prescription, which is subject to the regulations on narcotics, is off-label in France. This article aims to provide practical considerations for the management of ADHD and associated disorders in adults, in this particular French context.

Psychometric Properties and Factor Structure of the Short Form of the Affective Lability Scale in Adult Patients With ADHD

Objective: Affective lability is an important dimension of adult ADHD, associated with marked impairments and worse outcomes. A valid and quick tool to measure affective lability may therefore be of interest. Method: In 187 adult ADHD patients, we explored psychometric properties of the Affective Lability Scale-Short Form (ALS-18 items). We analyzed the construct validity and the external validity of the scale. Patients were compared with 48 healthy adult controls. Results: The three-factor structure of the ALS-18 presented a good fit and a good internal consistency. The correlations between the ALS-18 and ADHD symptoms and other psychological dimensions were, respectively, low and moderate. ALS-18 scores were higher in patients than in healthy adults. Conclusion: ALS-18 showed good psychometric properties in ADHD adult patients, allowing us to recommend the implementation of ALS-18 in assessing affective lability for clinical and research purposes. Use of ALS-18 should improve the clinical assessment of affective lability in adult ADHD patients.

Resting-state alpha and gamma activity in affective disorder with ADHD symptoms: Comparison between bipolar disorder and major depressive disorder

Although comorbid attention deficit/hyperactivity disorder (ADHD) symptoms are very common in mood disorder, its neurophysiological correlates have not been explored. This study aimed to examine clinical and neurophysiological correlates of ADHD symptoms in major depressive disorder (MDD) and bipolar disorder (BP). A total of 67 subjects with mood disorder, current depressive episode (38 subjects with MDD and 29 subjects with BP depression) were included in the analysis. Resting quantitative electroencephalography (qEEG) recordings were collected under eyes closed condition. ADHD symptoms, depression, anxiety, and lifetime hypomania were evaluated using self-report questionnaires. In MDD, ADHD symptoms did not show significant associations with anxiety and depression. In BP, ADHD symptoms showed significant associations with depression, anxiety and lifetime hypomania. Significant correlations with Adult ADHD self-report scales (ASRS) inattention score and total score were detected in left and right frontal alpha powers in MDD while significant correlation with ASRS hyperactivity score and ASRS total score were detected in right frontal gamma power in BP. Linear regression analyses revealed that left and right frontal alpha powers, depression and lifetime hypomania showed significant association with ASRS inattention score and ASRS total score in MDD. In BP, linear regression analysis showed ASRS hyperactivity score was associated with lifetime hypomania and the right frontal gamma power. MDD and BP showed different correlation patterns between frontal qEEG measures and ADHD symptoms. This might be associated with distinct neurobiological underpinnings of co-occurring ADHD symptoms in MDD and BP.

Emotional dysregulation subgroups in patients with adult Attention-Deficit/Hyperactivity Disorder (ADHD): a cluster analytic approach

Emotion regulation deficits (ERD) are evident in about 34–70% of the adults with ADHD. In contrast to this, they are not considered in the diagnostic criteria of the disorder. In a recent study of our research group using confirmatory factor analysis, we modeled positive and negative emotion as well as emotion regulation skills along with the classical ADHD-core symptoms. We showed that negative affect and the failure to apply adaptive emotion regulation skills were distinct and indicative dimensions in adult ADHD. In this study, we used a person-centered approach based on cluster analysis to subtype patients on the presence or relative absence of ERD. This results in important information to individualize treatment decisions. We found two clusters, with cluster 2 showing high ERD that were associated with higher impairments indicated by depressive mood, negative affect and elevated psychological distress. There were also higher rates of comorbidity in cluster 2 such as somatoform disorders which were associated with ERD. Women were overrepresented in this cluster 2. Neuropsychological variables did not contribute significantly to cluster formation. In conclusion, ADHD in adults is a heterogeneous disorder with specific subgroups that need differential treatment approaches.

The relationship between attention deficit hyperactivity disorder, bipolarity and mixed features in major depressive patients: Evidence from the BRIDGE-II-Mix Study

OBJECTIVE

This study primarily focused on the relationship between comorbid attention deficit-hyperactivity disorder (ADHD), mixed features and bipolarity in major depressive patients.

METHODS

The sample comprised 2777 patients with Major Depressive Episode (MDE) enrolled in a multicentre, multinational study originally designed to assess different definitions of mixed depression. Socio-demographic, familial and clinical characteristics were compared in patients with (ADHD + ) and without (ADHD-) comorbid ADHD.

RESULTS

Sixty-one patients (2.2%) met criteria for ADHD. ADHD was associated with a higher number of (hypo)manic symptoms during depression. Mixed depression was more represented in ADHD + patients than in ADHD- using both DSM-5 and experimental criteria. Differences were maintained after removing overlapping symptoms between (hypo)mania and ADHD. ADHD in MDE was also associated with a variety of clinical and course features such as onset before the age of 20, first-degree family history of (hypo)mania, past history of antidepressant-induced (hypo)manic switches, higher number of depressive and affective episodes, atypical depressive features, higher rates of bipolarity specifier, psychiatric comorbidities with eating, anxiety and borderline personality disorders.

LIMITATIONS

The study was primarily designed to address mixed features in ADHD, with slightly reduced sensitivity to the diagnosis of ADHD. Other possible diagnostic biases due to heterogeneity of participating clinicians.

CONCLUSIONS

In a sample of major depressive patients, the comorbid diagnosis of current ADHD is associated with bipolar diathesis, mixed features, multiple psychiatric comorbidity and a more unstable course. Further prospective studies are necessary to confirm the possible mediating role of temperamental mood instability and emotional dysregulation in such a complex clinical presentation.

Affective instability in those with and without mental disorders: A case control study

BACKGROUND

Affective instability (AI) is transdiagnostic, and associated with suicidality and healthcare use. It has rarely been compared between diagnoses or to controls. We investigated: whether AI differs between clinical cases and controls and between diagnoses; how different AI components are correlated; and whether AI is associated with functioning in clinical cases.

METHODS

Cases (N = 69) from psychiatric services had a diagnosis of borderline personality disorder, bipolar disorder, major depression or psychosis and were compared to primary care controls (N = 25). Participants completed the affective lability scale (ALS), affective intensity measure (AIM), affective control scale (ACS), scored mood fluctuation rate and the WHO-DAS.

RESULTS

There was a significant difference in affective lability between cases and controls and across diagnostic groups (p < 0.001). Compared to controls, cases showed lower affective control (p < 0.05). There were no differences in affective intensity between cases and controls or between diagnostic groups, or in mood fluctuation rate between groups. ALS score (p < 0.001), and total number of medications (p < 0.046), were associated with functioning, independent of diagnosis.

LIMITATIONS

The sample size was modest. Cases were not in an acute illness episode and this could bias estimates of group difference towards the null.

CONCLUSION

Individuals with mental disorder demonstrate higher levels of affective lability and lower affect control than those without mental disorder. In contrast affective intensity may not be useful in demarcating abnormal affective experience. Independent of diagnosis, affective instability, as measured by affect lability, adversely impacts day-to-day functioning. It could be an important target for clinical intervention.

Using an emotional saccade task to characterize executive functioning and emotion processing in attention-deficit hyperactivity disorder and bipolar disorder

Despite distinct diagnostic criteria, attention-deficit hyperactivity disorder (ADHD) and bipolar disorder (BD) share cognitive and emotion processing deficits that complicate diagnoses. The goal of this study was to use an emotional saccade task to characterize executive functioning and emotion processing in adult ADHD and BD. Participants (21 control, 20 ADHD, 20 BD) performed an interleaved pro/antisaccade task (look toward vs. look away from a visual target, respectively) in which the sex of emotional face stimuli acted as the cue to perform either the pro- or antisaccade. Both patient groups made more direction (erroneous prosaccades on antisaccade trials) and anticipatory (saccades made before cue processing) errors than controls. Controls exhibited lower microsaccade rates preceding correct anti- vs. prosaccade initiation, but this task-related modulation was absent in both patient groups. Regarding emotion processing, the ADHD group performed worse than controls on neutral face trials, while the BD group performed worse than controls on trials presenting faces of all valence. These findings support the role of fronto-striatal circuitry in mediating response inhibition deficits in both ADHD and BD, and suggest that such deficits are exacerbated in BD during emotion processing, presumably via dysregulated limbic system circuitry involving the anterior cingulate and orbitofrontal cortex.

The Mechanism of Cortico-Striato-Thalamo-Cortical Neurocircuitry in Response Inhibition and Emotional Responding in Attention Deficit Hyperactivity Disorder with Comorbid Disruptive Behavior Disorder

The neurocircuitries that constitute the cortico-striato-thalamo-cortical (CSTC) circuit provide a framework for bridging gaps between neuroscience and executive function in attention deficit hyperactivity disorder (ADHD), but it has been difficult to identify the mechanisms for regulating emotional problems from the understanding of ADHD comorbidity with disruptive behavior disorders (DBD). Research based on "cool" and "hot" executive functional theory and the dual pathway models, which are thought of as applied response inhibition and delay aversion, respectively, within the neuropsychological view of ADHD, has shed light on emotional responding before and after decontextualized stimuli, while CSTC circuit-related domains have been suggested to explain the different emotional symptoms of ADHD with or without comorbid DBD. This review discusses the role of abnormal connections in each CSTC circuit, especially in the emotion circuit, which may be responsible for targeted executive dysfunction at the neuroscience level. Thus, the two major domains - abstract thinking (cool) and emotional trait (hot) - trigger the mechanism of onset of ADHD.

Emotional face recognition in individuals withattention-deficit/hyperactivity disorder: a review article

This review focuses on facial emotion recognition (FER) in individuals with attention- deficit/hyperactivity disorder (ADHD). Behavioral studies of FER in ADHD have resulted in inconsistent findings. Here, we discuss the factors that vary across studies and the way that they influence FER processes in ADHD. Across reviewed studies, fear was the most deficient facial expression to be recognized. Our review suggested that FER deficit in ADHD does not alleviate across development and is partially distinct from ADHD symptoms. In conclusion, assessment of FER in ADHD and targeting that in interventional plans could lead to social skills improvement in ADHD.

Screening for attention-deficit/hyperactivity disorder in borderline personality disorder

BACKGROUND

A valid screening instrument is needed to detect attention-deficit/hyperactivity disorder (ADHD) in treatment-seeking borderline personality disorder (BPD) patients. We aimed to test the performance of the widely-used Adult ADHD Self-Report Scale v1.1 screener (ASRS-v1.1).

METHODS

317 BPD subjects were systematically assessed for comorbid ADHD and completed the ASRS-v1.1. 79 BPD patients also completed the Wender Utah Rating Scale (WURS-25).

RESULTS

The prevalence of adult ADHD was of 32.4%. The overall positive predictive value of the ASRS-v1.1 was of 38.5%, the negative predictive value 77.0%, the sensitivity 72.8%, and the specificity 43.9%. Combining WURS-25 and ASRS-v1.1 improved sensitivity to 81.8% and specificity to 59.6%.

LIMITATIONS

Cross-sectional study on treatment-seeking patients.

CONCLUSIONS

We found a high prevalence of ADHD using structured interviews. The ASRS-v1.1 was not a sensitive screener for identifying possible ADHD cases in a BPD population, with a high number of false positives. When combined with the WURS-25, it offered improved screening.

Pharmacotherapy of emotional dysregulation in adults with ADHD: A systematic review and meta-analysis

Emotional dysregulation (ED) is a dysfunction in modifying an emotional state in an adaptive and goal oriented way, with excitability, ease anger, and mood lability. It is present in up to 70% of adults with ADHD, regardless of other comorbidities, and substantially worsens the psychosocial outcomes of the disorder. Besides fronto-parietal circuits mediating top-down control, brain regions involved in bottom-up processes (e.g., amygdala, orbitofrontal cortex, and ventral striatum) are implicated in ED. We performed a systematic review/meta-analysis of double-blind randomized controlled trials of ADHD medications to assess their effects on ED in adults with ADHD. We searched an extensive set of databases, international trials registries, and contacted study authors/drug companies for unpublished data. We retained 21 trials. We found small-to-moderate effects (methylphenidate: SMD=0.34, 95% CI=0.23-0.45; atomoxetine: SMD=0.24, 95% CI=0.15-0.34; lisdexamfetamine: SMD=0.50, 95% CI=0.21-0.8). We suggest that, whilst ADHD medications are effective on ADHD core symptoms, they may be less effective on bottom-up mechanisms underlying ED. Further research on novel pharmacological and non-pharmacological strategies for ED in adults with ADHD is warranted.

PROSPERO

CRD42017068426.

Affective lability mediates the association between childhood trauma and suicide attempts, mixed episodes and co-morbid anxiety disorders in bipolar disorders

BACKGROUND

Many studies have shown associations between a history of childhood trauma and more severe or complex clinical features of bipolar disorders (BD), including suicide attempts and earlier illness onset. However, the psychopathological mechanisms underlying these associations are still unknown. Here, we investigated whether affective lability mediates the relationship between childhood trauma and the severe clinical features of BD.

METHOD

A total of 342 participants with BD were recruited from France and Norway. Diagnosis and clinical characteristics were assessed using the Diagnostic Interview for Genetic Studies (DIGS) or the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I). Affective lability was measured using the short form of the Affective Lability Scale (ALS-SF). A history of childhood trauma was assessed using the Childhood Trauma Questionnaire (CTQ). Mediation analyses were performed using the SPSS process macro.

RESULTS

Using the mediation model and covariation for the lifetime number of major mood episodes, affective lability was found to statistically mediate the relationship between childhood trauma experiences and several clinical variables, including suicide attempts, mixed episodes and anxiety disorders. No significant mediation effects were found for rapid cycling or age at onset.

CONCLUSIONS

Our data suggest that affective lability may represent a psychological dimension that mediates the association between childhood traumatic experiences and the risk of a more severe or complex clinical expression of BD.

Alcohol use disorders are associated with increased affective lability in bipolar disorder

BACKGROUND

Affective dysregulation is a core feature of bipolar disorder (BD), and inter-episodic affect lability is associated with more severe outcomes including comorbidity. Rates of daily tobacco smoking and substance use disorders in BD are high. Knowledge regarding relationships between affective lability and abuse of the most commonly used substances such as tobacco, alcohol and cannabis in BD is limited.

METHODS

We investigated whether dimensions of inter-episodic affective lability as measured with the Affective Lability Scale - short form (ALS-SF) were associated with lifetime daily tobacco use or alcohol (AUD) or cannabis use disorders (CUD) in a sample of 372 French and Norwegian patients with BD I and II.

RESULTS

ALS-SF total score and all sub-dimensions (anxiety-depression, depression-elation and anger) were significantly associated with AUD, while only the depression-elation sub-dimension was associated with CUD, after controlling for possible confounders such as gender, age at interview, age at illness onset, BD subtype, duration of illness and other substance use disorders. Daily tobacco smoking was not significantly associated with affective lability.

LIMITATIONS

Data for recent substance use or psychiatric comorbidities such as personality or hyperkinetic disorders were not available, and could have mediated the relationships.

CONCLUSION

AUD is associated with several dimensions of inter-episodic affective lability in BD, while CUD is associated with increased oscillations between depression and elation only. Increased affective lability may partly explain the increased illness severity of patients with BD and AUD or CUD. Affective lability should be treated in order to prevent these comorbidities.

Relationships between adult emotional states and indicators of health care utilization: Findings from the National Health Interview Survey 2006-2014

OBJECTIVE

Adults with serious psychological distress have a high likelihood of mental health problems severe enough to cause serious impairment in social and occupational functioning requiring treatment. These adults visit doctors frequently yet have poor health compared to adults without serious psychological distress. This study examined associations between emotional states of serious psychological distress in relationship to healthcare utilization indicators. A guiding hypothesis was that somatization underlying emotional states contributes to excessive healthcare seeking among adults with serious psychological distress.

METHODS

Using 2006-2014 National Health Interview Survey, in adults with serious psychological distress (n=9271), the six states: unable to make efforts, nervousness, hopelessness, sadness, worthlessness and restlessness were assessed in multivariate models in relation to four healthcare utilization indicators: change in the usual place of healthcare, change due to insurance, having seen a healthcare provider in the last 6months and having 10 or more doctor visits in the last 12months. Models were adjusted for sociodemographic variables, having seen a mental health provider, and health conditions.

RESULTS

Adults feeling unable to make efforts were more likely to seek healthcare in the last 6months and at least ten times in the last twelve months. Adults feeling hopeless were less likely to be heavy healthcare utilizers.

CONCLUSIONS

Predisposing medical conditions do not fully explain healthcare utilization in adults with serious psychological distress. Educating healthcare providers about the emotional states motivating healthcare seeking, and integrating mental healthcare into primary care, may improve the health of adults with serious psychological distress.