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 to find any practical takeaways.
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." Just to give a bit of 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 to see what's actually out there. 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.
To get started, let's try to get a quick definition of what we're talking about with emotional dysregulation and, of course, rejection sensitive dysphoria. You want to hit that one, Skye?
If you'd life to follow along on the show notes page you can find that at HackingYourADHD.com/319
https://tinyurl.com/56rvt9fr - Unconventional Organisation Affiliate link
https://tinyurl.com/y835cnrk - YouTube
William Curb: 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 to find any practical takeaways.
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."
Just to give a bit of 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 to see what's actually out there. 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.
To get started, let's try to get a quick definition of what we're talking about with emotional dysregulation and, of course, rejection sensitive dysphoria. You want to hit that one, Skye?
Skye Waterson: Yeah, 100%. We know that ADHD is associated with executive functioning deficits—this is the core part of the DSM diagnosis. But when we're looking at emotional regulation, this is a particular piece of interest.
For emotional dysregulation, there's a different paper from 2019 by Thompson which talks about emotional dysregulation as a theme in search of a definition. 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 specifically at how people do that and how ADHD may affect emotional dysregulation was the purpose of this paper.
William Curb: Yeah. The important part for me here is both getting the definition and understanding the reason behind looking at this. It's the number of people I know who say, "Yes, I have trouble with my emotions, and it is because of my ADHD." But we don't quite have all the research behind it because measuring emotion is very hard.
That comes up in this paper in an interesting way because this ended up being a narratively structured systematic review rather than a meta-analysis due to the heterogeneity of the studies they gathered. They found 22 studies through their methodology, but concluded that things were too dissimilar. Nothing was quite the same, making it hard to group things properly. For example, they had 12 different scales measuring emotions across those 22 studies—which is wild when you think about trying to compare those properly in a meta-analysis, which is why they didn't.
Skye Waterson: Yeah, 100%. The idea of emotional dysregulation, and RSD as a part of that, is on the cutting edge of current ADHD research. It's also worth noting—because this comes up a lot—their criteria required participants to be diagnosed with ADHD following the DSM or later criteria.
If participants did not have a clinical diagnosis and only presented symptoms or probable ADHD, they were not included. That's relevant because a lot of papers focus more on symptomatology than diagnosis, but you can see why it was really important here to focus on the diagnosis itself.
William Curb: Yeah. And because this specifically looks at adult ADHD, it also cut out a lot of papers, given that ADHD is more often studied in children.
Skye Waterson: Exactly. So we ended up having three sections:
Features of emotional regulation in people with ADHD (covering 10 studies).
Neurological and psychophysiological activity during emotional regulation tasks in ADHD.
Interventions.
William Curb: Yeah, and that first section is where we get the most overlap and data we can properly compare. Still, a lot of the data is incompatible because of uncontrolled variables—for instance, many studies didn't look at gender, which has a big effect on how ADHD plays into emotional regulation.
Skye Waterson: Yeah, 100%. What they did find was that ADHD groups had consistently lower emotional regulation scores than control groups, ranging from medium to very large effect sizes. So they saw what they expected to see: emotional dysregulation is higher in people who have ADHD.
William Curb: Yeah. They found that most people dealing with this are using maladaptive strategies—like suppressing their emotions—to deal with emotional outbursts. That creates a terrible cycle of worsening mental health and increasing emotional problems.
Skye Waterson: Yeah, for me, that was maybe the most interesting part of the whole paper.
William Curb: If you don't know about your ADHD and the emotional side of it, suppressing becomes your main strategy because you're thinking, "I don't want to be different. I don't want to be a problem."
Skye Waterson: Yeah. This reminded me of masking as well. Suppressing and masking are very similar because, in some ways, you're being taught to just not have the problem—to mask it. When you think about it like that, you can see why this strategy gets used: it's a strategy that has been encouraged because it feels easier for everybody.
William Curb: Oh, at least it feels that way in the moment.
Skye Waterson: Oh yeah, easier for everybody in the moment.
William Curb: It's one of those things where you think, "If I just shove all this down, it's going to make everything better." But that's usually not a good long-term strategy.
Skye Waterson: No, it's not. Though, a bit sideways here, I remember back in the day studying relationships, and research showed two kinds of approaches. There were relationships where things got brought to the surface to argue about and resolve, and then there were people who sat on things. As long as both people agreed on that approach, it seemed to be okay.
William Curb: Yeah, and I think that's a bit different than saying, "I'm just not going to feel this feeling," versus being more introspective about why you're feeling it and how it affects your relationship.
There have been times where I get very upset about something, and at the time it feels so important. But if I tell myself, "I'm not going to react to this right now; I'm going to let myself think about it," then 10 or 30 minutes later I realize, "You know what? I'm glad I didn't go off, because it's not as important as it felt at the time."
Skye Waterson: That is one of the things about ADHD and emotional dysregulation—impulsivity is involved. We see how that works with ADHD, and it means we can be, quote, "hot-headed." We can have that initial hot-headed reaction, so managing that is key.
William Curb: Yeah, I've talked about this in therapy. It feels like going from 0 to 100, but usually I've been silently boiling over inside—that's the suppression part. So really it's 90 to 100, but I didn't notice the jump to 90.
Skye Waterson: That's an important distinction. If you're suppressing your emotions, that's exactly how it feels.
William Curb: You just hit your boiling point and can't hold it anymore.
Skye Waterson: 100%. Should we dive into the neurological and psychophysiological activity related to ADHD?
William Curb: In terms of brain activity, they had four studies conducted with adults diagnosed with ADHD. They looked at emotional regulation strategies in adults with and without ADHD using event-related potentials. This gets into the neuroscience of it all—and it's been a while since I learned about event-related potentials!
Skye Waterson: What they essentially found were significant group differences between people who had ADHD and people who didn't. The frontal amplitudes of the late positive potential (measured via brainwaves) were higher in unmedicated ADHD adults compared to the control group.
This relates to a conversation later in the paper where they noted a question mark around whether medication affects emotional dysregulation in ADHD.
William Curb: What they saw was that medication improved emotional dysregulation symptoms across the board, but they didn't always have data across all studies on whether participants were medicated during the assessments.
Skye Waterson: Yeah. They had a few papers where they could observe these brain systems in unmedicated individuals compared to a control group. But again, we're talking about three or four studies here. Even though this has the trappings of a meta-analysis, it is very much a narrative discussion about a small group of papers rather than an overall consensus, because there are so many gaps. This episode is really about how much we don't know about emotional dysregulation at this point.
William Curb: Yeah, that was one of the interesting things: the title of the paper versus the actual discussion within it.
Skye Waterson: The title says, "Evidence of Emotional Dysregulation as a Core Symptom of Adult ADHD," which sounds almost like clickbait. Then in the discussion, they acknowledge there is a lot we still need to know.
William Curb: They are completely transparent that there just wasn't enough data to support definitive conclusions yet. Out of 22 studies, they couldn't even perform a meta-analysis.
Skye Waterson: Exactly. Moving on to emotional regulation outcomes in ADHD and treatment, there were just four studies. They looked at mindfulness and found some benefits for ADHD. We may have even talked about these studies before.
William Curb: Yeah, that makes sense. Mindfulness has generally been shown to help control impulsivity, which is a major component of emotional regulation.
Skye Waterson: Definitely. The discussion was probably the best part of the whole paper because they brought everything together. They wanted to unify all available data related to emotional dysregulation, and looking across their hypotheses:
Comparison: When comparing adults with and without ADHD, the ADHD group consistently scores lower on emotional regulation.
Strategies: People with ADHD are more likely to use non-adaptive strategies—blaming themselves, catastrophizing, blaming others, ruminating (feels like reading my diary here!), and emotional suppression rather than cognitive reappraisal.
Brain Activity: They looked at differences in brain activity and found that when participants were able to layer on reappraisal strategies to reevaluate what was happening, clear differences in brain activation emerged.
William Curb: Right. The emotional dysregulation piece changes—you see significant differences in cortical activation when you aren't engaging in rumination and instead have positive strategies in place. That's true whether you have ADHD or not, but especially true if you have ADHD and have built up unhelpful strategies over time.
When you relearn how to engage with your emotions instead of just suppressing them—
Skye Waterson: —like reevaluating how you're feeling and why you're feeling it—it makes a big difference in living with your emotions in healthy ways. Riding the wave, as they say.
I think that's a helpful note to end on. We went hunting for RSD research and found this paper saying, "Look, a lot more research needs to be done here." Even though it feels true in lived experience, the literature is still catching up. But what we do have indicates that this link is real, and that there are strategies we can use to reduce emotional dysregulation—and potentially RSD as well.
William Curb: Yeah. It's worth noting that these strategies often imply RSD is something reinforced by how we learned to handle our emotions through countless past corrections—not on purpose or to blame the victim, but as a learned coping mechanism. That might be a core piece of what RSD is, and why some people suffer from it less if they didn't develop those same unhelpful strategies.