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April 19, 2014
by LuAnn Pierce, LCSW

Adult ADHD: Emotional Regulation and Dual Diagnosis

April 19, 2014 02:55 by LuAnn Pierce, LCSW

The problem of emotional regulation in Adult ADHD has received much less attention than others, yet plagues at least half of those who are diagnosed. In fact, many with ADHD are misdiagnosed with other disorders, like BiPolar Disorder or Borderline Personality Disorder because of these mood changes. Although ADHD is 10 times more prevalent than BiPolar Disorder, about 20% of people with ADHD also have a mood disorder on the BiPolar Spectrum.

Adults with ADHD often have a dual diagnosis of ADHD and one of these or other disorders. As many as 50% of adults with ADHD report also having depression, and the same number report problems with anxiety. In those cases, once the ADHD is treated effectively, depression and anxiety often decrease as the symptoms are often related to the ADHD, ie. feeling like a failure or not living up to potential. Treating coexisting disorders successfully is difficult and requires a proper diagnosis.

A careful assessment of a person’s signs and symptoms over time is the key to proper diagnosis and treatment. It is critical that people who have symptoms with emotional regulation work with a well-trained clinician who understands the subtle differences in these overlapping conditions. Emotional regulation is present in all of these disorders, but the age of onset,  frequency of mood changes, duration, triggers and other critical details determine which diagnosis (or combination) should be treated.

The most important difference between these disorders is that people with ADHD have executive functioning deficits dating back to childhood. A thorough medical and educational history is necessary to make a proper diagnosis. It is helpful to have parents, siblings or others report on their observations, as people with ADHD tend to forget or normalize their behavior.

Recent Research about ADHD and Deficient Emotional Self Regulation (DESR)

A study conducted at Mass General in 2011 found that at least half of the adults with ADHD in their study also demonstrated DESR (Deficient Emotional Self Regulation). The researchers describe DESR as ‘excessive emotional reactions to everyday occurrences’.

For the purposes of the study, they described those who are deficient in emotional self regulation as having “emotional expressions that are brief and occur in reaction to situations that would be expected to produce similar but much less extreme responses in most individuals”.  They identified the participants in the study as having DESR if “their control of emotional reactions was worse than that of 95 percent of a large group of individuals without ADHD”.

The results of the study suggest that DESR runs in families. About half of the study participants who had ADHD also had DESR. They studied the siblings of those with ADHD and found a high incidence of ADHD among siblings. However co-occurrence of both ADHD and DESR was found almost exclusively among siblings of the original participants who reported both conditions. Their researchers suggest that about 5 million adults in the U.S. may have the combination of ADHD and deficient emotional self regulation.

Sorting Out the Differences Between ADHD and Other Disorders

People with Adult ADHD may experience mood changes frequently throughout the day, often due to low frustration tolerance. Living with ADHD can be very stressful – little things seem to send you into orbit, but the change in mood seems to end as quickly as it begins – or within hours unless there are on-going stressors. People with BiPolar DO have mood fluctuations that last for four days or longer. The mood changes may be weeks or months apart, with normal mood between highs and lows. There is no trigger with BiPolar mood changes. People with Borderline PD are often triggered by interpersonal relationships. Any slight or perceived rejection triggers an abrupt shift in mood. People with Borderline PD have frequent mood changes, usually related to fear of abandonment or rejection.

Age of onset: ADHD is a condition that is present since childhood. In most cases (not all) of BiPolar DO, the first episode is after the age of 18 with the average age of onset at 26. Borderline PD is not usually diagnosed until one an adult, though some teens may have a diagnosis of ‘Borderline PD traits’. In Borderline PD cases, especially before adulthood, there is usually a history of self injury or suicide attempts.

Presence of Symptoms: ADHD does not go away – not even for a day. If you have Adult ADHD, you have symptoms every day, unlike BiPolar DO that is episodic. Borderline PD is also present at all times, but the intensity is usually dependent upon interpersonal relations. Theoretically, for a person with Borderline PD, as long as their relationships are going smoothly and they do not perceive any rejection or fear of abandonment, they may be asymptomatic. With ADHD, there is generally a day-in and day-out level of frustration and impatience that lead to brief mood fluctuations.

Executive Functioning: People with ADHD generally have problems that are not seen consistently with BiPolar DO or Borderline PD. These include concentration, memory, staying on task, organization, planning, prioritizing, waiting your turn, restlessness and others. Some of these may be present during BiPolar mania episodes, or anxious/depressed times for those with Borderline PD. However, an adult with ADHD will have symptoms daily since childhood or adolescence on a regular basis.

Getting the right diagnosis is critical to proper treatment. Treating a mood disorder without treating underlying ADHD will be ineffective. Treating ADHD with stimulant medications can trigger mania or hypomania in those with coexisting BiPolar DO. Find a clinician or medical provider that specialized in Adult ADHD for best results.


"Combination of ADHD and Poor Emotional Control Runs in Families." Massachusetts General Hospital. Web. 29 Oct. 2013.

Dodson, William, MD. "Is It Bipolar Disorder or ADHD?" ADDitude Magazine. Web. 11 Nov. 2013.

Kreger, Randi. "Three Easy Ways to Differentiate Bipolar and Borderline Personality Disorder." Psychology Today. Web. 11 Nov. 2013.

Shapiro, Scott. "The Difference Between Bipolar Disorder, Borderline Personality Disorder and Adult ADHD." Web. 11 Nov. 2013.


About the Author

LuAnn Pierce, LCSW LuAnn Pierce, LCSW

I offer solution-focused counseling to people in Colorado and Wyoming from the comfort of your own home via teleconference or telephone.

LuAnn Pierce, LCSW can be found at
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