Emotional Dysregulation and Executive Dysfunction in Patients With ADHD and Bipolar Disorder

A session on distinguishing between bipolar disorder and attention-deficit/hyperactivity disorder (ADHD) was presented by David W. Goodman, MD, FAPA, assistant professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, and director and founder, Adult Attention Deficit Disorder Center of Maryland, at the 2017 Neuroscience Education Institute Congress.

First, Goodman gave statistics on the prevalence of ADHD and bipolar disorder in both children and patients.

In the United States, the prevalence rate of ADHD in children is 8%, and the prevalence in adults is 4.4%. The rate of bipolar disorder in US children is 0.5% and in US adults is 2.5%. The comorbidity of ADHD and mood disorders in children from the Multimodal Treatment Study of Children with ADHD study is about 4%, but when looking at adults, the comorbidity is about 40%, and 19% have comorbid bipolar disorder, said Goodman.

Goodman then explained that many of the symptoms for the 2 disorders overlap in Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.

Symptoms of bipolar disorder include hypomanic/manic symptoms of increased talkativeness, racing thoughts, distractibility, psychomotor agitation, and increased risky behavior. For ADHD, the symptoms include talking too much in social situations, difficulty maintaining attention, and being fidgety and restless, and impulsivity.

“Executive function is a categorical, cognitive, higher-cortical thinking ability, and it encompasses several factors,” said Goodman.

The factors of executive function are:

• Response inhibition: impulse control
• Working memory: holding information while making decisions
• Set shifting: moving from task to task
• Interference control: resisting distractions

There is a symptomatic overlap of emotional dysregulation and executive dysfunction in ADHD and bipolar disorder, said Goodman.

“Where emotional dysregulation used to be part of the bipolar mood disorder arena, we now understand it to be part of ADHD as well,” said Goodman. “And the cognitive problems and the executive function, which were subsumed under ADHD, are now understood to be part of bipolar disorder, major depression, and a variety of other psychiatric disorders.”

In regard to emotional dysfunction, compared to controls, patients with bipolar disorder had a poorer performance on immediate verbal memory tasks, said Goodman. Both clinical groups exhibited significantly lower scores than controls on the recognition phase of verbal and non-verbal memory tasks, and tasks of executive functioning with high working memory demand.

Emotional dysregulation, when associated with ADHD, involves 2 primary deficits:

• An inhibitory deficit: socially inappropriate behavioral responses to strong emotion
• A self-regulatory deficit: an inability to self-soothe psychologic arousal that strong emotion induces, refocus attention, or organize the self for coordinated action toward an external goal

Emotional dysregulation in bipolar disorder has been extensively studied and is marked by:

• Emotional hyper-responsiveness
• Poor recognition and acceptance of emotions
• Difficulties in adapting behaviors to experienced emotions

During manic or mixed episodes, patients with bipolar disorder show a high degree of emotional hyper-responsiveness. During depressive phases, 2 types of patients are identified: emotional hypo-responsiveness patients and emotional hyper-responsiveness patients, who are more at risk of experiencing mixed episodes.

Emotional regulation causes several social impairments for patients, including a low threshold for emotional excitability/impatience, behavioral dyscontrol in the face of strong emotions, and an inflexibility/slow return to baseline.