Attentional, emotional ADHD classifications provide ‘more clinically relevant’ diagnosis approach among adults

Frederick W. Reimherr

ADHD in adults presents as an attentional type and an emotional type, according to results of a replication analysis published in Journal of Clinical Psychiatry. Researchers posited that this system provides a more clinically relevant approach to ADHD diagnosis among adults than does the DSM system.

“The emotional symptoms in [patients with ADHD] often lead to confusion with depressive, anxiety and bipolar disorders,” Frederick W. Reimherr, MD, adjunct professor emeritus in the department of psychiatry at University of Utah School of Medicine, told Healio Psychiatry. “Consequently, many cases of ADHD in adults are not being accurately assessed. The lack of criteria for this diagnosis reflecting emotionality has contributed to this problem. Given the many reports of adults with ADHD experiencing comorbid depression, anxiety or bipolar disorder, this system will help lead to more appropriate treatment of patients with and without comorbid disorders.”

Prior research supported the significance of emotional symptoms among adults with ADHD; however, these symptoms are not reflected in DSM-5 or ICD-10 criteria. In a 2015 study, Reimherr and colleagues used the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) to assess emotional symptoms, as well as inattention, hyperactivity and impulsivity. With the scale, the investigators divided adult ADHD into ADHD inattentive presentation and ADHD emotional dysregulation presentation.

In the current study, the researchers refined these previous observations using a larger, more diverse sample of 1,490 participants who were assessed with the WRAADDS, an alternative ADHD measure and the Clinical Global Impressions-Severity of Illness Scale (CGI-S) in eight double-blind adult ADHD clinical trials. They conducted confirmatory analyses of the data and compared ADHD presentations, including treatment response. They defined ADHD inattentive presentation as having high levels of problems with attentional difficulties and disorganization, as well as lower levels of emotional symptoms — a presentation that resembles the analogous DSM category but is based on diagnostic criteria more appropriate for adults, Reimherr noted. Further, they defined ADHD emotional dysregulation presentation as having high levels of emotional dysregulation combined with inattentive symptoms, with these emotional symptoms defined by temper control problem, affective lability and emotional overreactivity.

Results showed the original factor structure did not fit well with the new data; however, the researchers’ alternative two-factor solution fit both the original and new subject samples. They reported ADHD inattentive presentation among 774 participants and ADHD emotional dysregulation presentation among 620 participants. Across the eight studies, the proportion of ADHD emotional dysregulation presentation ranged from 25% to 73%. Moreover, the researchers reported associations between this presentation and a greater severity as measured by the CGI-S (P < .001) and more manifestations of childhood ADHD as measured by Wender Utah Rating Scale (P < .001).

“Our data also demonstrate that among patients with ADHD, the symptoms comprising emotional dysregulation show significant response to both methylphenidate and atomoxetine without the need to resort to additional pharmacologic interventions,” Reimherr told Healio Psychiatry. “The improvement in these emotional dysregulation symptoms with medications shown to be effective in treating ADHD supports the inclusion of these symptoms in the diagnostic criteria.”

Further, the researchers noted that the inclusion of emotional dysregulation symptoms in the diagnosis of ADHD "cannot be over-estimated."

"We have demonstrated that they can be incorporated into clinical assessment in a manner that is neither complex nor burdensome," Reimherr said. "The fact that our earlier results were fully replicated in this larger, more heterogeneous sample gives us confidence that it can be applied to the full spectrum of adults with ADHD." – by Joe Gramigna

Disclosures: The authors report no relevant financial disclosures.