Exclusion of Emotional Dysregulation from DSM-5 ADHD Description: A New Perspective

The days of the Diagnostical and Statistical Manual of Mental Disorders (DSM-5) are probably numbered.

For one, the rest of the world already defines the criteria for conditions using the International Classification of Diseases (ICD-10-CM), which became the official health classification of the U.S. government in 2014. But, more significantly, the DSM simply does not describe ADHD as the rest of us experience it.

The DSM was written solely by and for the use of researchers, not for consumers or for practicing clinicians, and it describes only childhood behaviors. Everything else has been intentionally ignored since the very beginning of ADHD, for the sake of publishing research validating ADHD as a real thing with extremely significant impairments in children ages 6 to 12.

Our diagnostic definition is incomplete and grossly inadequate by virtue of ignoring emotional dysregulation, cognition, gender, hormones, ADHD in old age, ADHD at menopause, and the effects of ADHD on a developing personality.

Here are the dimensions missing from the DSM‘s criteria for ADHD:

Emotions: The most impairing feature of ADHD at all ages, emotional dysregulation, was not mentioned in the DSM as a fundamental component because emotions are hard to research. Why?

Age: The ADHD criteria have never been validated in a study of participants over the age of 16. All the research on adults has been done using twisted versions of the childhood criteria. For an adult to meet the child-based criteria, they would have to be functioning on the level of an elementary school-age child with untreated ADHD. Though it was officially acknowledged in 1980 that ADHD usually persists into adult life, work has only just begun on writing official adult ADHD criteria 43 years later.

Development: ADHD remains the same throughout life. We are the ones who change as the challenges of life grow, shift, and demand more of us. We are very different at age 28 from what we were at eight or 18. This makes ADHD look as if it is changing when it’s not. The sources of the impairments from ADHD are the same, the medications and doses of medications used for ADHD are the same, and the problems with controlling emotional expression remain the same.

Gender: Simply put, it was once thought that females did not get ADHD because they are not as hyperaroused and disruptive as are males. This is still a significant problem. No existing research studies involve only females in adulthood.

Emotional dysregulation: The problems of controlling emotions are more disruptive and painful than are all the other core features of ADHD (inattention, impulsivity, and hyperactivity/hyperarousal) combined. The subject of emotional regulation in ADHD has begun to appear in research literature only within the last few years and, even now, mostly in European journals.

ADHD was once a vague, controversial idea. Today, no rational person doubts that ADHD exists and that, if left untreated, it can have devastating consequences through adulthood. The time has come to see the full picture of ADHD. It is more than a disorder of behavior; it impairs emotions and affects the lives of millions of people.

While we are at it, we should give the same attention, thinking, and research to additional components of ADHD that impair people every day: the sleep disturbances caused by the hyperarousal of ADHD, rejection sensitivity, and the effects of an ADHD nervous system on the development of personality.

William Dodson, M.D., is a psychiatrist and consultant on adult ADHD medicine.

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