Emotional Dysregulation as a Clinically Relevant Dimension of Adult ADHD: A Multidimensional Clinical Study

Abstract

Background Emotional dysregulation (ED) is increasingly recognized as a clinically relevant dimension of adult attention-deficit/hyperactivity disorder (ADHD), yet its multidimensional structure and independent contribution beyond impulsivity and psychiatric comorbidity remain incompletely understood. This study aimed to characterize the profile of ED and its clinical correlates in a large, well-characterized clinical sample of adults with ADHD. Methods In this cross-sectional observational study, 231 adults with a DSM-5 diagnosis of ADHD, confirmed through structured interview (DIVA 5), completed the Difficulties in Emotion Regulation Scale (DERS). Associations between ED and ADHD presentation, psychiatric comorbidity, current substance use disorder (SUD), impulsivity (BIS-11), problematic internet use (IAT), camouflaging behaviors (CAT-Q), and clinical functioning were examined using independent-samples t -tests, Pearson correlation analyses, and multiple linear regression models. Results Participants showed elevated emotional dysregulation relative to reference data. When DERS subscales were interpreted against Italian reference values, the largest elevation was observed for Clarity, followed by Goals, Nonacceptance, and Impulse, whereas Strategies showed a more modest elevation and Awareness was only slightly higher than the reference value. The combined ADHD presentation was associated with significantly greater dysregulation compared to the predominantly inattentive presentation. Higher DERS total scores were observed among participants with combined ADHD presentation, psychiatric comorbidity, and current SUD. DERS total score was positively correlated with current ADHD symptoms, retrospective childhood ADHD symptoms, depressive symptoms, state and trait anxiety, impulsivity, problematic internet use, and camouflaging behaviors, and negatively correlated with ADHD-related quality of life. In multiple regression models, current SUD, current ADHD symptoms, retrospective childhood ADHD symptoms, trait anxiety, and ADHD-related quality of life were independently associated with DERS total score. Conclusions Emotional dysregulation in adult ADHD represents a clinically relevant affective dimension that is only partially accounted for by impulsivity and is closely associated with psychosocial impairment and maladaptive coping behaviors. These findings support an integrated affective-executive framework for the assessment and treatment of adult ADHD, with implications for targeted, skills-based interventions addressing emotional regulation across clinical subgroups.