In comparison to the DSM formulation of ADHD, we have proposed that ADHD in adults should be divided into Inattentive and Emotional Dysregulation Presentations. Under both systems, there is potential overlap with generalized anxiety disorder (GAD). We compared data from four distinct populations: ADHD clinical trials, GAD clinical trials, an ADHD clinic, and a forensic clinic. Approximately 25% of patients in each population had comorbid ADHD and anxiety. Comorbid subjects reported more childhood ADHD symptoms and higher scores on ADHD scales and were more likely to fit criteria for ADHD Emotional Dysregulation Presentation or DSM-IV combined type. Comorbid subjects did not drop out at a higher rate and showed significant drug-placebo differences on ADHD symptoms, including Emotional Dysregulation. Conversely, although symptoms of anxiety decreased, there was no drug-placebo difference in improvement.

To test an expected relationship between life-events (LE) stress (Social Readjustment-Rating Scale) and severity of psychopathology among 1st-admission functional-disorder psychiatric inpatients, the present study considered LE in multivariate combination with other factors relevant to the severity of mental disorder. Intensive, reliable, structured interviews with 217 15–54 yr old patients yielded LE variables reflecting stress levels and changes in stress levels for various time periods during the preadmission year, 9 indices of pathology severity, and measures of demographic, prognostic, and social supports control factors. Bivariate correlations and a replicated multiple regression data analysis procedure were employed. Small, positive significant relationships were found between LE variables and types of symptomatology. Stress levels were related to severity of neurotic and suicidal symptoms, and increases in stress just prior to admission were related to severity of schizophrenia and psychotic symptoms. Stress variables were not related to overall impairment or severity of diagnostic classification. (48 ref)

Much recent research describes the importance of emotional symptoms in ADHD. While there is no accepted system for including emotionality in diagnosing ADHD, the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) provides a tool to facilitate this. It assesses a range of adult ADHD symptoms which load on two factors: inattentive and emotional dysregulation. The consistently high inattentive factor was used to define significant elevation on the more variable emotional dysregulation factor (which contains four WRAADDS domains: hyperactivity/restlessness, temper, affective lability, and emotional over-reactivity) allowing the definition of two ADHD diagnostic types. We compared these two types on a broad range of adult subject characteristics, including response to methylphenidate (MPH) treatment assessed during two clinical trials. Marked impairment in three of the four emotional domains reflected a symptom severity level equivalent to that of the inattentive factor. 59 % met this threshold, defining them as ADHD emotion dysregulation presentation, as opposed to 41 % with ADHD inattentive presentation. Cluster analysis validated these groups by generating similar clusters with 85 % agreement regarding membership. ADHD emotional dysregulation presentation subjects showed more childhood ADHD symptoms, adult symptoms of oppositional defiant disorder, and evidence of personality disorder. Both types showed similar improvement during the double-blind MPH arm of the trials and during a 6-month open-label phase. Based on the presence of symptoms of emotional dysregulation, ADHD in adults can be conceptualized as two types. Impairment and comorbidity in adults with ADHD are largely concentrated in ADHD emotional dysregulation presentation patients.

Objective: Research supports the importance of emotional symptoms in adults with attention-deficit/hyperactivity disorder (ADHD), which are not reflected in the DSM-5 or ICD-10 criteria. The Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) assesses these symptoms, plus inattention, hyperactivity, and impulsivity. This scale allowed us to divide adult ADHD into 2 subtypes in a 2015 publication: ADHD inattentive presentation and ADHD emotional dysregulation presentation. The present study refines this observation using a larger, more diverse sample. Methods:Eight double-blind adult ADHD clinical trials (encompassing 1,490 subjects) were selected because they included assessment with the WRAADDS; a second, alternative ADHD measure; and the Clinical Global Impressions-Severity of Illness scale (CGI-S). These data were subjected to confirmatory factor analyses, and ADHD presentations were compared, including treatment response. Results:The original factor structure fit poorly with these new data. However, an alternative 2-factor solution fit both the original and the new subjects. ADHD inattentive presentation (n = 774) was defined by the inattention factor, and ADHD emotional dysregulation presentation (n = 620) was defined by additional elevation of the emotional dysregulation factor. The proportion of ADHD emotional dysregulation presentation ranged from 25% to 73% across the 8 studies. The emotional dysregulation presentation was associated with both a greater severity as measured by the CGI-S (P < .001) and more manifestations of childhood ADHD as measured by the Wender Utah Rating Scale (P < .001). Conclusions:Factor analytic results supported the validity of 2 adult ADHD presentations based on levels of emotional dysregulation. This system offers a more clinically relevant approach to the diagnosis of ADHD in adults than does the DSM system. J Clin Psychiatry 2020;81(2):19m13077 To cite: Reimherr FW, Roesler M, Marchant BK, et al. Types of adult attention-deficit/hyperactivity disorder: a replication analysis. J Clin Psychiatry. 2020;81(2):19m13077. To share: https://doi.org/10.4088/JCP.19m13077

This sub-study of the WHO Determinants of Outcome of Severe Mental Disorders research project was aimed at characterizing the behavioral and expressive qualities of schizophrenia in two highly diverse cultures. Early research has indicated that the core elements involving affect, perceptual and cognitive dysfunction in schizophrenia are highly similar in form in most cultures of the world. Much of the cross-cultural literature emphasizes, however, strong differences in the ways in which schizophrenia is actually expressed and manifested in different settings. The basic methodology for psychiatric description and diagnosis in the WHO program was the Present State Examination. In five of the field centers a method for investigating the expressive quality and the social behavior of patients in their own communities through the eyes of significant others was applied. This method was then subjected to psychometric tests of cross-cultural applicability and found to be valid for comparing behavior across settings. The expressive patterns of the Indian and Nigerian patients were studied from two perspectives. Indian schizophrenics were described by family members as manifesting a more affective and "self-centered" orientation; the Nigerian patients presented with a highly suspicious, bizarre, anxious quality to the basic behavioral pattern. The main features of pathology were in general accord with the descriptions of indigenous psychiatrists. The special qualities of the psychosis in the two cultures were interpreted against the background of traditional psychopathological and anthropologic theories concerning the psychodynamics and the influence of differing social conflictual themes in the two cultures. Analysis of psychopathology in this manner was found to enhance understanding of underlying mechanisms and the role of cultural conflicts in its expression.

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We studied 40 young adults with attention-deficit/hyperactivity disorder (ADHD; 18 predominantly inattentive type, 22 combined type) and 38 demographically comparable controls in a go/no-go choice reaction time task with 2 levels of difficulty. The ADHD/combined group was less accurate and had more variable reactions than controls. The ADHD/inattentive sample was slower than controls and had smaller early lateralized readiness potentials (LRPs). Compared with controls, both subtypes had (a) smaller early LRPs for no-go stimuli and (b) relatively earlier LRP onsets for difficult no-go events. The ADHD/combined sample also had smaller late LRP waves than controls. The results suggest that adults with ADHD, particularly those with the combined subtype, exhibit weaker central preparation to respond to both stimuli requiring a motor response and those prompting response inhibition.

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