Questions about Adult ADHD Patients: Dimensional Diagnosis, Emotion Dysregulation, Competences and Empathy

Objective: To analyze certain diagnostic personality components of Attention Deficit and Hyperactivity Disorder (ADHD) patients and explore their consequences in competences, as well as to explain possible relationships to empathy. Given that emotion regulation is altered in ADHD, we seek to distinguish these disturbances from certain personality disorders. Method: We have conducted a short review of dimensional personality components and emotion dysregulation. The results of our study with several personality dimensions in adult outpatients comprise the background. Furthermore, we examine certain competences and comment in empathy in these patients. Conclusions: Adult deficit attention and hyperactivity patients exhibit high neuroticism and low motivation. This may imply the need to evaluate certain competences in forensic settings. This population reveals specific components of emotion dysregulation. Additionally, they display lower empathy in their mentalization subtype.


Introduction
Adult Attention Deficit and Hyperactivity Disorder (ADHD) patients share certain symptoms with child and adolescent ADHD [1]. Increasing attention is being paid to ADHD and emotion dysregulation in the literature [2][3][4][5][6], although it has not been reflected in DSM-V diagnostic criteria.
Dimensional components of personality provide greater insight as to what these patients are actually like. One of these personality dimensions is conscientiousness, which several studies have shown to be diminished [2,[7][8]. This can be interpreted as low energy or motivation in planning or decision-making.
This paper seeks to analyze certain diagnostic personality dimensions of ADHD patients and explore how they manifest in competences. The author's opinion about their possible relationship to empathy is also explained. The results of our study of several personality dimensions and their emotional disregulation in adult ADHD patients comprise the background for this paper [2].

Competence
Competence is the condition or quality of effectiveness, ability, sufficiency, or success (Webster´s Revised Unabridged Dictionary and Oxford English Dictionary) and can be assessed in several ways: Task execution, interpersonal change over time, or by comparing interpersonal with a normative standard [22].
Competence is relevant at a wide range of levels: from concrete actions, to specific outcomes (e.g., test results), to patterns of skill and ability (e.g., playing football), to higher-order characteristics (e.g., making a will), and other life activities.
Competence can be thought of as the fundamental motivation that serves to help people develop and adapt to their environment. People learn to use tools to achieve competence aimed at specific experiences and outcomes [23]. Some authors propose achievement as competence and achievement motivation as competence motivation [22]. This is ubiquitous in daily life, has an impact on emotion and well-being, is operative across a person's lifespan, and is present in all individuals across cultural boundaries [22].
ADHD patients have less need for motivation and achievement, but do they have less competence in general? In my opinion, they are experts in specific hobbies and sports, but not in several life characteristics, such as study, job, social, and organization in their lives. We must ask ourselves about their competence/motivation and if they would be able to take care of their children or enter into a contract. Forensic evaluations may be necessary in some cases to examine their competence and motivation. There will be greater concern if they have some kind of comorbid PD, such as BPD, and they may need help in the area of competences.

Emotional disturbances
Gratz and Tull proposed an integrative model of emotion dysregulation [24]. According to this model [24,25], emotion regulation is conceptualized as a multidimensional construct involving: (a) Awareness and understanding of emotions; (b) Acceptance of emotions; (c) Ability to control impulsive behaviors and behave in accordance with desired goals when experiencing negative emotion, and (d) Flexible use of emotion regulation strategies to modulate emotional responses in a given context or situation in order to meet individual goals and situational demands. The relative absence of any or all of these abilities is considered indicative of the presence of difficulties in emotion regulation; i.e., emotion dysregulation.
Emotion dysregulation has been observed in several ADHD patients [26][27][28]. In our study, we have seen how regulation strategies and control of impulsive behaviors and desired goals fail in adult ADHD patients experiencing negative emotions [2].
BPD patients have affective instability, owing to marked reactivity of mood, inappropriate anger, or difficulty controlling anger.
Deficits in emotional clarity (e.g., awareness of emotional experience) and psychopathological symptoms are differentially mediated by various emotion regulation strategies (e.g., attention deployment, impulse control, and acceptance). Emotional awareness entails recognizing one´s emotions and is indispensable for emotion regulation. BPD patients exhibit less emotional awareness than normal, whereas ADHD patient's awareness of emotional experience is similar to control patients (euthymic depressive and anxiety disordered controls) [2].
Trans diagnostic emotion disturbances can be: Core affect, emotional awareness, emotion regulation, and emotional disconnections. These constructs were developed on foundations laid by research in basic affective science and psychopathology [29].
Core affect reflects neurophysiological states indicating a person's relationship to his or her environment at any given time [30]. It is experienced as feelings of pleasure or displeasure and, to a lesser extent, arousal or activation. Disturbances in core affect may reflect an emotion-related trans diagnostic process in psychopathology [30].
Unpleasant affect is common across several disorders: depression, anxiety, eating disorders, substance-related disorders, and some PD. ADHD patients associate high neuroticism, which can be manifested as some component of negative affect. Moreover, they often suffer depressive and anxiety disorders. As in BPD, emotion regulation is under-regulated in ADHD, albeit with certain differences: BPD patients present greater emotional sensitivity and are slower return to emotional baseline [31].
Emotion disconnection reflects a disconnect between the expressive component and other components of emotion. It is observed in schizophrenia [32] or psychopathic patients [33]. Alterations in emotion disconnection also reflect a lack of awareness of one's own emotional responses. ADHD patients do not exhibit disconnection per se, but rather variability in emotional responses.
In conclusion, emotion dysregulation is present in ADHD, particularly in the presence of impulsivity to achieve goals and the use of strategies to modulate emotion. ADHD patients do not differ with respect to awareness, clarity, and non-acceptance versus control patients. Core affect may associate neuroticism. It can be difficult to demonstrate emotional disconnection; i.e., expressing affect differently from how they actually feel it. Patients often express themselves without thinking, making comments that are not very pleasant, although they do so without hurtful intent.

Empathy and ADHD
Empathy is the ability and tendency to share and understand others' internal states [34].
The components of empathy are:

Acta Psychopathologica ISSN 2469-6676
Sharing experience or the tendency to take on the states (facial movements, bodily postures, sensory-motor, affects, moods) [35] observed in others. It takes place outside awareness.

Mentalizing:
The perceiver's explicit reasoning about internal states using theories about how situations produce internal state [36]. It infers emotions, intentions, and beliefs.
Prosocial motivation: Like sharing and mentalizing, prosocial motivation is the perceiver's desire to help others is another component of empathy [37,38].
Some cases of empathic failure, such as in clinical populations, do not necessarily signal the inability to empathize, but rather decreased motivation to comply with social norms or personal values that encourage empathy [38].
In ADHD patients, we see that mentalizing is challenging for them, but that their prosocial motivation may be higher. They might require additional learning about their capacity to socialize.

Conclusion
Adult ADHD patients display the same components of emotion dysregulation as controls in clarity, awareness, and nonacceptance, but exhibit a greater emotional deficit of strategies, goals, and impulses. Moreover, their profile of empathy components can vary: less mentalizing, but more prosocial motivational [37].
High neuroticism, a tendency toward negative valence, and low conscientiousness, a tendency toward low motivation, can produce some doubts as to their competences in several aspects of daily life like custody or entering into contracts. Greater impairment in these areas is seen in the presence of comorbidity with certain PD.