Titration, mood and women’s reality
A lot of women arrive at an ADHD medication conversation having already spent years somewhere else. Anxiety, depression, sometimes a bipolar or personality disorder label that never quite fitted but stuck for a decade anyway. Asherson and colleagues (2014) set out why this keeps happening. The emotional lability, impulsivity and mood instability of adult ADHD overlap heavily with both bipolar disorder and borderline personality disorder. And adult mental health services have historically been slower than child services to recognise how ADHD presents.
For women the picture is sharper still. Over thirty years ago, Berry, Shaywitz and Shaywitz described girls with ADHD as a “silent minority”. Their difficulties were more internalised, so they were under-identified. Kilic and Young (2021) note that even when women are referred for assessment, their ADHD is often missed or misdiagnosed as anxiety, depression or a personality disorder. The restlessness is still there. It simply turns inward, where it reads as anxiety. When Kitsune and colleagues (2016) compared adult women with ADHD and with bipolar disorder, the ADHD group showed higher current emotional lability and mania scores than the bipolar group. Telling the two apart reliably needed ADHD-specific interview measures that track how symptoms run over a lifetime.
Then, after years of waiting, often in deep distress, maybe in burnout, maybe arriving as the last hope for a life worth living, ADHD gets named, medication starts, and mood gets put down a second time.
Picture the second or third titration call. Someone tells their prescriber about emotional intensity. It’s the texture of what has always been there, maybe closer to the surface now, maybe easier to name, maybe stronger because of the medication. The prescriber asks how it relates to the dose. When she tries to describe what’s underneath it, she’s told that belongs in therapy. I’ve heard this from many of the women I work with, and I recognise it in my own experience too.
Which is odd, because mood is central to titration (right..?). Barkley (2010) argued that deficient emotional self-regulation is a core component of ADHD in its own right. Soler-Gutiérrez and colleagues (2023) went further in a systematic review, proposing emotion dysregulation as a possible fourth core symptom in adults. Estimates suggest emotion regulation difficulties affect roughly 34 to 70% of adults with ADHD (Hirsch et al., 2019). Clinically, mood is also one of the plainest signals of whether a dose is working. Irritability and a flattened affect are commonly described as signs that a stimulant dose has drifted off target, in opposite directions. So the thing being waved off the call is, by the field’s own logic, one of the most diagnostic pieces of information in the room.
That makes titration only ever semi-possible for a lot of women. The exact data a clinician needs to calibrate a dose gets routed to a different appointment, with a different professional, who can’t see the prescription at all.
The cycle nobody asks about
Hormonal cycling adds a layer almost no titration call accounts for. Zaritsky, Reed and Evans (2025) ran a small pilot study tracking women on stimulants through a full cycle. Their ADHD symptoms were most severe during menstruation and eased soon after. The women whose mood dropped most also reported the biggest rise in ADHD symptoms. Earlier clinical work points the same way. De Jong and colleagues (2023) described women whose ADHD and mood symptoms worsened in the premenstrual week, even though they had been on stable doses for months. When their prescribers raised the dose in that week, all nine women improved. A mood shift in week four of someone’s cycle can look identical to a mood shift caused by the dose. Without asking, a clinician can’t tell the two apart, so the mood data goes missing at exactly the point it would be most useful.
A system built to hold the dose
None of this happens because any one psychiatrist doesn’t care (or at least I genuinely hope we all do care, caring professionals, huh?). A lot of adult ADHD assessment and titration in the UK now runs through Right to Choose pathways. Providers manage enormous caseloads, often with locum psychiatrists working remotely. Several ICBs have now set activity plans that limit how many assessments providers can deliver, which pushes waits out and puts pressure on everyone still seeing patients to move faster. A fifteen-, twenty- or even thirty-minute call inside a system like that was never going to hold hormonal cycling, internalised presentation and a decade of prior misdiagnosis all at once. It holds the dose. Everything else gets triaged out, because there’s nowhere in the structure for it to go.
When restlessness turns to skin
The restlessness that was never named as hyperactivity has to go somewhere too. For many women it becomes a body-focused repetitive behaviour, such as skin picking or hair pulling. These behaviours are commonly understood as a form of self-regulation: tension finding an outlet through the body. It’s the same restlessness a clinician might expect to see as fidgeting with a pen, aimed at a person’s own skin instead.
Medication doesn’t resolve this cleanly either. A literature review presented at the British Association of Dermatologists (Malik et al., 2026) found that skin picking often improved on ADHD medication, especially where it was automatic or inattentive, as inhibitory control strengthened. A minority developed new or worse picking after starting treatment or raising the dose, particularly alongside anxiety, OCD or tics. In a follow-up study of adolescents with ADHD and skin-picking disorder, Yazıcı and colleagues (2026) found that improvements in emotion regulation on methylphenidate tracked reductions in picking. A dose that eases picking for one person may intensify it for someone else, and there’s no way to know which without someone actually asking. It’s the same shape as the hormonal cycle problem. The one thing that could tell a clinician whether a dose is right never comes up on the call.
Mood as data
All of this argues for a more structured titration process, one that treats mood as a primary data point for calibrating the dose. Many women spent years having that same emotional intensity misread as something else entirely. Tracking it properly, including where it falls in their cycle, might be the single most clinically useful thing a fifteen-minute call could do. Redirecting it removes the one signal that could tell a prescriber whether the dose in front of them is actually working.
References
Asherson, P., Young, A. H., Eich-Höchli, D., Moran, P., Porsdal, V., & Deberdt, W. (2014). Differential diagnosis, comorbidity, and treatment of attention-deficit/hyperactivity disorder in relation to bipolar disorder or borderline personality disorder in adults. Current Medical Research and Opinion, 30(8), 1657–1672.
Barkley, R. A. (2010). Deficient emotional self-regulation: A core component of attention-deficit/hyperactivity disorder. Journal of ADHD and Related Disorders, 1(2), 5–37.
de Jong, M., Wynchank, D. S. M. R., van Andel, E., Beekman, A. T. F., & Kooij, J. J. S. (2023). Female-specific pharmacotherapy in ADHD: Premenstrual adjustment of psychostimulant dosage. Frontiers in Psychiatry, 14, 1306194. https://doi.org/10.3389/fpsyt.2023.1306194
Hirsch, O., Chavanon, M. L., & Christiansen, H. (2019). Emotional dysregulation subgroups in patients with adult attention-deficit/hyperactivity disorder (ADHD): A cluster analytic approach. Scientific Reports, 9, 5639. https://doi.org/10.1038/s41598-019-42018-y
Kilic, O., & Young, S. (2021). Presentation and outcomes of attention deficit and hyperactivity disorder in females and males [Conference abstract]. European Psychiatry, 64(S1), S72. https://doi.org/10.1192/j.eurpsy.2021.224
Kitsune, G. L., Kuntsi, J., Costello, H., Frangou, S., Hosang, G. M., McLoughlin, G., & Asherson, P. (2016). Delineating ADHD and bipolar disorder: A comparison of clinical profiles in adult women. Journal of Affective Disorders, 192, 125–133. https://doi.org/10.1016/j.jad.2015.12.024
Malik, N., Motedayen Aval, L., Nikookam, Y., Searle, T., Ahmed, A., & Assalman, I. (2026). PS51 Attention deficit/hyperactivity disorder treatment and skin picking: Help or harm? [Conference abstract]. British Journal of Dermatology. https://doi.org/10.1093/bjd/ljag086.666
Soler-Gutiérrez, A.-M., Pérez-González, J.-C., & Mayas, J. (2023). Evidence of emotion dysregulation as a core symptom of adult ADHD: A systematic review. PLOS ONE, 18(1), e0280131. https://doi.org/10.1371/journal.pone.0280131
Yazıcı, M., Kıvrak, M., Tekeoğlu, U., & Hocaoğlu, Ç. (2026). Associations with methylphenidate treatment in emotion regulation and skin-picking severity in adolescents with attention-deficit/hyperactivity disorder: A clinical follow-up study. Journal of Clinical Medicine, 15(6), 2401. https://doi.org/10.3390/jcm15062401
Zaritsky, R., Reed, S. C., & Evans, S. M. (2025). Changes in ADHD symptoms and mood across the menstrual cycle in females treated with stimulants: A pilot study. Journal of Attention Disorders. Advance online publication. https://doi.org/10.1177/10870547251400038
