The Invisible Struggle: The Truth About Women's ADHD (Explained by a psychiatrist) | Dr Shyamal Mashru

25:07Dodson found was that in up to a third of patients it was by far their most crippling symptom. I think that's, in my own experience, I think it's higher. More common in women than in men, but I've seen it in tons of men as well. So the reason why it's been hard to research this is because it's actually very hard for patients to describe and it's hard to quantify. And when something's hard to quantify, it's very hard to do research on it.

25:37The closest that I have got to describing this from patients is for some patient it feels like a physical pain, like chest pain or they feel tight in their chest or quite physical. It comes on all of a sudden and there's normally an obvious trigger. Those are the qualities of it and it can last for varying amounts of time actually. For some people it can go on for a long time actually.

26:09when i bring this up in an assessment with someone because it's obvious when i when people are giving me examples of it they don't know what it is they break down this happens so many times people just break down into tears because they finally feel seen right and there's a lot of shame that comes with RSD where you try and hide this feeling from everyone. You hide it. And when it's finally seen, it's like that's what this is. And just knowing in itself that's what this is, is a massive part of the therapy afterwards. Because if you know now what this is, you start to start picking up the warning signs.

26:57or the triggers. And then you can prepare yourself a bit more mentally because you know this is what this is. And eventually, it doesn't feel great, I don't like it, but it will pass.

27:09Dr Shyamal Mashru:And then you start rationalizing things a bit better. Maybe that full stop is actually all right. It doesn't have to be the enthusiastic exclamation mark all the time. Is your boss asking you for a quick chat on a Monday morning? So triggers, triggers. I mean the worst one that's the worst one I mean that's that's a a clear one you know or showing someone your favourite film and they get up to use the bathroom and say don't worry about pausing the film or you could find out there's a social event and you ask the person if you're invited and they say come if you like no worse still you're going to go to the social event you are invited then you start thinking about i don't put my foot in it i'm going to be meeting people this is say a work event so it's work events are not you know they're not really a party right it's still a work event you can't just go mad you're not amongst your closest buddies still a work event you've got your boss and other people there so you absolutely start stressing out about that event it's an overwhelming intense instant and i want to talk about this because we say sadness internalized or externalized but i feel like there's sometimes a lot of rage that can come after a trigger immediately after a trigger and often that's internalized and i feel like if you know someone well you can see it i feel like the partners of people with adhd can often see the moment they're triggered and they can see that they're hiding it but this rage that if not understood and you do externalize it, it can be the cause of so many blowups, arguments, rage quits of jobs.

29:00Dr Shyamal Mashru:Where does that rage come from? Is that coming from a different place to the sadness? I think it's all, there's a mixture of emotions that go on. I think the rage is coming from frustration, right? A lot of it's frustration. so it's if you go through life being misunderstood and you don't even know how to put words to this so you don't know how to make other people understand you that's very frustrating so I've had patients tell me when I asked them a question in a history saying have you self-harmed they said well I've not cut myself but I've bashed myself in the head I've hit myself out of frustration it's frustration and frustration has to either go external or it goes internal and you just get angry because you're feeling misunderstood and you don't know how to explain yourself it makes so much sense I think you could be on social media and you see a picture of a group of friends and you haven't been invited and it can completely derail your day to the point where you fill up with shame because you don't understand how 30 seconds ago you were in a great mood, almost euphoric sometimes, depending on what was going on.

30:25Dr Shyamal Mashru:And then suddenly you've seen something and you've completely changed, whether it's internally or externally. And the optics of that can expose you to comments like, why are you so Dr. Jekyll and Mr. Hyde? It was instant, the change and the shame. Do you think as a consequence of RSD, people with ADHD are more destined to feel shame? Is it part of our wiring? No, I don't think it's part of your wiring or destiny. I think it's a learned emotional response.

31:03If you've had experiences throughout your life, so I've, as part of assessment, some people bring their school reports, whoever has them, but some people bring their school reports, right? Especially with kids, when we have kids in the clinic, they've got their school reports. There are certain themes that go through their school reports. One of them is that they're not meaning their potential. It might not be written like that, but that's basically what it means.

31:34Parents, I think there's a cultural bias with this as well, but parents sometimes are just looking at the kid as lazy. Especially if the sibling is not maybe like that, for example.

31:47So you go through life basically feeling shame, not good enough, etc.

31:59When you feel not good enough, essentially, you feel guilty as well. that you're, in other aspects of life, that you're becoming a burden to other people. So you try and hide away your feelings. It's an acquired response according to the responses that were given to you throughout your life.

32:20Dr Shyamal Mashru:Do you think the journey you just explained, does that show up differently within men to women? I think in, so in women, although I do see this in both, But in women, there's a couple of themes that I hear a lot. Emotional overwhelm and burnout. So there's a lot of masking that goes on, probably more with women than in men. It does happen in men too, though. Actually, I'm not going to say it's only happening in women. There's a lot of masking that's going on. So there's a lot of compensatory mechanisms. What is masking? Masking is you're not being you. You're not being your true you, right? so from a social perspective it's actually bloody exhausting if you are that person that's rehearsing their conversation before they go to the the date or the work party or whatever it is that's that is exhausting right that's going to drain your social battery and then when you're in that social situation you're worried about not putting your foot in it and paying attention etc etc.

33:26Then in terms of masking at work, you might be, I've had loads of patients tell me I'm working after hours at home to get the same things done that my colleagues are not having to do for sure. I know that they're not doing that. And then where that changes over time in women is the link with the sex hormones. That's a big thing. So where you have hormonal fluctuations, teenage years, perimenopause, menopause. With those hormonal fluctuations, the classic description that I hear sort of female patients say is, look, I was struggling before and managing, but now I'm just not managing. Like this is now too much for me.

34:16And I'm totally overwhelmed and I'm totally burnt out i'm done and that is where also rage i've seen happen there because they're masking so much at work they're bottling everything in where is it going to come out because it has to come out it's going to come out at home and i guess now they've just lost their cool with their partner

34:39Dr Shyamal Mashru:and their kids etc and i guess many people around that particular person who is working through the night, putting in all that extra time to achieve the same, or maybe even more, the optics of that could look like high achieving. They could be getting the good marks, they could be getting the promotion, but I guess it's the extra work that's happening behind the scenes that other people don't see. It's the arguments with the partner, it's the being so burnt out after work that the door closes and they just fall to the floor. And they've got nothing left because they've exerted so much more invisible energy in the workplace.

35:14Dr Shyamal Mashru:Are there any other areas do you think that women ask for help that might be different to men? I think another area, the big one is relationships, right? So yes, relationship with a partner. But the other big one is mums that are parents. And this is where a lot of guilt comes in. the mum that's the parent that's struggling to cope with parenthood right so nowadays schools are you're on these whatsapp groups I'm saying this as a parent myself so my wife's on these whatsapp groups which I constantly have today's this day and you've got to wear this particular outfit and then tomorrow's another thing with a different outfit how embarrassing is it you've got ADHD, you misread that message your kid's the only one that's come in in school uniform everyone else is dressed as a teddy bear or whatever right that's embarrassing on you i'm talking about young kids the young kid just well they might think something's happened but they don't quite get it that's really embarrassing to you as the mum right or you know you just struggling to keep up and then when you feel you're letting people down, that's where I get mums come to me.

36:35Because they're just feeling so bad. They might even tolerate, you know, the partner, fine, we have arguments. But if it's affecting the kids, that's something that they can't tolerate.

36:47Dr Shyamal Mashru:I want to talk about comorbid conditions that might appear alongside ADHD. But I suppose, firstly, how common is it to have a comorbid condition with adhd so it's a very poignant question so yesterday on my linkedin popped up a very recent it must be a very recent article it popped up yesterday from attitude magazine you know attitude magazine um and it said up to 80 percent of people with adhd have comorbid mental health symptoms and i would agree with that in my experience as well so highly comorbid is the answer and what would be the main ones the more common ones most common ones are what we call mood disorders so 70 to 80 percent of people with adhd have cycles of anxiety and depression

37:46the classic story that I hear is I've been feeling like this for as long as I can remember this is how I've always had this experience I've been treated with antidepressants they made me feel rubbish I felt emotionally numb and just had loads of side effects when you hear this as a healthcare professional You need to have some understanding of the nuances.

38:18Dr Shyamal Mashru:Otherwise, you're going to diagnose that person with generalized anxiety disorder. The anxiety in ADHD, in my experience, is different in its quality. It's typically task-related. Or there's an element of social anxiety. We've spoken about RSD. So task-related is I've got that big project. I've got that big presentation. I've got my dissertation to get done and I just don't know where to start. And it's due. That's different to generalized anxiety. Because in generalized anxiety, someone is naturally a worrier about everything. So they might develop health anxieties, they might develop phobias, all sorts of other things.

39:07Why is it important to know the difference? because you're treating different things with different chemicals. Most antidepressants contain a chemical or enhance a chemical called serotonin. That's not what's deficient in ADHD. What's deficient in ADHD primarily is dopamine and noradrenaline. So you're just now going to get the side effects of high serotonin levels, basically. Other mood disorders, bipolar disorder. very very careful to tease out if someone's got bipolar disorder because if you give someone who's got undiagnosed bipolar disorder stimulant medication which is the first line of treatment in adhd they are 10 times more likely to become manic than than if they didn't have that medication so what are the the characteristic differences in bipolar disorder you get mood dysregulation but you typically get weeks of hypomania or mania and then months of depression.

40:14You can almost see them, those changes, they're that prolonged. Whereas the mood swings you see in ADHD are going on within a day typically. Number two, the mood changes that you see in bipolar disorder are what's called non-congruent with the situation. So what that means is, if someone's manic, there might be a terrible circumstance that's going on, and they're laughing away, bizarrely. It looks strange. That's not what you see typically in ADHD. What you see in ADHD is people experience appropriate emotions, but more intensely. They experience the high highs and the low lows more intensely, but it's appropriate to the situation.

41:05Other conditions, which I know you've discussed in this podcast before, but autism, of course. And I think it's very important, again, to find the right healthcare professional because if you have autism or autistic traits, you want to see someone that knows about that. Because again, when it comes to ADHD treatment, when you treat someone's ADHD symptoms, their autistic traits become more prominent. And they need to be cancelled about that. That person will describe saying, I feel like I'm losing my personality here. Becoming more inwards. It's because I've taken out the other thing that made you more extroverted and now you're left with the autism.

41:48Dr Shyamal Mashru:As a healthcare professional like yourself, because it sounds like there's a lot of potential comorbid conditions, How difficult is it a job to tease apart and identify them individually? I think this is where seeing someone with the appropriate expertise is really important. I'm not having a knock at any other healthcare professionals here. I'm really not. But for example, a consultant psychiatrist. We've had to do training and had clinical experience in lots of other conditions. another one actually is addictions which maybe we can talk about but that's another one there's that phrase the man with a hammer sees every problem as a nail right if you only know if you've been on your few days training course about adhd and you really don't have other experience of other mental health conditions you don't know what someone with what does a patient with bipolar disorder look like what do they say right for example or you don't have experience about addictions, for example, you're not going to even know to ask the right questions.

43:01So you're going to have your list of ADHD symptoms and you've either got that or you haven't got that. That's, to me, not the way to do things. You need to do a comprehensive overview of a person. If I was a patient, don't just tell me yes or no, have I got ADHD? That's not what you want to know. I think you want to know, well, give me an overview of everything that's going on with me. And what can I do to help myself? What can you do to help me? Treat the person as a whole.

43:33Dr Shyamal Mashru:And as a healthcare professional, you must have to have an awareness of masking, right? Because is it possible for the different comorbid conditions to perhaps mask each other? Yeah, and look like each other, right? there's a lot of talk in this field around is this a condition that's being overdiagnosed and i think we're coming to more and more understand that actually it's probably been misdiagnosed and looking like other conditions all along but actually i think it's even more dangerous to diagnose someone with adhd when actually it's not adhd and then you start giving them treatment for something that it's not and you might be making those other things worse if you give stimulants to someone who really does have generalized anxiety disorder, who doesn't have any management with, say, an antidepressant, you're going to make that person really anxious.

44:25You're going to aggravate the generalized anxiety disorder.

44:29Dr Shyamal Mashru:How do we make sure that there isn't a misdiagnosis and therefore a misprescription causing someone with generalized anxiety disorder or maybe another BPD who might therefore go into a mania? How do we limit those misdiagnoses from happening? So, well, maybe at this point I'll talk about how me and my colleagues, for example, at our clinic, try and untangle these different conditions, right? The first step, if you came to see us at our clinic, you're going to get given some pre-assessment forms, which is probably the bane of your life as an ADHD person. But those forms are important. One of those forms is asking about ADHD symptom frequency.

45:11The other form is asking about autistic traits, even though it's not potentially, I mean, so we have a certain type of assessment where we do a combined ADHD and autism assessment, but even with our generic ADHD assessments, because it's highly comorbid, we ask about autistic traits. Number three, there's another form asking about depression and anxiety symptoms. We then ask you to give us informant reports from collateral, other people close to you, about your childhood and your adulthood to get a longitudinal picture of you, right? What has Alex been like his whole life, if at all possible? During the assessment itself, we will ask about ADHD symptoms, obviously, because that's what you came for.

45:51But we will also ask about past psychiatric history. We will get information from your GP with your consent, from your medical records. Have you seen other mental health professionals? Can I see those letters? because of knowledge of medication

46:08Dr Shyamal Mashru:if you tell me your medication history I'll tell you what you were diagnosed with whether that was correct or not and then we'll do a mental state exam a mental state exam is a description of how is Alex presenting to me right now and again this comes with pattern recognition and experience if I have seen enough people with all these other conditions I'll spot it but if you haven't you don't know what you're spotting so then it's just ADHD not ADHD what about dementia because I've heard some scary headlines that are linking ADHD to a heightened risk of developing dementia is there any truth to that?

46:53Dr Shyamal Mashru:is there any new research that backs that up? there's some very interesting research around this and it's current in the last year there have been studies done across Europe big-scale studies that show where they've looked at populations of people with ADHD and without ADHD and matched for other confounding factors, right? If you are left untreated across your lifespan with ADHD, you are at two and a half to three times more risk of developing dementia compared to someone who doesn't have ADHD. But then follow-up studies have showed, specifically with stimulant medication, that if you are treated, you are at the same level of baseline risk as someone who doesn't have ADHD.

47:44Dr Shyamal Mashru:So without treatment, what is causing the heightened risk? Lifestyle choices? that's very hard to answer I think if we look at the treatment some theories are around neuroplasticity so if you're modulating neurotransmitters the dopamine and the noradrenaline you are changing brain chemistry across time so there's very interesting studies about actually so in the US where they quite aggressively medicate even children right i think we're a bit more reluctant to do that in the uk and what they're starting to see and this is not completely conclusive or proven by the way because i know i can imagine you're gonna get lots of people in the comments talking about this one but what they're starting to see is actually if you treat this early you might actually be able to change brain chemistry to such an extent the person is no longer presenting with this later on in life which is actually phenomenal because now you're talking about a cure we're not there yet just want to really highlight this okay so you know we don't want the bbc to come down at us but we're not there yet so i think there's a thing about neuroplasticity you're changing the brain structure a bit at a chemical level not the whole brain, obviously.

49:12Dr Shyamal Mashru:How many people did you say you've assessed? About 15 ,000 at least. And do you see any, because I suppose when someone's in that room with you, right, and they have probably spent years and years feeling misunderstood, not understanding where the shame comes from, being called lazy and not understanding why, when you say ADHD, when you first say that there's a reason, do you see a change in the person when you say that to them? Yeah, it's a bit like the bereavement process. Okay, so there's four stages in the bereavement process. Number one is shock and disbelief. So what, Dr. Mashie, do I have ADHD then?

50:00They'll say this two or three times at the end of the assessment after I told them that they've got it. And I've explained through the diagnostic criteria why I think they've got it. so there's that element of imposter syndrome and that's there because their whole lives they've been told something different about themselves as to why they are the way they are and it's not ADHD so that's stage one stage two is anger they are angry at parents teachers partners they've been wronged and misunderstood and they're angry about it naturally so angry at themselves actually as well they're not picking up on it sooner stage 3 sadness they grieve the life that could have been had they been treated earlier and really met their potential especially people who are diagnosed much later in life now.

51:06Stage four is acceptance. Because only if you then accept, right, this has happened, can you then start accepting treatment and moving on. So four stages is what I generally see post-diagnosis. And it's like the bereavement process.

51:24Dr Shyamal Mashru:And who do you think the diagnosis helps the most? Do you think it helps the person who's been diagnosed or do you think it helps the people around them? if done correctly, it can help everyone. And I say that, if done correctly, right? Naturally, it can help the person if you give them the right tools, whether that's medication, talking therapy, both, whatever it is. I think the next step is the really important one. So, for example, in our service, we have coaches who will actually have sessions with family members just to explain to them. What's going on for their child or for their partner?

52:06We even offer sessions to employers if the employer is willing to listen, right? Or if the person wants us to talk to their employer about reasonable adjustments. Or sessions with the university to explain what kind of reasonable adjustments can be put in place to help that person. So if it's done properly, comprehensively, then yes, I think it could help everyone.

52:32Dr Shyamal Mashru:When I got my diagnosis, I started speaking to as many people as I could in the community. And one of the main words that got repeated time and time again was broken. People felt broken. And it kind of became the slogan of this podcast, really, not broken, just different. because of that motivation to try and change the narrative. Is a feeling of being broken a word that gets brought up by the people that come to see your clinic? And why do you think that is? I think the word that gets brought up and the people that I see is despair. Right? Despair. There are loads of people who are watching this podcast right now.

53:16Two or three in the morning, you're not going to sleep. and you're watching this. What's driving that, apart from your ADHD maybe? You're desperate. You're desperately, internally maybe stuck. You're stuck and you don't know what to do. And that goes back to the original question about what my mission was. Don't remain in that desperate, stuck stage, people. go and seek the appropriate expert help because there are things out there to help you. Neurodivergence has got its strengths. People can be really creative. When they find their passion, they do extremely well. Look at yourself as an example.

54:07But it also causes a lot of difficulties. Don't remain stuck in a difficult place. go and get help and get the right help.

54:16Dr Shyamal Mashru:Really profound and amazing advice to finish on. So Shai, thank you so much. Thank you. I want to move on to my favorite part of the show, which is the ADHD item section. Your item has been patiently waiting underneath that cloth, and I'm going to reveal it now. Okay. Right, I'll say what that is first. That is a remote control and a tie. and I think we're going to cut. Okay, and through the magic of editing, I've now put on your instruction, your tie as a blindfold and I've got the TV remote in my hand and I'm pointing it at an imaginary TV. Yes. So, Alex, press number one for me. I'm scared.

55:01Yeah, okay, number one. So what you're actually pressing, I think, is the volume button there. I can't.

55:07Dr Shyamal Mashru:That was a guess. That was a guess. Right, press number three. I don't even know if the remote's facing the right way. It's facing the right way, which is quite incredible. Three. So that's... Are the numbers up here? So you've now turned the TV off there. Oh, no. Okay. So I'll press it on again, I think. Yeah. Well done. I'm going to guess three's around there somewhere. I don't know. So now you've pressed number nine, but you've stumbled across number nine, and there's a really interesting channel on there. A lot of noise in the background. Let's turn the volume up. Okay, so you turn the volume down.

55:39All right. So now you can take off your blindfold, Alex.

55:42Dr Shyamal Mashru:Okay, I think I know where you're going with this now. That remote is a reminder to everyone. That's the ADHD brain. And I want to quickly touch on this, actually, because to me, ADHD, what it stands for, Attention Deficit Hyperactivity Disorder. This is not a deficit condition. It's a dysregulation condition. It should actually say attention dysregulation. people can't regulate their attention they're hopping around in their brain from channel one to channel three to channel five channel five's really interesting let's put all the volume up then the tv turns off attention is not being appropriately regulated people ask me what does treatment do for you i'm talking about medication for example doesn't have to just be meds gives you that remote control so that you can appropriately regulate attention but it's not just attention it's your emotions emotional dysregulation helps you to regulate your emotional responses to a situation rationalize things better hyperactive symptoms impulsivity not regulating your physical movements but in adhd even more that physical energy moves inward so it's mental restlessness right i'll ask patients show me their web browser how many tabs have you got open that's a visual representation of what your brain pattern your thinking patterns are doing it gives you the remote control go and get yourself a remote control without a blindfold go and get yourself treated you never know what's going to be on each channel i accidentally put on channel nine and it could be a space program and that could trigger a hyper focus for two days pulling me away from my primary objective and then i the self-esteem issues that can come with being distracted again but the symbol of that remote control is to give yourself the power to control your symptoms yeah shy truly fascinating and this will grace the shelves behind us where all the other adhd items are placed i want to move on to the adhd the agony aunt, which is called the washing machine of woes.

58:00Dr Shyamal Mashru:And an audience member writes in with a question, a woe, it goes in the washing machine. And it's a washing machine because it represents for me, memory loss. Okay. Because I always forget my clothes in the machine after the cycle is finished. All right. And I do ask all my guests, do you relate to that? Do I relate? I definitely see that in other patients. I'm not sure if I relate to that all the time. I have been using the Timo app, which is the sponsor of the show, and I've been getting a lot better. They gave me a little prompt to remind me to empty my washing machine. This week, Shai, someone has written in and asked, both of my parents have ADHD and I'm 16 without a diagnosis.

58:40Dr Shyamal Mashru:If I want an assessment, what can I expect and why are waiting lists so long? Okay. So I think we can go through this actually. So I'll tell you what we do in our service. for children. The first step is, there are some forms which you're probably going to hate, especially as a 16-year-old potentially with ADHD. Those forms are for three people to fill out, your teacher or your school, yourself and your parent. You will then have a detailed assessment that goes through, like I said, not just ADHD, other possible things that might be going on for you. How do your symptoms impact you? And where do you want help with?

59:31So we tailor that towards you. If there's also then liaison required with your school, for example, maybe at 16, we would assist with that as well, because I think that's probably a big problem area, but not just school, but there might be lots of other things going on too for you. And then essentially treat you appropriately according to your needs. I think the second part of the question is why are we waiting this so long? I think the reason for that is because the current resources are being outstripped by the current demand. Simple supply and demand. there's been increased awareness about ADHD and other neurodivergences so schools etc have not been given the funding to match that demand so a lot of these people were unrecognized before especially if they weren't tearing up the classroom like the more inattentive people they were just going through their sort of education system quietly doodling away to themselves, being distracted in their own thoughts, not troubling anybody those people were missed but now there's more awareness so those people are putting their hand up saying I need some help but the help hasn't caught up

1:01:06Dr Shyamal Mashru:fascinating Shai, and it makes a lot of sense I want to say thank you so much again and just finally we're going to do a new part of the show actually it's the previous guest has written a letter to the younger version of themselves and I want to deliver it to you and if you could kindly read it out to us if you could kindly read out the letter okay dear my younger self the life and version of yourself that you want to be when you grow up is even better than you wish it to be the hopes daydreams ideas and fear you have is your gift that will make your future amazing. Don't stop dreaming. Believe in yourself.

1:01:48It is all going to be a wild ride. Enjoy it. It's very positive and exciting. That's nice.

1:01:54Dr Shyamal Mashru:Amazing. Thank you. Once again, Shai, thank you so much. On behalf of everyone watching, listening, on their mission, grappling to try to understand how their brain works. Thank you so much. Thank you.