611- RSD Coming Into Focus: Rejection Sensitive Dysphoria in ADHD Brains

0:00James Kustow: This episode is brought to you by Progressive Insurance. Do you ever find yourself playing the budgeting game? Well, with the Name Your Price tool from Progressive, you can find options that fit your budget and potentially lower your bills. Try it at Progressive.com. Progressive Casualty Insurance Company and Affiliates. Price and coverage match limited by state law. Not available in all states.

0:26Welcome to the Attention Deficit Disorder Expert Podcast Series. by Attitude Magazine.

0:36I'm Carol Fleck, and on behalf of the Attitude team, I'm delighted to welcome you to today's ADHD experts presentation titled RSD Coming into Focus, Rejection Sensitive Dysphoria in ADHD Brains. Leading today's presentation is Dr. James Cousteau, and we're so fortunate to welcome him back. Dr. Cousteau was here earlier this year to educate us about the association between ADHD and inflammatory disorders. It was a blockbuster presentation and you can listen to it by searching attitudemag.com for podcast 545 or by subscribing to the ADHD Experts podcast on most streaming platforms. Dr. Cousteau is a leading London-based psychiatrist and a trained integrative psychotherapist.

1:28He is the author of the book, How to Thrive with Adult ADHD. His expertise is informed not only by his work as a psychiatrist, but also by his own experience. He was diagnosed with ADHD as an adult. As many of you know, rejection-sensitive dysphoria is a unique and sometimes crippling form of emotional dysregulation. People with RSD feel intense physical and emotional pain when they experience real or perceived criticism or rejection. It is an aspect of ADHD that many individuals struggle to explain and live with. Dr. William Dodson, an esteemed psychiatrist, a longtime medical advisor to Attitude, and a dear friend is responsible for giving a name and attention to RSD in people with ADHD.

2:21Dr. Dodson has been researching RSD for years and has been advocating for updated ADHD diagnostic criteria to include RSD. Dr. Dodson is working on a new book, The Recognition and Treatment of ADHD, and in it, he talks about how to manage and treat uncontrolled and overwhelming emotions. The book will be available in 2027. Clinicians sometimes overlook emotional dysregulation when evaluating patients for ADHD. This underscores a huge gap in knowledge because as Attitude readers have told us, in survey after survey, the struggle to control their emotions is the most impairing ADHD trait. The Attitude team recently launched a survey on RSD specifically, and more than 3 ,000 people participated.

3:14We'd love for you to be a part of the survey too. Today, Dr. Cousteau will discuss what we know about RSD, why it remains under-recognized in research and in clinical practice, and what to do when RSD shows up in everyday life. So without further ado, I'm so pleased to welcome Dr. James Cousteau. Thank you so much for joining us today. Thank you very much, Carol. And it's lovely to be here. I'm very honoured to have been invited to talk about this important and new cutting-edge topic, I would call it. So I'm going to dive straight in and try and leave a little bit of time at the end of the session for some questions.

3:59And I'm going to set the scene really, but spend quite the bulk of today's session really talking about practical strategies in real life to hopefully minimise the impact of this very impairing phenomenon. them. I'm very excited and delighted that Dr. Bill Dodson is one of the attendees today. He reached out to say hi and I thought I would say a shout out to Bill and thank you very much for your work in this area. So rejection sensitivity as a concept has been around for a little while and many would agree that it falls within the umbrella of emotional dysregulation. I, as you probably saw on the introductory slide, I understand ADHD very much through the lens of regulation or essentially as a disorder or an issue with the regulatory functions of the brain and the body in fact.

5:07And I have a model called the 10 domains of dysregulation and domain number four is emotional dysregulation. It's quite clear this is a core symptom of ADHD and some recent studies have actually clarified that and really put it on the map as being a very central issue that needs more attention. And rejection sensitivity very much falls within the bracket of emotional dysregulation, but it needs some thought on its own. Now, as you're probably aware emotional dysregulation is not unique to ADHD it's seen in a number of different mental health and neurodevelopmental conditions and I've listed some of those there I'd probably add to that list body dysmorphic disorder as well and certainly with body dysmorphic disorder and with borderline personality or emotionally unstable personality disorder the theme of rejection sensitivity is most certainly present.

6:09So what is rejection sensitivity and what is supported scientifically? Well the broader concept of rejection sensitivity was first formally described by psychologists Geraldine Downey and Scott Feldman in 1990s and they defined it as the tendency to anxiously expect, rapidly perceive and intensely react to rejection. Their work showed that some individuals become highly attuned to signs of social threat, particularly if they've experienced repeated criticism, exclusion or inconsistency early in life. Other rejection sensitivity research by a researcher called Gao and colleagues in 2017 has linked high rejection sensitivity with anxiety, depression, loneliness and emotional instability.

7:12And as I mentioned there are also established associations with borderline personality disorder and body dysmorphic disorder as well as of course trauma linked presentations. Importantly, rejection sensitivity is not simply being too emotional. It appears to involve a combination of heightened emotional reactivity, attentional bias towards threat, and difficulties regulating the distress once it's been triggered. And this attentional bias to social threat is very important. And it even occurs when the cues are ambiguous. So we see rejection sensitivity as a form of ADHD-linked emotional dysregulation.

8:00And pretty much across the board, many, many adults and children with ADHD report or illustrate heightened sensitivity to rejection and criticism, where even subtle social feedback or well-meaning constructive criticism can feel totally overwhelming. And this phenomenon, which may or may not be unique to ADHD, within the ADHD field has been termed rejection-sensitive dysphoria. And it brings me back to some of my own memories around this area. Now, I have a diagnosis of ADHD made in adulthood, but I very much had the experience of growing up as a child and adolescent and a young adult with undiagnosed ADHD.

8:51And a couple of things stand out to me before I even understood that ADHD could move into adulthood. I always experienced exquisite sensitivity to rejection. And in my teens, for some odd reason, I remember always actively inviting constructive criticism, as I called it. It was almost to bring it out in a controlled way or to avoid the weight of getting feedback. And I never really understood it until I understood RSD. In my 20s, I remember being in therapy and talking to my therapist about how I feel like I carry a protective shell, like a hard skin of an onion, which I termed the facade at the time.

9:39and I was talking in the therapy about how confusing it was in terms of identity to have this facade or what I understand now to be masking which is a really common response again supported by the literature in this area and I remember in my 30s making quite a bold decision not to sign up to any social media accounts of any form, and I haven't to this day. And I always described it as making life too complicated and struggling to keep up with everything as it is, and this is an extra layer, but I'm pretty confident that this was a form of withdrawal or avoidance to even entertain the possibility of that level of rejection or criticism.

10:36Now, as I've understood it in my later years, in more recent years, it makes a huge difference. And that's really what I'm trying to do today is normalize, validate, and hopefully give a few useful tips and tricks.

10:56James Kustow: This episode is brought to you by Progressive Insurance. Do you ever find yourself playing the budgeting game? Well, with the Name Your Price tool from Progressive, you can find options that fit your budget and potentially lower your bills. Try it at Progressive.com. Progressive Casualty Insurance Company and Affiliates. Price and coverage match limited by state law. Not available in all states. So, as mentioned, the term RSD was coined by Dr. William Dodson, who is based in the U.S. and an ADHD psychiatrist. Importantly, it's not a formal diagnostic category. It's not in the DSM or the ICD. So it's not a diagnosis.

11:40It's a description. But a description that many people consider as a very central feature of ADHD. And people really resonate with it. I remember when listening to Bill, I think on a webinar a few years ago, describing RSD, there was a very distinct resonance, a strong connection with what he was saying, my own life and my own story. and the word dysphoria which is in greek is translates to unbearable really does capture the depth the intensity of the emotional and actually physical pain as well but it's important that we are all aware that quite a lot of it of what we know about it at the moment is anecdotal and conjecture there is some research there's research as i mentioned on rejection sensitivity more broadly um but more recently um some early research on rsd as a concept within the adhd field but there are many questions that remain unanswered such as how common is it who is most affected it?

12:59Is it actually a valid construct? And is it unique to ADHD? And if not, where else do you see it? Where does it come from? And what can you do to help it? Now, we've got some early ideas of the experience of it from some studies I'm going to introduce in a moment. But I think in the field presently, the clinical language that we are using perhaps has moved faster than the formal science and we're in a bit of a catch-up mode. What exactly do we mean by RSD? Well, we mean intense emotional and physiological reaction to actual or perceived criticism, rejection, teasing, exclusion, disappointment or disapproval and it may also be triggered this intense dysphoria may be triggered by one's own negative self-talk or simply an inner sense of having messed up.

14:06Now typically well pretty much always there's a trigger to an attack of RSD and usually it happens in real time and I think distinguished from a future fear of being rejected I'm not sure I might challenge that because I do think there is an anxiety about RSD happening and people adapt and change the way they live their lives in order to avoid it certain situations but there is always a trigger whether the trigger is about to happen or is happening in real time and that trigger could be a comment a correction or even just a facial expression it could be something that's not said or a slight delay or simply a perception that something's not right and when triggered the response which is a body and brain response is often very rapid and it's overwhelming and it's very somatic physical experience in the body and difficult to regulate and it can feel like a almost like a nervous system seizure or assault of some form the inner experience is out of proportion to the actual event and as well as the word unbearable people talk about shame and how unpleasant it is and overwhelming to the system and it manifests in broadly speaking two different ways either the distress is internalized turned inwards and looks like someone is low in mood they might be sort of restless with overwhelming anxiety or even cut off dissociated detached but alternatively it can be externalized usually with anger and sometimes with rage and that anger is directed either towards the situation or oneself or the other the the source and I think an RSD probably underlies quite a lot of aggressive and violent outbursts in individuals with ADHD.

16:24Once in full motion a distress can be difficult to stem it usually lasts minutes or hours but sometimes even days and I've certainly been in situations where my RSD has been triggered and it's carried over to the next day until somehow it's dissipated and I think when this happens over one's lifetime we tend to shape our self-image and our style of engagement around trying to avoid the pain because this repeat emotional what I call micro fracturing really does lead to identity level pain and many people will describe it as the worst part of ADHD. So why does it happen? Well, there's two broad schools of thought around this, and I would describe them as the nature versus nurture.

17:23So let's start with nurture. So nurture theory is that a lifetime of these micro rejections, or sometimes referred to as small t traumas, comments, sort of body language, comments that you can see there, things like you're to this, you're to that, you're always this, you're so sensitive, what's wrong with you? We know from studies that children with ADHD receive thousands upon thousands of these micro comments that really do have an impact. and the individual and it's not just the words it's the non-verbal stuff as well it leaves the individual feeling that they're not right that they're too much they're not enough and this causes an accumulation of shame and self-doubt and hypervigilance that's carried through one's life.

18:20Theory number two is the nature theory and this is that there are clearly differences in both brain and body physiology and the workings of the brain and the body in ADHD. We know that there's been lots of study of the brain, not as much study of the body by the way which is my area of interest. I feel like we have been a little bit overly focused on the brain whereas I think attached to the brain is the rest of the body. Anyway, are the differences in the ADHD brain and body accounting for this nervous system sensitivity? We know that there's the autonomic nervous system, which is essentially the threat response, one of the threat response systems of the body is more jumpy and dysregulated there's more dysautonomia in adhd we know that there's less inhibitory control the frontal part of the brain which acts as the the breaker or the inhibitor isn't isn't working as strongly so less inhibition and we also know that there's differences in sensory processing non-difficult sensory profile and also there are differences in other physiological variables such as the connective tissue in the body and many of you will know now because we've been talking about it a lot over recent years but almost half of individuals with ADHD are hypermobile they have lax connective tissue and when you have lax connective tissue or fascia in the body all the systems of the body work slightly differently and it leaves the system in a hypervigilant state looking for danger and the sense of safety is most definitely interrupted so this rejection sensitivity could well fit in the this picture we know that there's altered pain appraisal and pain thresholds both physical and mental pain and there's differences in sleep in terms of the architecture and the quality and all of these factors could contribute towards a physiological priming as it were for rejection sensitivity and it is important because as mentioned it can really shape your personality and it can drive chaos in one's life in terms of primarily in terms of relationships in terms of conflict and those relationships can be with a partner with children with parents with colleagues with friends um and it can cause real problems um and it takes a lot of energy to mask and it and shame certainly zaps that energy as well over time that takes its toll and some people over time decide it's safer and easier to avoid, to withdraw, to not get involved, to stay silent, to avoid triggering that pain.

21:26And that's a very narrowing thing. And I think when you start to avoid and withdraw, you become more lonely. When you become more lonely, you become more depressed. And we thrive and need connection. And this is anti-connection in many ways. And obviously, when you combine this sensitivity with other features of ADHD such as impulsivity, it can certainly contribute to risky behaviours. So in terms of the research around rejection sensitivity or RSD in ADHD specifically, there are what we call qualitative studies exploring the lived experience of adults with ADHD and they consistently identified intense emotional pain related to criticism and rejection.

22:18In one study from 2023 by Ginnap and colleagues, participants described emotional dysregulation as one of the most impairing aspects of ADHD, often more distressing than inattentiveness itself. And another excellent recent qualitative study qualitative means descriptive study by rowney smith and colleagues including jessica eccles this is a study from the uk and found that adults with adhd describe rejection experiences as rapid overwhelming physical and deeply identity based often leading to avoidance masking withdrawal or emotional outbursts. And there is studies of a more qualitative nature, so this is involving numbers essentially, that's beginning to support these observations.

23:15In particular one from 2024 by Muller and colleagues that found that ADHD symptom severity correlates with higher rejection sensitivity scores and poorer well-being and importantly more interpersonal difficulties. So at present it's probably most accurate to view RSD not as a fully validated standalone disorder but as a clinically meaningful pattern sitting at the intersection between ADHD, emotional dysregulation and social pain and nervous system sensitivity. So just for a moment let's do an experiment and I want you to shift the focus to your own life and if you would like close your eyes. I want you to imagine that you've sent an important piece of work to someone you respect professionally.

24:12You worked very hard on it, you checked it repeatedly and an hour later you receive an email um the email says can we talk about this tomorrow there's no reassurance there's no context um just notice what happens in your body and and does whatever happens what comes first is it the thoughts or is it the body sensations or the emotions and when you hear something neutral like that what assumptions does your mind begin making automatically for some people nothing will happen but for others and particularly those with adhd the threat prediction kicks in quickly and the nervous system moves into this hyper vigilant and almost attacked state well before anything bad has happened.

25:08So it's the uncertainty really that is very uncomfortable for people. Now, Carol mentioned before that Attitude recently did a survey. Many of you will have completed a survey and I had a look at the results of it and they're going to be described in more detail in the spring copy of Attitude magazine. But I wanted just to capture what people said they wanted help with the most so people wanted help with how to avoid spiraling so quickly and they wanted to understand why criticism affects them so deeply how to stop it how to stop overthinking everything how to calm down before saying something that they regret and a few people commented on how the body reacts before the mind people were not asking how to become less sensitive they're asking how to manage this better and i would say relationship themes really dominated at the most and people were asking about how to avoid arguments escalating how to avoid feeling so devastated by what objectively appears to be minor criticism, how to cope with this tendency of over-apologising and fear of upsetting people and really putting other people first, which causes problems, of course.

26:36Difficulty asking for reassurance and also trusting it and generally overall feeling too much in many different settings. Feedback at work and social exclusion and social media came up a lot as well. And this exhaustion that's associated with having to mask or having to monitor all the time. And there's a few quotes there that you can have a look at. So I mentioned before that RSD or rejection sensitivity really does shape one's personality or way of engaging with the world and very much in a protective way. Now, not all protections work in the long term. And I would argue that some of these approaches are problematic over time.

27:30So these experiences, as mentioned, become internalised and the system starts to anticipate or predict pain before it happens. and these patterns which I'm going to introduce you to really were developed or taken on to boost safety really become part of one's identity over time and these are the three common adaptations that I see and that the studies that do exist allude to quite strongly. The first, I've actually called it self-abandonment. Many other people call it people-pleasing, but I wanted to shift the focus from the other to the self. So it's the idea of suppressing one's own needs in favour of prioritising others' needs, trading authenticity for a sense of safety in that interaction.

28:30So this chronic people pleasing really challenges one's sense of self. The second is avoidance or withdrawal, not applying for the job, not agreeing to go on the date, not attending the seminar, not posting on social media, not speaking up or asking for help. because if I don't put myself out there if I don't risk it then it's likely that I won't be rejected but as I mentioned before this has numerous knock-on effects that are not good for mental health and physical health as the system is actually all integrated the third which I've suffered from in the earlier part of my life which I'm now thankfully letting go of is perfectionism whether it's overworking, excessive checking or over apologising.

29:28But this idea that you need to be above criticism. If everything's perfect, I won't be criticised. I won't be rejected. I'll be safe. Now, many people might think these are character flaws, but they are much better interpreted as nervous system survival strategies. So I'm going to briefly tell you about three separate cases to illustrate not only the settings that RSV can play out in, but also some of the range of different responses and triggers. So through the cases, hopefully you'll pick up a bit more of a deeper understanding of rejection sensitivity. So let's talk about Emma first. Now, Emma is 34 years old.

30:15She's a senior marketing manager. She's bright. She's capable. She's respected. She's actually known at work as being the reliable one. And she's frequently staying late and overworking and really struggles to switch off. At school, just by means of some background, she was bright, but she made lots of careless errors. And she quickly learned that being good was not good enough, that she had to be flawless, that she had to be perfect. Her internal message to self was, I must not get things wrong. Now, there's a meeting at her workplace, a marketing role, to discuss a pitch presentation that she's put together.

31:03And the boss, her boss at one point says, this is really strong overall. Just tighten up slide four. Now, it was said in a neutral tone. it was a brief comment there were lots of other comments and the meeting moved on normally no one else seemed to react negatively there was no sense of anger so objectively this was ordinary feedback but Emma picks up on the subtleties the small pause before the comment the subtle tone shift the word but being implied not said but implied and suddenly a sense of being exposed in front to her team. Nothing dramatic's happened, but Emma has been triggered. And what's her response to this trigger?

31:54Well, her gut drops, her chest tightens, she feels her face flushing and an adrenaline surge rushing through her. And she can't really engage anymore. It's almost like she's been shut out of the meeting, but she's trying to pretend that she's there. She's thinking, oh my god i've missed something and she's over interpreting and thinking they've lost confidence in me i've been exposed now the emotions she's feeling are shame and anxiety and panic and there is a tendency if she just left left her to her own devices that she would make a point about this she'd over apologize she'd she'd think it's rubbish and rewrite the whole thing ruminate and etc however that's not necessarily the most helpful way of approaching the situation so in this case what might Emma do in the moment well I think it's about regulating first buying some time and then later if necessary unpicking interpreting so it's all about bringing in a pause before knee jerk reaction avoiding that tendency to over-apologize particularly during the spike and there are different ways of regulating and some people will use the breath others will just do a grounding brief grounding exercise or orient to the room but it might be that she needs to extract herself and regulate outside of the room and for her to name what's going on internally that this is a spike this is rsd this is not the whole truth um and maybe she should say something like even if it's like a scripted thing that's helpful i'll review it and then unpack it later let's move on to David now David is 42 years old and he is in a long-term relationship with Jenny he's warm he's loyal he's highly accommodating and he tends to avoid conflict often suppressing his own needs and if others were to describe him he'd be described as easygoing until suddenly he's not.

34:13He grew up with an alcoholic mother who possibly had ADHD in herself, and he quickly learned, as children of addict parents do, is to keep out of it, not to aggravate, to avoid conflict. And he realised that he needed to do this to feel safe and to feel like he belonged. and his internal rule as he grew up was if I keep people happy I won't be abandoned. Now Jenny as David is just getting ready for bed Jenny opens up to him and said I've noticed that you've not really been listening to me lately. Now again mild tone objectively you could argue that Jenny's seeking connection rather than attacking there's certainly no hostility in her voice but the comment triggers David he picks up on the disappointment in Jenny's voice the word not stands out and suddenly he's fearing disconnection he's fearing the worst even though the words are neutral or mild that David is spiralling.

35:35He describes heat rising and agitation in his system that his fight or flight response has been activated. He wants to either get out or defend himself. He's feeling fearful and shamed and soon after angry and he starts thinking in very black and white terms um and sometimes when you have feelings you do what's called emotional reasoning so you experience the feeling of rejection and you assume that you are rejected whereas there's very little evidence to support that so he tries to keep the peace that's his modus operandi and but soon it gets too much he gets overwhelmed and he snaps he gets defensive and he gets angry and He projects and he feels bad afterwards.

36:31And then sheepishly comes back to try and repair. What might David do in the moment? Again, that all important pause before the shame flicks into anger. So he might call time out and say, he might have had the conversation with Jenny before to say, look, this happens. I get triggered and if it happens I'm no good to you to have this conversation in the moment I need to regulate first I need to take time out it's not personal but I just I can't think straight when I'm triggered so hopefully that time out script is is has already been prepared he might take a moment go to the bathroom splash his face with cold water do some breathing and acknowledge to himself name what's going on for him I'm flooded I'm triggered and the message to Jenny would be I want to respond to you properly but I need a few minutes I've been triggered but it's so important to return back to the issue once the nervous system is back online and finally Sophie Sophie is 29 years old.

37:45She's a creative freelancer. She's warm. She's socially capable. She's creative. But she is increasingly withdrawn, despite really wanting to connect. she's been pulling back over recent years and she's masks a lot she comes across as much more confident than she actually feels it takes a lot of work to maintain this facade as it were she's always felt from childhood she's always felt like she was on the outside she's learned the skill of scanning groups of people for possible signs of being excluded and what happens is that she's looking at her Instagram and notices that some of her friends are out together and they've been tagged on the Instagram and she wasn't invited.

38:39They were at this spontaneous gathering. There weren't any rifts in the friendships. She hasn't explicitly been rejected. It's probably unintentional, but it's triggered her. The image stands out in her mind. She can't think about anything else. She's not got any friends anymore. she's been excluded on purpose and the response in her body and mind is strong she's all she can think about was why am I not there and noticing even just the looks of everyone's faces are how comfortable they are and how much they belong and how how separate she is and she wants to just detach and cut off even further and unfollow her friends but she she doesn't she reacts she feels this hollow in her stomach this feeling of an internal sense of collapse a shutdown and feels sad and humiliated and even more lonely than she did before and her thoughts are very black and white i'm not really part of the group they didn't want me there so she's mind reading she's over generalizing and the temptation is to withdraw is to unfriend is to not message their friends and to decline future invitations because she doesn't need this anymore they obviously don't like her and the tendency to ruminate and isolate so in this situation it's really important not to let the story develop not to let the rumination build because that uncertainty is the thing that's really uncomfortable so rather than react in the moment and do something impulsive she's learned to hold off and in the time that she has when she calmed herself down she's going to challenge the reality what else could explain this and see clarity rather than guessing um so let's see the core model the model is that an individual with ADHD gets triggered and it triggers a body response it's very much a body response the body responding triggers some sort of interpretation or meaning that then drives the emotion which drives behavior and that behavior which is whether it's perfectionism or avoidance or people pleasing very much reinforces the situation and the original fear and so people find themselves in this rsd loop that can continue so the central idea is that regulation whether you're dysregulated or not very much influences the way that you interpret situations.

41:30If you are overwhelmed, then even ambiguous things feel dangerous. Even mild criticism feels global, and emotions cease to be emotions that are fleeting, but they become facts. And many people will use alcohol or substances in order to manage these difficult emotions to prepare oneself for going into a social situation. The problem is that although they might offer some short-term value, they risk addiction and there's long-term vulnerability associated with it. And there's clearly other factors that can aggravate risk, whether there's trauma in the mix and this low self-esteem that's built up over many years.

42:25and often a situation where someone's already very isolated. So what can you do about it? We're thinking here about medication, about therapy, about skills, about relationships. So there are practical strategies. I'm going to summarise them again briefly, but we've touched on a few of them. We're managing RSD in the moment. There's the need to build resilience in the system to prepare, to give perspective and to work on one's relationship with self. There's obviously some clinical approaches, pharmacological and non-pharmacological. And then there's the education that's needed to loved ones, to other people.

43:08So let's just briefly look at those. One of the most important things is to learn the triggers. What sets you up? What triggers you? 10 top tips. We're not going to dwell on these because we've really talked about them. name what's going on this is rejection sensitivity i am triggered pause before reacting ground yourself in the present notice where your contact of your body notice the breath you could there's strategies for grounding regulate the body through breathing walking cold, tapping, movement, challenging the story. Are you overreacting, catastrophizing, overgeneralizing? Don't leave things uncertain.

43:55Seek clarity, ask gently, request context. Check your assumptions. And remember, the feeling of rejection is not necessarily meaning that you are being rejected. It's important if you do mess up, and everyone messes up, to separate isolated mistakes from one's entire identity. So you don't need to globally condemn yourself if you do mess up in some way. And remember to use perspective and past experience where perhaps you assumed you were being rejected, but in reality afterwards you realised that you words and prepare prepare for predictable triggers what about building resilience so if you build resilience in your nervous system it means that you're likely to have a higher threshold at which time you trigger and a lower intensity response and a faster recovery time now we need to study this we need to work out whether this makes a big difference but I can tell you anecdotally from my own life from the working and I have an interest in emotional regulation techniques and have done for many years and I can tell you when the system is when the system is um more resilient uh there's a lot there's a lot more flex in the system so it's not about changing the sensitivity it's about building in resilience and agility into the system And these are some of the things that help that nervous system feel safe, whether it's focusing on sleep.

45:31Movement is very important, especially movement that involves rhythm and balance and coordination and bilateral stimulation. One's nutrition and blood sugar stability is important. And how we regulate our sensory systems and how much load is there in the system? If you're juggling 100 things and you've got no systems for managing time and tasks, then your whole system is going to be primed with anxiety. There's all the cognitive techniques that we talked about and a whole load of body-based regulation techniques, which you can see there. And then there's the relationships and the communication.

46:17And also not exposing yourself unduly to things. Now, this is an approach that I've developed called Solo Soma, which is a 20 minute movement meditation, sensory based movement meditation. And I've realised that it was designed as an approach to calm and balance the autonomic nervous system, engaging all sorts of different approaches, tapping and breath work and touch and sound and rhythm and repetition, stretching and even cognitive approaches as well. And I find that people with sensitive nervous systems, not solely ADHD, but most certainly ADHD, approaches like this can work really well. And so this is what I refer to as somatic practice, so body-based regulation.

47:08And equally, you can use stretching, yoga, pilates, qigong, tai chi. There's a whole list of different things. But solo soma is what I do and I teach my patients and it works really, really well. I need to have a study to really demonstrate that. But many of the individual components is drawn from maybe 13 or 14 existing approaches, many of which have an established evidence base. But something along these lines, I think, is excellent for resilience. And I think identifying, know your trigger. Remember, identify your high risk situation. And that might be any of those examples there. And prepare for it.

47:49rehearse script and really think about things in advance and remember this separating identity making a mistake does not mean you are globally effective and we've mentioned some of these things already so finally clinical management well we don't really know is the answer we know that treating ADHD can be helpful you know you bring regulation when you use stimulants in ADHD you reduce emotional impulsivity but there's a class of medications called the alpha-2 agonists and they include two medications guanfacine and clonidine they're both non-stimulants and at least anecdotally they have very powerful effects regulating emotions and calming the system and calming the hyper arousal and i think they are most likely well in my experience of prescribing hundreds upon hundreds possibly thousands of people with ADHD medications without a doubt the extended release ideally extended release brunfacine can be extremely helpful at calming the system now obviously there might be a role for other medications depending on what else is going on but I wouldn't use antidepressants for example to treat RSD when there's no depression present and non-pharmacological clinical approaches can include education we talked about how important knowing about this thing is but there's cognitive behavioral therapy and and other approaches as well acceptance and commitment therapy which is very much about um this sort of area as well and relationship work where necessary and finally what does other someone, loved ones need to know about RSD.

49:40Well, there's some things that don't help, like calm down and you're overreacting, that might not be that helpful. But validating, offering space, gentle reassurance, all these things can be helpful. So it's about lowering the emotional temperature, naming the fact that they're there for the individual, but it's not the time to debate at this level of peak activation. Finally, RSD is real, it's embodied, it's deeply impairing and we know that anecdotally even if the formal science is still catching up. Its best way of understanding RSD I think is an overloaded or oversensitized nervous system that is hyper vigilant and remember that order it's body story emotion behavior and that those those adaptations that can occur over one's life and how important it is that you focus both on in the moment regulation as well as long-term nervous system resilience and preparedness So you don't beat RSD by becoming less sensitive.

50:55You heal by becoming safer inside your own nervous system. A few references for people who want to look at the data, the research that I've alluded to today. And on that note, just a quick mention of the book, How to Provide with Adult ADHD, which is doing pretty well in the UK at least. and I discuss RSD amongst those other aspects of ADHD in some depth. Thank you very much indeed and I'm going to end there. Thank you so much for that wonderful presentation, Dr. Gusto. We got so many questions so I'll just get right into it. Do men and women experience RSD differently and do people who have trauma in their past experience, do they experience RSD differently than those who maybe didn't have trauma?

51:50Is trauma an aspect? So I do know that women and girls tend to mask a little bit more. I think there are subtle differences between the sexes. In fact, there's a very good, rather than take up too much time now, there's an excellent article on attitude on the differences between RSD in men and women and it directs anyone interested to that article because it really captures the subtleties and the difference between male and female responses and they are I think there's more masking and there's other subtle issues that come up as well in terms of the trauma question I mean the nurture argument that I put forward earlier is essentially saying that this is a small t trauma reaction.

52:47These events from one's past have primed the system and increased the hypervigilance. So the model is already there. If someone's had big t traumas, large traumas, PTSD level traumas, And without a doubt, the system is even more primal. And that triggering, it connects that individual to their index trauma, is going to result in a more likely result, in a more dramatic response. So without a doubt, trauma is a modifying factor in this picture. But we could see the whole thing as partly explained by trauma. um are rsd symptoms exacerbated by perimenopause or menopause and does this get worse with age do we know so we don't know the answer to that and many questions but without a doubt adhd symptoms are unmasked during the perimenopausal period and anecdotally women in that period of their life.

53:59There's a lot going on, isn't there? If they've had children, the children are often leaving the family home. The role of the woman might be changing at that stage in life. And then suddenly ADHD, which was previously managed or not even reaching the threshold of ADHD is very much unmasked. And as a rejection sensitivity is a central component of emotional dysregulation, and emotional dysregulation is a core feature of ADHD, the answer is clearly going to be yes. But is it worsened over and above other symptoms? That needs some research to look at that in more detail. um someone asks how early does the onset occur of rsd or does it begin to present itself regardless if the person has adhd or another diagnosis so um i can talk from my own experience i i remember experiencing what i now understand to be rsd at primary school and um thinking one thinking that everyone must experience it and then realizing at some point that I was more sensitive than other people in the class and I was responding differently I think it's I think most people who recognize this pattern of rejection sensitivity will remember experiences as they think back to their childhood whether it's being picked for a sports team or being left out of a group that's huddling together in the playground that those experiences were perceived dramatically at times.

55:48And there was quite a lot of shame that was carried. So I think it comes into play very early, possibly even before all that negative talk that a child with ADHD experiences, suggesting that it may be more than just a response to these micro-criticisms, that it's a system that's already primed for vigilance to threat. So I think where it occurs, it seems to occur early on in life and travel with an individual throughout their life. And the factor that I think modifies it the most is understanding it's a thing and learning about the patterns and the responses. That was the thing that made all the difference to me in my own journey.

56:34It's understanding that this is a thing that happens and that I can't trust and rely on my responses. Therefore, I need to build in some pause, learn to regulate better. And for me, I became one of my areas of expertise is about different ways of regulating the system. And I'm pretty confident I migrated towards this because I felt the huge impact of this thing that needed me to react differently. And when I was able to put a name to it, over the five, six years ago, really, probably, it made a huge difference. So education is very, very important. Someone asked, is there an assessment tool for diagnosis of RSD?

57:21Or is it given that someone with ADHD will likely have RSD? There's not a validated tool. um william dodson um has a screening question um which is pretty much along the lines of uh the that i put on the screen a bit earlier so uh have you ever i don't want to get the wording exactly wrong but um you can look on any of the articles of rsd and get the exact two questions i think that uh that he asked i i don't think it's been validated so uh it might there might be useful questions just to get a sense of whether someone relates to this concept but one of the things we need to do is not just investigate the experience that people have and you know on a qualitative basis but we need to find ways of assessing for it and work out what's the best way to manage it as well what works what doesn't work as i said all those unanswered questions so there's a lot we don't know and so important to recognize that this might not be specific to ADHD this might be overlapping with multiple conditions but what we do know is that it is occurring more in ADHD but we don't know why or what to do about it properly.

58:46Okay I just want you to know that so many people commented that this was the best webinar ever and they just really appreciated the information and the validation and the guidance. So thank you so much, Dr. Cousteau, for joining us today and for sharing your expertise with our ADHD community. We appreciate you. Thank you very much indeed, Carol. I hope it's helpful. very helpful. And thank you to everyone here today. If your question wasn't answered during the webinar, we do share audience questions with our experts and yours may appear in a future edition of Attitude Magazine's Ask the Advisor column.

59:27If you'd like to access today's event resources, visit attitudemag.com and search for podcast 611. The slides and recording are posted a few hours after each live webinar. If you're listening in replay mode, simply click on the episode description. Please know that our full library of Attitude webinars is available as a podcast. It's called the ADHD Experts Podcast and it's available on most streaming platforms. Make sure you don't miss future Attitude webinars, articles, or research updates by signing up to receive our free email newsletters at attitudemag.com slash newsletters. Thanks, everyone.

1:00:10For more Attitude podcast and information on living well with attention deficit, visit AttitudeMag.com. That's A-D-D-I-T-U-D-E-M-A-G.com.

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