Do you have ADHD?

0:00This BBC podcast is supported by ads outside the UK. This podcast is sponsored by Pocket Hose. I'm a mom and a homeowner, so I feel like I'm always outside using a hose for something. And I used to go through a new hose every year because of kinks and tangles. I'm definitely not gentle with my hose. I drag it across the driveway, around the yard, and I just wanted something that's easy and durable. That's why the Pocket hose ballistic has honestly been such a great upgrade for me. It's super lightweight, easy to manage, and easy to store. You turn the water on and it grows, and when you turn the water off, it shrinks back down to pocket size.

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1:18In 15 minutes, he's in an ambulance, unconscious. In 15 years, he's a billionaire. This is Toto Wolff, Formula One's most powerful team boss and the breakout star of Drive to Survive. This week on Good, Bad, Billionaire, how Toto Wolff made his billions. Listen wherever you get your BBC podcasts. Hello and welcome. I'm Kimberley Wilson. I'm a counselling psychologist and this is Complex. The psychology podcast that I hope can help you cut a path through the many peaks and troughs of information around mental health. In today's episode, I'm exploring attention deficit hyperactivity disorder, which we know better as ADHD.

2:05If, like me, you see ADHD popping up seemingly everywhere on your social media feeds, the kind of posts that say things like the top five symptoms or three things that tell you you have ADHD, then this is the episode for you. Because looking at these lists, it's very easy to think that you have the condition. But according to research that we found, 70 % of the information shared on one social media platform about so-called ADHD symptoms were considered to belong to normal human experience by a group of clinical psychologists. And these are the people, my dear listeners, that we can trust. And so I really want to put ADHD under the complex spotlight to help us separate fact from online fiction.

2:58So, let me be your guide from the rusty bicycle of misinformation to the Formula One racing car of understanding.

3:10And my guest today is Joshua Munn, a therapist specialising in ADHD and OCD who also has lived experience of both conditions. Josh, a very warm welcome to Complex. Hi, Kimberly. Thank you for having me. It's a real honour to be here today. It's a real delight to have you here. Could you tell me and the audience a little bit about your work? So I'm a cognitive behavioural psychotherapist. I've worked in a mental health space now for over 10 years and I primarily work with ADHD, anxiety and OCD. Thank you. And how does ADHD show up in your work? It can show up in chronic stress, burnout. It can show up in constant overthinking, guilt, shame.

3:50And it can just show up across the board. I work with many clients who have been diagnosed with anxiety for many years and actually translate that actually have had ADHD and their anxiety has been this massive coping strategy that they've used. Thank you. And I think, so I've been told, like me, you were one of the youngest in your kind of training cohort. So when I started training, I was in my early 20s and I literally had people say, are you sure? this is really heavy work are you sure so what got you into this work and so early yeah I think I've just always been passionate about mental health growing up both my parents are dyslexic so I think from early I saw differences in learning processing the world and thinking okay so these brains work like that and these brains work like this yes what's going on yes Why does my brain work like this?

4:41And now listeners know that I love to start with a definition. So Josh, could you give us an outline of ADHD? It's defined by a persistent pattern of difficulties in three main areas. Inattention, so struggling to focus, hyperactivity and impulsivity. so for ADHD to actually be diagnosed you need five or more symptoms of inattention and or impulsivity or hyperactivity. And so inattention you can't keep focused attention. Yeah very forgetful as well. Hyperactivity is that kind of agitation physical irritability what does that look like? Really good question because for years we used to see it as like an external hyperactivity and I think this is why a lot of females didn't get diagnosed because what we know now as hyperactivity can also happen in the mind.

5:31So it can be a physical or a psychological behavior. Exactly. Like myself personally, my hyperactivity is very much in my mind. My mind doesn't really switch off. And a lot of the clients I work with sort of say the same. And then the impulsivity is kind of not having that break between a desire and an action. Exactly. It's sort of struggling to control those urges, impulses, but the impulsivity can also be emotional responses as well. So we can see it in more like addictive behaviors like excessive spending, gambling, but we can also see it in more like emotional outbursts, being snappy, saying things that you regret in the moment.

6:03That's a really important distinction actually. And you said how it presents in the people that you work with and some of your clinical work. What do you see? Yeah. So how often people describe it to me is like it's having a hundred tabs open at once in their brain and they find it so hard to shut them down and it feels like their brain is a hundred miles per hour all of the time. They find it hard to shift their focus of attention. So I think there's a big misunderstanding with ADHD that it's about not being able to pay attention. It's not that. It's more so that we struggle to regulate our attention.

6:32So many people I work with can hyper-focus. They can zone in on things that they enjoy, that they get reward from. However, they then struggle to shift their attention to the things that they need to do, which can become very problematic in their everyday life. And I can definitely see in the therapy room how seemingly straightforward tasks can suddenly become really difficult so for example a passport renewal you know you just have to take your form down to the post office and send it off but then perhaps you know my clients are something like oh well do i should i take my photos at home or do i have to take them in the booth at the post office and do i should i change my i'm going to change my hair but do i change it now or do i wait till afterwards and sure and suddenly their brain is just taken over by all of these other questions rather than just the you need to fill in the form.

7:23Yeah yeah I see that all the time our brain just getting in the way of everyday tasks and again being hijacked by it. Feels exhausting. And I think that's a big word Kimi that I hear every day is it's exhausting to live like this because we can go about our day and get things done but it comes at a huge cost because often people I work with burn out they feel very tired because a lot of time in sort of social settings, in work settings, they mask. So they can present as like a perfectionist. They can try really hard, but underneath that, they're really struggling. And sometimes it's not visible to other people as well.

7:54Well, a lot of time it's not. Yeah. And do you mind me asking what it's like for you? I've always been a bit of a perfectionist myself. I've always thrown myself into things. I think that's because I've always overcompensated because I've always been a bit worried about how I might be viewed if I took my mask off. I have to have structure and routine in my everyday life because if I don't my life is chaos so people often think I'm super organized but I'm not naturally I have to put a lot of effort into having structures in place each day so that I can function and it almost sounds like the perfectionism is both part of the mask kind of covers up the chaos but also part of the strategy that helps you to kind of function in the rest of the world exactly that because in some ways it helps, helps me to function.

8:38But then in other ways, it's like then I never feel like I can switch off and be quite hard to relax at times. And again, a lot of the people I work with will relate to that as well. You said that there was a kind of compensation happening. Was that because you recognised perhaps that your brain was working differently or you perceived that other people were finding things easier than you did? Yeah. So even when I was at school, you see people like be in class and pick up things very quickly. And I couldn't even remember what was being said unless if I was really interested in the topic or I really liked my teacher the opposite I would like really zone in I'd love it but if it's a topic that I found really difficult I would zone out and then I would feel quite different because if like the teacher would ask you to read out your answer I didn't even know what was going on so that would cause a lot of anxiety so I think that's why I've overcompensated as an adult to always make sure I'm on the ball so if I'm in like a team meeting I'll take extensive notes and if I get picked on I have an answer so that it helps me sort of recall the information.

9:34Yes we've heard a lot about how social media is stealing our attention shortening our attention spans is there any link to that in ADHD? Massively and although there's no data at this point to back it up I think there will be in years to come I hear every day and in my clinic room many people I work with ADHD they find their phones just really hijack their attention it just makes everyday tasks that bit harder because they find so much time doom scrolling.

10:03And at this point, I'd like to bring in a listener story for you to listen to. So this is from someone that we're going to call Trinity to protect her identity. And Josh, I wonder if you can kind of understand or relate to what's been emailed into us. So Trinity says, I'm a therapist and I also live with ADHD. For me, it's never just been about attention or organisation. it's been about pleasing people second-guessing myself feeling things deeply and carrying a lot of quiet shame for finding life harder than it seems to be for other people a lot of people with ADHD carry deep shame from years of being misunderstood or feeling too much how do you help people work with that in a way that actually lands emotionally and not just make sense in their heads.

10:56Actually, I think this is the first email that we've had that's from a therapist. So thank you, Trinity, for sending that in. What do you make of that, Josh? Yeah, first of all, thank you, Trinity, because everything you said in that email is relatable to me and my life. And in terms of your question about shame, I think it's such an important one, because sometimes what I find in therapy as well, particularly with cognitive behavioral therapy, which is very skills-based, technique-based, if we go too quickly into teaching techniques and working on changing behaviours. I think it sort of misses a huge part of ADHD, which is the emotional component, which often shows up in shame.

11:30Yes. I'm thinking of someone that I've worked with. Whenever they're trying to sit down to do a task, whether it's folding their laundry or filling in a form, they're actually sitting down with this kind of big shame monster that they end up fighting with. Exactly that. And sometimes when we go into sort of like teaching the techniques too soon, I think it sometimes reinforces a lot of these negative beliefs because they might struggle to do the homework as we call it in CBT and then it might reinforce the shame like I can't even do therapy right yes which then obviously sort of compounds the problem that's a real threat isn't it oh come on you know why can't you do this exactly then exactly that perhaps you feel like you're beyond help yeah and that's why it's so important to work with shame because insight alone rarely touches shame like most people can logically see that they might not be a failure on paper but they don't feel it they don't feel it in their heart because shame shows up in the body yes I don't see shame as like a primarily a thinking problem.

12:24Thinking contributes to shame, but I think it's more so to do with our nervous system and how particularly early experience in life have been stored in our nervous system and come out in various ways. I think shame is entrenched in the body, so we can't sort of logic our way through shame. I think we have to use the body. So some ways I do this, Kimberly, is first of all by just slowing down, just noticing where do you feel that shame in your body, seeing if we can make some space for the shame, which takes a lot of work because we spent our whole life trying to avoid shame and trying to push it away so I think it's really slowing down and learning ways to hold shame with more kindness and compassion to hold it more lightly so we're not always trying to resist it get rid of it because that's how it shows up in perfectionism people pleasing because it's like our shield against shame yeah so in a way what I do with my clients and myself is trying to gently drop that shield and see what it's like to actually just respond with some kindness towards these more vulnerable parts of ourself That's really lovely.

13:15And I think it's really helpful perspective on the emotional side.

13:23Okay, so I'm going to try and stay calm when I say this, but one of my bugbears about the way that ADHD is depicted on social media is just these really generalized, vague symptoms. So for example our assistant producer said that she'd seen a clip where if you leave your cupboard doors open it's a sign that you have ADHD what do you think about that yeah very similar to you Kimberley I need to take a deep breath because I hear this all the time I'm a little bit ADHD or my ADHD is playing up today no ADHD is constant I don't get to pick and choose when my symptoms show up they do get exacerbated by stress don't get me wrong it's every day it's constant doesn't matter if I'm on holiday, it doesn't matter if I'm at work, at home, these symptoms will be a part of my everyday life.

14:14Yes and so to put that into context because again I think when you look at these listicles of symptoms it's easy to kind of identify yourself in them. How many people do actually suffer from it? What do we know? Yeah so the prevalence for adults is two to five percent but we know that there's many more adults that haven't been diagnosed so there's a whole thing at the moment we're overdiagnosed in ADHD but it's been undiagnosed for many years and for children the prevalence rate worldwide is about five to seven percent. And is that because it's harder to diagnose in adults? Yeah because I think usually ADHD is picked up at school and I think once you're an adult it's much harder for it to be noticed by others.

14:53Yes and I think also doesn't the hyperactivity kind of mellow as you get older is that right? Yeah so the traits can actually change based on age and where you're at in life as well. And how does it present differently between the genders? Yeah so what I often hear in my sessions is for a lot of females the hyperactivity is internal. I think that's a big big distinction so a lot of female clients I work with will say that their whole life are just constantly in their head daydreaming, overthinking, over-analyzing, questioning and that's where their hyperactivity shows up so they're not sort of being really loud and super impulsive externally, but internally it's very different.

15:30I think that's the key. The key that makes it ADHD because I think the traits, yeah, they can be universal, but what makes it ADHD is when this stuff is constant and it's been there since childhood. And it makes me think that because one of the things that girls are often taught and socialized into is to be quiet and to be thoughtful and to be considerate. And so maybe that kind of creates more of a mask, more of a shield for young girls who might be struggling with internalised ADHD symptoms compared to the boys who might be, I don't know, getting into fights, kicking things, you know, however it expresses for them.

16:06Yeah, I often find with the female clients I work with, it shows up a lot in anxiety. And for a lot of the male clients I work with, it shows up in anger. It's a lot more outward with their behaviours, whereas a lot of the females I work with, it's just, yeah, that internal clutter. Just not being able to switch off, always feeling like you should be doing more. And what do we know about the causes of ADHD, Josh? So what we know from the research looking at twin adoption and family studies is that there's a huge genetic component, roughly about 70 to 80 percent. So likelihood is if you have it, you'll see it in a family member as well.

16:37But we also know that the environment can also play a part. And the way I often think about it is like the genes are like the ingredients and the environment is like how we cook the ingredients. So the environment is more like risk factors. the environment can really impact the severity of symptoms. Do we know anything about those risk factors? Yeah, so we know that chronic stress and early trauma can impact neural development and increase the severity of ADHD symptoms. But also we know that premature birth and prenatal exposure to tobacco and alcohol can also be risk factors.

17:18earlier on we heard from trinity but we have had as i said a lot of emails in about adhd and so i actually want to bring in another one and this is from someone that we're going to call billy billy says the constant thread through my career has been a sense of overwhelm either multiple small tasks build up to an impassable coagulation or a particularly difficult task results in inertia that can last for days. Thank you for that, Billy. Josh, what do you make of that? Yeah, we often find with ADHD, we just live in our stress system. Often people will describe it like they bounce between excitement of like chasing dopamine and reward, and then it's just replaced them by chronic stress and anxiety.

18:02So it's like a lot of people I work with, they in a way use anxiety and stress to get things done. But it means that they spend a lot of their days. What do you mean by that? They use the stress to get things done? Yeah, so they will like leave things last minute. So even though they know that they've got a few weeks to start tasks, they'll leave it till like the night before, particularly students that I work with. And then because they get sort of a rush in cortisol, adrenaline, the ADHD brain likes that. Yeah, they use the pressure as their driver. And they do get things done, but it means that they're at high risk of burnout because it means like we live in a cycle of just constant stress.

18:34And we know with ADHD, it can be quite hard to prioritize tasks. So things that might actually be urgent, if they don't give quick reward or you might not enjoy it, might be dismissed and replaced by things that give quicker reward but aren't very urgent. Yes. I always think about the time management matrix. Yes. Is it urgent? Is it important? And how we can so often get pulled into the quadrant that is not urgent, not important. Yeah. And then this just leads to this living in this constant state of stress and overwhelm because it's like people I work with, they actually know what they need to be doing.

19:04They know they need to be doing this stuff, but they just find it so hard because of how their brain is wired that they just constantly find themselves in these repeated loops, which then triggers more self-criticism. Because the picture you're building is a mind that feels overcrowded, feels noisy, almost like being stuck in a traffic jam in a busy city. And we've said it's exhausting. I wonder then how that impacts building relationships. And what do we know about the relationship between ADHD and kind of our interpersonal relationships? Oh, it's massive. again I see this all the time in the therapy space if you think about if we're just constantly trying to get by each day because of this internal chaos it's very hard then to hold other people in mind which again reinforces shame and guilt because you can feel like you're a bad parent you can feel like you're a bad partner bad friend and it's just never ended yes and I have a friend of mine who feels is constantly apologizing for themselves and I I know them long enough now to be like I think this is just a part of who you are like I think but I guess if you are still masking if you are still shielding if you are still trying to be a perfectionist about it that might not be obvious yeah even just as an example remembering birthdays anniversary stuff like that because people actually can struggle with their their memory and so busy they can sometimes forget and then this might show up as like they're being selfish or they don't care but actually they do care that's where the shame comes from for years we often blame ourselves why am I selfish, why am I too much, too sensitive, too self-absorbed?

20:34I hear people say all the time but it's not your fault. I'm aware that we've been kind of thinking about all of the downsides and the negatives and the problems and I wonder whether there are aspects of ADHD that are lighter or positive. Yeah that's so important. A lot of people I work with, myself included, with ADHD are very sensitive and for years I used to downplay that I'm not sensitive. I used to try I had to be like one of the lads and I don't show my emotion, but I have big emotions. And it's only since becoming a dad in recent years, I've started to accept that that's fine. It's okay to have emotions.

21:08I think it's highlighting that to the people I work with that a lot of them are super caring, super kind. They care a lot. They care deeply. And that's why they often feel so anxious because they care about their life a lot. They care about their relationships a lot. And so in your example, you've taken that care and that interest, translated it into your profession. Yeah. Yeah. Which is a beautiful thing. Yeah. And also, Kimberly, a lot of people I work with, they actually are extremely creative. We can think outside the box. You have all these bright ideas. Sometimes it's hard to put them into action.

21:37But we can still think about stuff. We can still come up with these wonderful ideas. And when we can commit to it, it's amazing. Sensitive, compassionate, creative. Is there anything else? Yeah. And this is going to sound funny, but a lot of people are actually good in crisis, believe it or not. Because I think, this is my own theory, is that we live in crisis every day. I think when actually like an actual crisis happens, we're prepared. Yes. And again, that attunement to emotion can actually make them very loving human.

22:08Now, we've talked about ADHD being a seemingly common self-diagnosis. So I'd really like to look at when disorganized or distracted behaviors that we might have in everyday life tip over into being an indication of a condition. if we put it on the scale from just being normally distractible, normally disorganized, into something that we might consider to be an indication of a condition? Yeah, that's a good question. Because, yeah, a lot of the core traits of ADHD are universal to humans, but it doesn't mean you've got ADHD. I think the crossover is when this stuff is longstanding. So from childhood, typically before the age of 12, it's across more than one setting, so it doesn't just show up at work, it shows up across your life.

22:53So it's not just that I'm not paying attention in the office. It's that I'm distractible when I'm with friends, when I'm doing leisure activities. You want to pay attention, but you can't. It's constant. I think that's the key. No matter what you've tried. I work with loads of people. I've done loads of therapy, meditation, exercise. And they're like, but my brain is still the way it is. And this consistency, this is where in the assessments, we'll often talk to people's parents or family members, siblings to say, were they like this when they were 7, 15, 21? Exactly that and also when ADHD is diagnosed they don't just look at the cluster of symptoms they also look at the cost so they really do explore the level of impairment that it's having on your life and how this impacts you.

23:37And can you say something about that impairment? What might that look like? Yeah, so that could look like not being able to hold down a job finding relationships very difficult to sustain experience chronic stress, burnout changes in your mood where you might feel more low, more anxious it might affect your sleep a lot of people i work with adhd have chronic insomnia so literally it can affect all walks of life and i think this is really important because and not just for people who have the diagnosis but what we do on this podcast is to try to delineate when you should worry yeah from when you shouldn't worry yeah and so i think if you're reading a lot of these social media posts and you worry yourself unnecessarily about your everyday bog standard disorganization then you create a lot of stress for yourself unnecessarily.

24:22Yeah, exactly. Are you seeing people worried about acknowledging a diagnosis because of the stigma, because of the conversation around it? Yeah, massively. They feel worried about how maybe family members might judge them or they're just jumping on the trend. And it's so sad to see because actually that diagnosis could change their life but they feel so reluctant because of now the stigma of it being overdiagnosed when actually it's not.

24:50so if we think about solutions and support what can people do either alongside a diagnosis or if they're waiting for an assessment because i mean depending on where you are in the country waits for assessments can be very very long what can people do to look after themselves yeah great question i think number one and this is one that i've worked on myself for a number of years now is self-compassion being able to hold yourself with a bit more kindness how would that sound because i think sometimes self-compassion just feels like a phrase yeah for years that's how i see it like be kind to yourself what is this it can look like compassionate behaviors looking after your nutrition trying to move your body taking a moment just to breathe i think when you live with adhd it's so important just to drop your shoulders throughout there and just take a breath take a breath offering yourself some kind words like i try to do this a lot when i'm doing hard tasks like just saying Josh it's okay you've got this so just trying to be a bit more supportive in your inner dialogue trying to be a bit kinder to yourself through your behaviors yeah talking to yourself like you would a friend this is hard I believe in you you can do this and it will feel very uncomfortable to begin with it might feel a bit alien it might seem like a bit pointless this isn't for me but it can really change things and I think the key with that it's not about replacing self-critical thoughts because they're going to show up just acknowledging the self-critic thinking about a more kinder way to respond can really help.

26:09Yeah, you don't have to entirely kick them out the house, but you can give them a cup of tea, sit them down, while the kind version of you takes control. Yeah, that's what I do. I often put an arm around my self-critic and I sort of just acknowledge it's okay. I know you're a bit scared right now, but we're going to go and do this thing anyway. Thank you. Anything else? Yeah, I think another one is trying to think about your values and relying on values as opposed to motivation. Motivation and ADHD, bad combo. So do people, do you think, wait and think, I'll do this when I motivate it? Yes. So like you might wake up and your brain will say, don't exercise today.

26:43What's the point? It's boring, etc. So think about the why behind it. Is it because you want to take care of your health, your body? Is it you want to take care of your mental health? So using your values as an anchor to help guide your decisions rather than your emotions. It's so good to hear that because we want to make clear that this is a serious diagnosis and it can lead to problems. but also at the same time it doesn't have to be a full stop but that having a diagnosis can allow you to identify the tools, the people, the services, the resources that can help you. Yes, I think my message would be that you're not broken.