ADHD & Rejection Sensitive Dysphoria: The Emotional Pain No One Explains

0:00How do you know if it's RSD or if it's not? So the big thing with RSD, if you really go into the detail of the history, there will always be... Welcome to The Hidden 20%, our neurodiversity charity on a mission to rewrite the future for people who think differently. Together with you and an eclectic range of brilliant guests, we can break the cycle of silence by smashing outdated stereotypes, exposing the myths, and sharing the most up-to-date truths about what it really means to be just different, not deficient. The best way you can help is really simple. Subscribe so you never miss an episode, and if you can, donate to our charity through the link below.

0:48So enough preamble. I'm Ben, your host. Let's get into today's episode.

1:00Shai, how many people do you think you've seen for psychiatric ADHD assessments? Oof, probably about 15 ,000 at least, yeah. So that's what I've seen. But then I've overseen other people's cases as a clinical lead, right? So I've overseen lots of other complexities, high risk patients, complaining patients. How many do you reckon then? Oh my God. Well over 20 ,000. Adults, by the way. Okay. Adults. I should caveat this. Let's clarify that. Yeah. So I'm a general adult psychiatrist by training background. So I came across ADHD in a strange way. I came across it when I was working in prisons and in the court system.

1:42So I came across ADHD mostly in its impulsive form, which leads to criminality. Yes. Where it played a role in crimes, especially certain crimes like, you know, random shoplifting, theft. Diagnosed or undiagnosed? Undiagnosed, right? So in the prison population, there is a huge proportion of patients that have got undiagnosed ADHD their whole life. And it's particularly the hyperactive impulsive type. Okay. Right, as opposed to the inattentive type alone. So people engage in dopamine-seeking activities in lots of ways. Some people will be as benign as they just play their PlayStation all day long.

2:22Some people will get into gambling. Some people will get into drugs. Some people will get into alcohol. Some people will get into crime. And it's certain types of crime that you see. So, for example, shoplifting when they're not sort of homeless or desperately needing food and water. Yes. Just because. Almost for a buzz. Sure. Right, or what we used to call joyriding. Yes. You know, stealing the car in 60 seconds type stuff. Yeah. So we used to see that kind of thing in the prison population. And when you treat them with stimulants, they're remarkably calmed down. So yeah, so that's how I, coming back to true ADHD fashion, coming back around to where I started.

3:00So this is how I came across it, actually, which is quite a strange route to come across it. And then after that, I've completely gone down the kind of neurodiversity route in my work, both in the NHS and privately. But it's in adults primarily that I do. And what surprises you about ADHD assessments and the people you've seen? The massive spectrum. Okay. From people that are so disabled with it that they walk out of their showers with their shampoo in their head. Okay. To people who forget to eat and drink, things like that. to people who, I know this is not the right word to use nowadays, but more higher functioning.

3:37I don't know what the right word for that is nowadays. Lower support needs. Lower support needs, right. And therefore, what I've learned is you should try and tailor treatment to the individual. So the national guidance says, start everyone on medication first night. I don't agree with that. I say that as someone who prescribes meds. I don't agree with that. I think for patients that I see that are definitely on the milder end of the spectrum, yes, medication might help them, but I tell them don't go to medication first. Try things like coaching, mindfulness, CBT, techniques that can help you yourself if you can without the meds and then go to the meds if you need to.

4:15But definitely for the moderate severity, not, I mean, the chap that's going out of the shower with the shampoo in the hair, that's very extreme. But even the moderate severity where it's impacting you in different domains of your life, medication might be a good first place, but then still do the coaching because in the longer term, if you can manage this yourself, it's good. Yeah. With your brain not on medication. Yeah. Or maybe you might need a lower dose. Yes. See that a lot as well. And then where has RSD come into your work or your assessments? Everywhere. Let's unpack RSD. So RSD stands for rejection-sensitive dysphoria.

4:52Dysphoria comes from the Greek word, which means unbearable pain. That's what it means. So rejection-sensitive dysphoria is a very strong emotional reaction akin to unbearable pain that occurs in the context of real rejection or perceived rejection, which is an interesting one. There might have not even been a rejection there. None of us likes to be rejected. Yeah. Right? No one would enjoy that experience unless you're particularly sadistic. But this is a lot deeper than that. Most of us will recover from a rejection. We can rationalize that after some time, typically. Or we'll go to friends and family for support, etc.

5:33And we'll get over it. Rejection-sensitive dysphoria. So one myth, you don't just see this in ADHD, but I'll talk about that in a minute. But you do see this a lot in ADHD as well. When I bring this up with a patient, they'll often break down into tears. really and in up to a third the study showed up to a 30 percent of patients it's the most debilitating outcome of having adhd okay more than attention concentration deficits okay right more than being physically executive function more than that wow it's worse and actually we'll talk about treatment of it as well but if that can get treated afterwards they'll say i don't even care anymore about my attention and concentration difficulties this was the thing that was causing me impact in my life.

6:18Wow. So it was a term that was coined by William Dodson, very famous psychiatrist still around. And it was initially coined in children. So this was described as the overly sensitive children who had temper tantrums over the small little things. Okay. Who were like inconsolable with their crying all the time. And then that evolves into adulthood. Now this rejection sensitive dysphoria, there's a lot of psychology behind what the causes are behind this. The key thing behind this is the mini traumas that someone goes through with undiagnosed ADHD. Not just ADHD. I'll come back to this. Yep. But let's just talk about ADHD for a minute.

6:59So if you go through your whole life with undiagnosed ADHD, you will often feel misunderstood for the majority of your life. Mm-hmm. Right? And often you will have feelings of inadequacy. Okay. So I am not a good enough son or daughter. I'm not a good enough parent. That one's a killer, actually, for people. I am not a good enough student. I'm not a good enough employee. I'm not a good enough partner, romantically. I'm not a good enough friend. Then the next phase of that is, I feel crap because I let you down. I've let down all these people. That's esteem focused, right? Right. Right. So if you then develop low self-esteem, what's your natural reaction to things?

7:47Number one, you're going to start fearing letting people down in the future. It's like a trauma response. I'm just unpacking this because people throw around the term RSD, but that's a natural evolutionary response. It's not just coming out of nowhere. Depending on your personality type, we'll either be defensive and attack the other person, or if you're more introverted, you'll attack yourself. If you're maybe an extroverted personality type, your defense is you're going to react to the person that you perceive is either rejecting you or you're going to take it in that kind of way. So therefore you're going to, as a child, come across as a difficult child or as an adult come across as a generally difficult adult.

8:29Now at this point, you might start getting diagnosed with other conditions like a personality disorder. Really? Yeah, because it can look like that. Okay. Right? Like a really reactive, this person is very difficult to get along with, they're very attacking. If you're more introverted as your nature, you're going to attack yourself. And that looks like depression. Sure. That looks like anxiety. In some cases, it can even be suicidal ideation and suicidal attempts. I've had patients who had a breakup when they're young. So I'm not talking like a breakdown of a marriage. I'm talking a teenager breakup.

9:07then they've been self-harming, right? Or actually attempted to take their own life, which is pretty extreme at that age, right? And then they get diagnosed with things like borderline personality disorder. And are you saying that that is RSD? It can be if you unpack it, right? So you have to know the nuances and the differences, right? But to an untrained eye, if you don't know what RSD is and you only know about borderline personality disorder, what are you going to diagnose that person with? the thing that you know, isn't it? The man with a hammer sees every problem as a nail. Yes. Yes. Right?

9:43So then you're going to take that person down a completely different treatment pathway, potentially. Coming back to different responses with RSD. Again, if you're more introverted as a person, how might you try and cope with this? Let's avoid the rejection. Sure. Retreat. Retreat. So you're going to avoid social interactions. If you avoid social interactions, what might you get diagnosed with? Social anxiety disorder. Okay. Because you're going to go to the GP or the psychiatrist who's going to say, no, I absolutely can't stand. I just, I avoid, I will make up excuses. I'm not going to my work party.

10:19Yeah. Social anxiety disorder, what are you going to get put on? Well, first of all, you might get some CBT, fair enough. You're going to maybe get put on some antidepressants. Okay. To try and correct your serotonin levels. Okay. You're going to take those antidepressants, you're going to feel emotionally numb. Okay. And you're still going to be anxious. Yeah, and still not want to go out. Right? So this is where, if this is not picked up, it can look like other things. Yes. And this is how ADHD in general can look like other things. Yes. Right? Another coping mechanism to RSD. Okay, I don't want to be rejected, so I'm going to become a people pleaser.

10:56Mm-hmm. You're not consciously thinking these things. Sure, sure. This is subconsciously happening, right? You stop learning to say no, even if it's not great for you. so I've had people who tell me that they've been in the worst relationships that were actually I'm not just talking this is a boring relationship like abusive etc and they've just stayed in it now there's there's more complexities to that than than that because there's there's the whole dynamics of abuser and a victim and that's that's more complicated but or they've stayed in maybe sort of saying yes to their employer oh yeah I'll do that over the weekend type of thing when you didn't want to do it over the weekend, right?

11:35Yeah. There's lots of different ways that people end up sort of coping with RSD, right? Unhealthy ways. With your clients, how do you know if it's RSD or if it's not? So the big thing with RSD, if you really go into the detail of the history, there will always be a trigger. Okay. What's called an external stimulus. Okay. A cause. Okay. And they will clearly be able to define that cause. Okay. It will come on all of a sudden. This is the nature of it. It can even be described as a physical pain. I've had some patients that experience chest pain, chest tightness, and then it almost looks like a panic attack.

12:25Wow. Right, so it's that visceral. Okay. And once it comes on, it's very hard for them to stop it, unless they've been trained, which we can talk about treatment in a minute. It's very hard for them to control it. Yeah, just tell me about that. Okay. Stopping it and controlling it is really difficult. Let's go into ADHD now a little bit here. The definition, what does it stand for? Attention Deficit Hyperactivity Disorder. It's not a deficit disorder, this. It's a silly acronym. Yeah, it will change. The name will change in the future. It's not a deficit disorder. What would you call it? It's a dysregulation disorder.

13:02Okay, a DD? Well, yeah, I don't know what that would be. We'd have to figure that one out. But it's a difficulty with regulating, okay? So it's a difficulty with regulating attention, meaning at times, this is where people talk about hyperfocus. So you can have moments of absolute focus where people have told me I've been sat there doing this project for 18 hours and I forgot to eat or drink. And then there are other times that they can't focus for more than a few minutes. And often it's interest-based, which is someone would say, well, isn't that everyone? But no, this is to an extreme. Sure.

13:33And sometimes to a detriment. Yeah, absolutely. Regulation of emotions. They're not regulating their emotional responses. So RSD is very much linked to emotional dysregulation. So if we look at what's happening in RSD, for want of a better word, there's a lack of rationalizing a situation. Yes. That's what is going on. The causes behind that might be the low self-esteem, the expecting people to look down upon me, blah, blah, blah. That's all underneath. Sure. But on the surface of it, you're not rationalizing the situation. So it's a disproportionate reaction to a quote-unquote normal reaction.

14:18So it's called mood congruent. Now, you asked me about the nature of RSD. Yeah. And how does it look different to some other conditions? RSD is mood congruent. Tell me what that means. That means on the surface of it, a sad situation, a sad stimulus produced a sad reaction. Yeah. The volume of that sad reaction was off the scale. Okay. Okay. So if we now look at, say, a condition like bipolar disorder with psychotic symptoms, When someone becomes really manic, properly manic in the sense of the psychiatric term, not just like I feel a bit manic today like people use colloquially, they will have mood incongruent symptoms.

14:59So they might be in a sad situation and they'll be laughing their head off and look very bizarre. This won't look bizarre. What this will be looking like is, bloody hell, they're blowing a mountain out of a molehill here. That's what it will look like. Extreme. Yes. But what is that? You've lost your ability to rationalize. And really what's going on at the prefrontal cortex level of the brain is there are the loss of inhibitory signals for their emotional response. Okay. So it's a lack of inhibition of the emotional responses. Yes. Okay. Right? Yeah. So that is then linked to emotional dysregulation.

15:40Emotional dysregulation, essentially, if you want to put it in a very non-medical way, is you feel the high highs and the low lows of life very intensely. Yes. It's the intensity, right, of those emotions. But it's congruent. Yes. It makes sense. Yes. But it's just extreme. A rejection sensitivity dysphoria response is basically an amplified response. It's an amplified emotional response. So the boss says, Shai, I'll have a quick chat on Monday about something. Not a big deal at all. Don't worry about it. I'll tell my admin to create just a 20-minute point. No one really likes that. Sure. Because that's crap feedback, right?

16:20Yeah. But for someone with RSD, that will ruin their weekend. Yes. So because they are imagining all the worst case scenarios, there's a lack of rationalization. But if I knew you were RSD and I said that to you on a Friday, that'd be really fucking cruel. Yeah, that's right. Wouldn't it? Yeah. But most people don't know these things. No, sure. And the reason why they don't know these things, and this is the next bit about RSD, which is linked to low self-esteem, is something called shame. People who have had longstanding RSD, number one, they don't know what that is. Yes. So there's no label to this.

17:05And in this case, a label is actually very important. Because otherwise, you just go through life thinking, what is wrong with me? Like, there's a level of you that will understand this is not rational. yes but you can't stop it yeah over time there's a level of you that will also understand because you'll have been told by your partner like calm down like what is up those rsd responses once people know and understand what they are does that then lessen them because there's a sense of psychological safety yes so i'm going to come to treatment in a minute so let's come back to shame though because this is important right because of shame you try and hide this from the world, right?

17:46Especially if you're that more introverted person. So then you don't talk about this to anybody, but you beat yourself up inside. And so if you don't tell anybody about this, then your boss doesn't know. Sure. Your partner doesn't know. And actually a lot of the time it's because you don't know. Yeah. You don't know, right? You just think, I'm just overly sensitive as I've always been. And you berate yourself. How do you see RSD present within relationships? Like romantic relationships? Okay, so there can be a lot of feelings of insecurity. This comes back to the original cause, which is the low self-esteem and I am not good enough.

18:29And I'm going to get found out that I'm not good enough. Yeah. That's the core underlying psychological hot thought. So if you feel that way, you're going to start becoming quite insecure in your relationship. So if you're insecure in your relationship and you're feeling a bit on edge, let's go into text messages. Okay. So I'll give you real examples. And this might sound really patronizing to the audience. Some of the people are going to relate to this, some of them are not going to relate to this. But they ended the text message with just a full stop. Right. Right? Or there's no smiley face.

19:05or there's no whatever emoji that's not here. Anything, right? Someone who's got really strong RSD now can completely read that in the wrong way. Okay. Right? Okay. And they'll be like, did I do something wrong? Yes. Now their partners got off and just busy with their work day, whatever they're doing. And that might actually kind of play on their mind quite heavily. But then because of embarrassment and shame, they don't bring that up they're not going to bring that up because they feel stupid almost yes and then from their partner's point of view they'll be like you're right something up and they'll be like yeah i'm fine so there's a complete sort of subtitles that's missing to this film now yes and then over time such stupid little things build up in misunderstanding so the partner who doesn't have the rsd now is like what is wrong with you yes and the other person again depending on their personality type either becoming more introverted with that and almost kind of berating themselves and feeling very more and more insecure or they start lashing out in other areas where it's coming out sideways it doesn't make sense Yes.

20:20To the other person. So it's like the things that are unsaid. But that then really can stack, right? And build and escalate. And then the other area where it can affect is if you're feeling insecure, you might be more prone to becoming jealous. Where then you start, you know, reading into like reading their phone. Yes. Or looking too much into things that were really quite innocent. Mm. Asking them too many questions. Looking a bit paranoid almost. Yeah. But again, the underlying reason is because of your own insecurity. But again, these are degrees, aren't they? It can be degrees, yeah. This is not...

21:05No, it's not happening in everyone. No, and this is not like, oh, I'm just asking my wife where she went today. Yeah. Because I'm interested in where she went versus like tracking her and interrogating her. Yeah. worrying that she's with another man all day, for example. Because ultimately you weren't good enough. Yes, yes. That's the thought. I mean, not saying that's what it is. No, no. But that's the thought, right? It can really be damaging in certain sense, right? So if my partner is RSD, how can I be kind, loving and supportive? So again, one thing about labels and understanding what this is.

21:43Because if you can almost understand what this is, at some point you might be able to have a laugh about this together. the humor is a wonderful thing in relationships. There's even channels about this with ADHD couples where they laugh about, this is my RSD, this is my ADHD. And I know that's really almost comical. Sure, sure. And maybe a bit cheesy. But if you can almost make it a bit more comical, this is this happening again. But naming it. And naming it. Naming the emotion. Naming the emotion, but not in a shameful way. Not in a like, this is your RSD happening again, isn't it? Not that, not in that way.

22:17Yes. Right? Because then that's not going to help. No. And if you really want to be there and support, then you're not going to do that. Understanding, naming, and maybe initially a bit of reassurance. Yeah. Until you can get to the point of rationalization where it's like, listen, we've been together for 10 years. We've got three kids, you know, let's. Yeah. Do you know what I mean? Like, have I got anywhere? Like, has anything actually ever happened wrong? Yes. Let's break it down. Let's break it down, right? Yeah. We've got a good marriage, haven't we? Everyone has ups and downs. Yes. So that's, you know, that's again, the imperfect world that we live in.

22:48Yeah. So introducing that rationalization. On a scale of zero to 10, how aware do you think society is of RSD? Because my algorithms on my social media is all twisted towards ADHD. I see RSD everywhere, right? But that's not probably everyone's algorithms, right? I know I keep going on about this, but the fact that it's not in the diagnostic toolkit, which most okay your average person who's not watching a hundred insta videos and stuff on on this subject yes will go to maybe their gp their gp will probably then refer them to some psychiatrist or whatever a mental health professional if that mental health professional doesn't know about this and it's not in the diagnostic toolkit so then why would they know about this unless they work in this field they're not going to be any wiser so therefore then let me ask a different question, which is in the field of psychiatry on a level of zero and 10, where is the awareness level of RST?

23:49I think if you're not working in neurodiversity at all, you're probably not going to be aware of this. Only if you're really working in this field, you start becoming aware of it because you start doing your own research because you're working in this field. If you don't work in this field, I can't see why you would do what this would do because it's not in the diagnostic toolkit. So where are you going to come across it? Yeah. And therefore, where does RSD feature within degrees and education for clinicians? Well, the whole of ADHD doesn't feature. I mean, it's not part of the training. There's the freaking system problem.

24:25Yeah. I mean, now, I mean, I don't know. I mean, it's been a long time since I was at medical school. When I was at medical school, ADHD was very much the hyperactive kid. Yeah. I think we're well behind in all honesty. Yeah. Sounds like it. RSD and hormones, thinking menstrual cycle, perimenopause, menopause. How does RSD feature there? Okay. So scientifically, we don't know the exact link. However, we do know emotional dysregulation is linked with hormonal cycles. Okay. So in your, say, teenage years, in the few days leading up to your period, your menstruation, you have a fluctuation of your estrogen and progesterone hormones.

25:06typically they fall. We definitely see worsening of emotional dysregulation there. So that's where some people get diagnosed with premenstrual syndrome. That starts improving about up to a week later when those hormone levels start coming back up. As you move towards perimenopause and then menopause, you have a declining overall estrogen level and the other sex hormones. And therefore you're in that phase all the time. And that's where you start getting, I see in clinic, for example, women presenting in their 40s and 50s, where they'll say, I was managing before, but now I'm not coping. That's like a red flag.

25:47Now, it's a complicated story here because some of that can actually be part of menopausal symptoms. So in terms of treatment, you'd want them to get their hormone levels checked because HRT might help in itself. Yes. But this is where, say if someone was on meds before, they might need higher doses now. Or if they weren't on meds before, some people might need meds at that point. Okay. Because those hormonal changes further worsen dopamine and neurodrenergic pathways. Got it. And serotonin are the chemicals as well. Yep. It's quite complex. Yep. But essentially that then makes the emotional dysregulation worse.

26:27And you hear the certain words like feeling overwhelmed. Yep. Particularly, obviously, in women. Yes. If we're talking about hormone or cycles here. Is there anything good about RSD? Sometimes in this world that we're living in, it's not a bad thing to be a sensitive person because it can lead to more empathy. Yeah. And actually, people who are neurodivergent, a lot of them, are actually quite empathic individuals. Yes. They feel other people's pain a lot. Yes. Maybe to an unhealthy sense. Yeah, yeah. But that's better than being a psychopath. Yeah, better than no feeling. Right. Yeah. Yeah. Just think of like whether you can channel it, you know, whether you can.

27:01Well, you see this a lot, like a lot of ADHD coaches, I almost joke about this, it's almost a prerequisite that they have to have ADHD or autism themselves. Okay. Yeah. Because when you have that level of empath, you will naturally want to then help other people that go through the same crap that you do. Yeah. Right? Because you just don't want to see that in someone else. Yes. And so they can end up becoming fantastic therapists, actually. Yeah. Yeah. And passing on, right? Because it's more than just, I get what you feel. I don't want you to feel like that because I don't want anyone to feel like this.

27:35Yeah. Right? Yeah. And then people become passionate. They take on podcasts and do all sorts of things because they want to spread a knowledge. Yes. So empathy, that's a strength. And sadly, in today's society, you're seeing less and less of empathy. Yeah, of course. Because it's not geared towards being an empath. To succeed in this world. yeah you can't be too empathic no in fact probably the opposite yeah right yeah don't be sensitive let's look at life right and i'm going a bit philosophical here but academically you're in a competition all the time sure especially in certain schools yeah i mean that's a whole different subject but the school system education system is wrong yeah in my view yeah then you go into certain work environments which might be very competitive so all the time you're constantly like the message of society is me me me me me me look after me you you you and that's why the person who's neurodivergent really struggles in this type of society because their brain's not wired to do me me me yeah and that's almost punished yeah you're almost punished for being too empathic nowadays because you just looked as soft or whatever exactly other words for it but Yes.

28:49So the advantage, if you want to look at it as an advantage of RSD, because you feel things strongly, you will be more empathic. Yeah. Because you will feel it in someone else. Yeah. So you'll pick up people's emotions in a positive or a negative way. Yes. Yeah. In terms of happiness, joy, sadness, fear, et cetera. You'll be very sensitive to other people's emotion. Yeah. And if you're very sensitive to other people's emotions, you're less likely to trod all over them. So you can become a nicer person, a better human being. It's quite a big deal. Yeah, which is a really important thing. Nice, I like that because it's a horrible sounding thing, rejection, sensitive dysphoria, right?

29:30And the meanings of dysphoria are dreadful. And I'm not trying to cover it over or put a nice plaster on it or make it seem like a positive because I know and you've told us it can be really debilitating for people. But if there's one thing to hold on to, it's the strength of feeling and the capacity for emotion. Yes. And relating to others. Is a very human thing. Yeah. That we need, ironically, more of. Yeah. Can anybody have RSD? Good question. I think this is a question that's not asked enough, actually. RSD does not just occur in ADHD. Okay. Right. What about ND people, neurodivergent people?

30:11Yes, it can occur in neurodivergent people in general. So you see this in autism a lot. Okay. But you also see this in generalized anxiety disorder. Okay. Where there's no ND, where there's no neurotype. Because in generalized anxiety disorder, the core psychological thought is the worst is going to happen. Catastrophic thinking, it's called. Okay. That's similar to an amplified emotional response. Okay. Because every situation, the worst is going to happen. Yes. So you're going to fear the outcome all the time. How does this correlate to a pessimist? A pessimist has a general what we call dysthymia, right?

30:49Well, their affect can be just generally a bit miserable. Yeah. You know, it's probably going to rain today. It's probably going to be like this. That's still a bit different from the acuteness of catastrophic thinking. Yes. Pessimists often don't look panicked because they are so sure about the crapness of the future. Yeah, there's less anxiety. There's this anxiety because you're just like, well, I know everything's rubbish. It's fine. You know what I mean? I'll just passively die. But pessimism is an interesting one because it's quite complex. And actually, some of that can come from upbringing.

31:20Okay. Yeah. Because pessimism is one form of your worldview. Sure. But it's also a form of where do I sit in society? If a lot of crappy things have been happening to you, or maybe your parents were generally quite pessimistic about their view of the world, that really gets transposed on you on levels that you might not recognize until you unpack that in adulthood. So that would therefore suggest that pessimism is part of the belief structure, right? I think so. Where is, we talked about rejection, which I assume a lot of people understand like the idea of rejection, right? Is there anything in failure with RSD?

32:00Massively. So coming back to compensatory mechanisms. So rejection is one thing. The other one is the fear of failure. That is me. So what do people do as a compensatory mechanism? They want everything to be perfect. Okay. Life's not perfect. Yes. For anybody. Yes. So that is exhausting. Yes. Because you try and make everything that you do perfect and it's not ever going to be. So you're constantly struggling. Patients will say that they're having to work harder than everyone else, that they are feeling like they're climbing a bigger wall than everyone else. It's also exhausting when you're trying to make an imperfect world perfect all the time.

32:44You can't do it. Yeah. But is that, is our failure and rejection like two sides of the same RSD coin? Yeah. And I think a lot of it's linking back to the cause, which is the self-esteem. And where does trauma fit in with RSD? Well, I think it's a chicken and egg, right, story here. Because if you have gone through your life where it hasn't been picked up that you've got ADHD, and I go back to what I was saying before, you're going to always feel a sense of inadequacy with no explanation behind it. Yeah. So therefore the messages you get from the people, the close people around you are initially supportive perhaps when you're really young, but eventually that comes with a taste of just get your act together, man.

33:36Yeah. Come on. School reports will just say, you know, just puts it needs to put a bit more, needs to apply himself a bit more. Yeah. Apply. Right. That's what they used to say a lot in people's reports. and then again depending on the type of kid that you were you're going to respond to that in two ways one kid will be like f off yeah and rebel sure and if i'm not good enough then f all of you lot you're not good enough for me but that will breed a lot of actual sadness inside but that is that is also a rejection yeah of that child to yeah the outside world correct or if you're another type of kid, you're going to just try and please everyone all the time.

34:18Yeah. To your own neglect, actually. Yes. And then you become the adult that can't say no. And then you become more prone to bullying. You become more vulnerable to things like bullying at school. Okay. You become more vulnerable to essentially bullying in relationships of one sort of another. In terms of dynamics of the relationships that you're in. You become always a subservient person to every type of relationship. I'm not just talking romantic ones so therefore can i just clarify for audience rsd does not only look like somebody who takes rejection really badly no it's not that simple it's far more incapacitating than that let's put it that way yes yeah so the intensity of it is huge so what can be outcomes of that in the work environment either they take on too much work or and this is even worse i think they don't put themselves forward for jobs that they should have done because they believe that they're not good enough they're not going to get it and this is where this whole imposter syndrome these are all words oh yeah let's talk about imposter syndrome imposter syndrome is i'm going to get found out that i'm not good enough yeah yeah but where did that come from that came from your whole life feeling you're not good enough.

35:36Yeah. People telling you in one way or the other, either politely or not politely, that you weren't good enough. So you start believing that. So your place in society, your worldview is I am not good enough. And eventually I'm going to get found out that I'm not good enough. Yeah. So I'm not going to put myself forward for that job. Yes. I'm not going to go for that relationship, whatever it is, right? I'm going to avoid certain social situations because I'm worried about how I'm going to appear and be judged and et cetera. Yeah. Because underlying all of that, I don't feel I'm good enough. Yes, yes.

36:07That's the point. Yes. If you don't feel you're good enough, then it's only a matter of time before you think, well, they're going to know that I'm not good enough. Yeah. Right? Based on that, how is this not included in the DSM? Good question. Actually, William Dodson did some work into this as to why this might not be included in the DSM. And one good argument was, was that this is very hard to describe. So things that are very hard to describe are very hard to study. So if it goes undetected and someone just looks as this is my personality type, how do you study it? How do you measure this?

36:43Things that are hard to measure are hard to publish about or do research about. And hard to manage. Yeah. And so they don't appear. now the wider thing that's more interesting about the dsm criterion is emotional dysregulation in general is not part of the diagnostic criteria emotional regulation isn't either no so therefore remember i said the man with the hammer can see every problem with a nail yeah so if i don't have that as part of the dsm as part of my diagnostic toolkit yes i can only diagnose you with things that are in the diagnostic toolkit yes which is not these things right so that's why tons of people with ADHD.

37:23In fact, if you're a GP out there, this is a good audit to do. I tell GPs when I go to GP talks this one. Maybe if you've got an eager trainee that's got ADHD, they'll do this. Go into your records, look for all the people that have got a diagnostic code of treatment resistant depression or treatment resistant anxieties. These are people that have had at least two different types of antidepressants for a significant period of time, and they're still treatment resistant, meaning they've still got symptoms. Any of those people who have then been diagnosed with ADHD and been on ADHD meds, have they improved?

37:57Are they no longer treatment resistant? And I know that there's going to be significant numbers there because I see them. Okay. Those are the people that never had a serotonergic deficiency, which is what's treated with antidepressants. Yeah. They had a dopamine and noradrenaline deficiency, which is a different chemical pathway. Those were the people that were missed. so there's this whole this big thing and i know everyone talks about this about over diagnosis this has been missed in plain sight yeah and who the hell would have thought this just vanishes on your 18th birthday what a load of nonsense now when you look at it how would that make sense yeah why where would it have gone yeah yeah from one day to the next literally just blow out your candles yeah it's just nonsense how did so many clever people think that like how okay it's to do with the types of people that were being researched on.

38:49Yes. It's about the hyperactive boys versus the inattentive girls. So let me just lay out some of what I've understood. Anybody can have RSD? Not anybody. Oh, okay. So let's say it happens in other conditions as well. So ADHD, autism, yes. It can happen in generalized anxiety disorder. Okay. It can happen in depression. Tourette's? I'm not sure about Tourette's. Dyslexia? So no. So dyslexia is a specific learning difficulty. Yep. Dyslexia, you can see in conditions like ADHD and autism. Sure, sure, sure. Dyslexia itself doesn't lend to RSD. Okay. On its own. Okay. So this is the importance now of being able to understand the different nuances.

39:28So I said in anxiety, they'll have catastrophic thinking where they're acutely worried about the worst case scenario. In depression, the picture will look a bit different. It will be about feelings of worthlessness, maybe suicidal thoughts. Okay. And therefore, they will reject me. Okay. Because I'm not worthy. Sure, sure. And then it will be accompanied by other symptoms like low energy levels, maybe not wanting to eat or shower or look after yourself. It will come in that context in a depressive picture. How would we see it in a child based on what we know now? In a child, and again, I'll caveat, I'm not a child psychiatrist, but in our clinic, we do see children as well.

40:11So in children, there's a few diagnoses that get battered around. They'll be very sensitive kids. Sure. Prone to temper tantrums. Yeah. At the smallest of things. And something called oppositional defiant disorder, where they basically look like they're just difficult kids. Yeah. Right? That's another way of calling that. Yeah. And that's that kid that might become the adult that has the externalizing response, which is FU. Yeah. Right? If I'm not good enough for you, then you're not good enough for me, and I'm not going to meet up with you, and I don't want to know you. That's that kid. But the oppositional side is different from RSD.

40:51Yeah, but it can look like that, right? Yeah. And again, because it's not a diagnostic, right, whereas oppositional defiance is, you can only pick up the things that's in the manual, right? If, for people listening, this can all be so overwhelming for people, right? A, because... Well, we should talk about emotional overwhelm, that's another thing. Yeah, but there's so many of us that are hearing this all so late because it can look so different and everybody's individual. And it's not a blood test. It's not a biomarker. No, not a brain scan. Yes, not a brain scan. I know I saw there was some psychiatrist somewhere talking about brain scans.

41:24This is not seen on brain scans, guys. Thank you. Yeah, 100%. If someone's listening going, this is singing some of my song, what's the one thing you would recommend them to do? first of all, get seen by an appropriate psychiatrist, professional or whatever. Yeah. Key points, okay? Let's talk about key factors in a nutshell. Number one, have you been like this your whole life? Okay. So have you been described as overly sensitive, prone to temper tantrums, blowing mountains out of molehills? Have you been described like this your whole life? That's important. Number two, has it impacted you? How have you responded with the breakdown of a relationship?

42:00Let's say a romantic one. How bad has it been? Have you not put yourself forward for things at work. How much do you fear your employer giving you constructive feedback? Can you handle constructive feedback constructively or not? Because that's often telling. Does this emotion come all of a sudden and it almost feels visceral, like painful, physical, that level? Is it to that level and that degree? Because if it's not to that degree, it's technically not RSD. Okay. Do you then beat yourself up about being this way? Mm-hmm. Do you feel ashamed to tell anyone else about this? And are you in tears right now?

42:41Yeah. Because if this is you, and I'm talking about this to you, and you're listening to this at three in the morning or whatever it is, this is going to hit a nerve very hard right now. Yeah. And if it doesn't, it's probably not RSD, in all honesty. So then do we know what percentage of ADHDers have RSD? Yeah, yeah. So William Dodson did some research on this. It's around about 96%. Wow. But in 30%, it's the most debilitating outcome. Got it. Okay. And it's more common in women than in men. However, however... The debilitating 30 %? Yeah, it's more common in women than in men. Okay. However, in my practice, and I've seen a lot of people, I certainly see this in men too.

43:28Okay. Right. So I don't think that's, I'm not sure. You're not sure that this is more a gender thing. Do you see any patterns of how RSD might show up at different stages in people's lives? Yeah. So as I said, in kids, see in kids, they really don't know how to explain their emotion. Yeah. A kid doesn't know. Yeah. So they're going to have temper tantrums because they don't know how to communicate that. I mean, if the adult finds it hard enough to communicate, the kid has no chance. Yes. So they're going to maybe have it in an angry way. As they go through teenage years, it might become more moodiness, but it's hard to differentiate that from teenage hormonal components to this.

44:10Yeah. And as you get older, this might look like the thing that I was about to mention, which is emotional overwhelm. And that I do see more described in women, to be fair, especially you go towards menopause. Yes. Okay. So there's a hormonal component where your estrogen levels fall and then it plays a role in that. And it's overwhelm. And the certain buzzwords you'd be like, that you'll hear is I was treading water before and now I'm drowning. Okay. So I was managing just about before and now I feel like I'm not managing. And at that point, that's the time when they're coming to see people like me.

44:45Okay. Because they're not managing anymore. Emotion overwhelm. Another thing that depends on your personality type, but another way that it could be described is I go to zero to a hundred real quick. Anger. Okay. Anger outbursts. That you see more in men. Okay. That's how it manifests. More in men. Interesting. Right? So they just blow up. Although I do see that in women too. But if we are looking at gender differences, there's a slight gender difference maybe there. Road rage? Yeah, road rage. Someone cuts you out. Yeah. Someone doesn't let you go. Yeah, yeah. Or it cuts you up in a queue. Yeah.

45:20Now, a lot of people are looking and saying, yeah, but everyone gets annoyed. Yeah, yeah, yeah. But it's just the intensities. Yes. It looks almost abnormal. Like if you saw the person in the queue reacting, you'd be like, all right, just settle down. You know, it's that person where you just hear them beeping constantly and you're like, all right, man. Like, it's okay. They're going to move. Yeah. Don't worry. But they can't because that inhibitory response in the cerebral cortex, you know, in front of the brain to the emotional response is weak. And so then combine that, I guess, with the impulsivity.

45:53That's what, there, it's all the lack of inhibition. Yeah. Basically, and this will come on to treatment now, the pause is gone. Okay. So where a more rational person might be able to just pause in that moment and say, is it that bad? Really? is it really worth this much energy to be expended on? That is gone. What do you say to your clients when this comes up? I talk about how to try and manage this. And there's two approaches to management as far as we know so far. One is medical and one is non-medical. I'll go into both. the medical approach is not actually currently licensed in the NHS. Okay.

46:42It's licensed in children and not yet in adults. And I think the reason for that is because it's been around for about 10 years and I think we just don't have enough research. Okay. So in children. But we do give it to kids. Because we've had, because ADHD has been around for a long time in children. Yeah. Okay. Right. Yeah. Not as a diagnostic classification. Yes. I told you, if it's not in the toolkit, what do you do? Yeah. Right. So in children, what is licensed in the NHS is non-stimulant medication. In particular for RSD, two types of medication. One that's more commonly used than the other one.

47:20Guamphacine and clonidine. Yes. And guamphacine is the more commonly used one. Okay. Interestingly, this was originally a blood pressure medication. Right. It works by, it's called an alpha receptor agonist. This is very technical, but essentially it enhances noradrenergic, noradrenaline activity, which sounds paradoxical almost. And we don't know exactly why this works in this way. But it works on the receptors at the prefrontal cortex, and it helps with that inhibition of the emotional response. A pause. The pause. so it works in children particularly with the very impulsive kids but similarly now this is done this is not adhd medication to be clear yeah it was originally a blood pressure medication yeah it is licensed now for adhd in children in the nhs okay it's very much probably more used in the private sector for adults over time it probably will get licensed i think we We just don't have enough research yet.

48:26Okay. Right? It came out about, I think it came out in 2009 or 2010. Okay. But essentially what it does is it introduces a calming effect. Now, one of the reasons why people are impulsive with ADHD is because their brain feels too busy. In the research, it's called excessive mind wandering. Okay. The mind is going on to a hundred different things all the time. So if your mind is that busy, it's very hard to stop yourself in that moment and actually just pause and rationalize. Coanfocin has shown some promise in that area. Okay. But I will remind people this is still in... Early. Well, I say that.

49:07In the US, when I go to conferences, US psychiatrists use it all the time. Really? We're well behind in the UK. Adults, children. Everything. We are well behind in the UK. Okay. Well behind. I mean, they use it quite routinely. Okay. They often combine it with stimulants as well. Like GPs can prescribe? I'm not 100 % sure. I don't want to be quoted on and then I'll get it wrong. Sure. Okay, I'm not sure. But I know when I go to conferences, the Canadians in the US, they're using it all the time. Somewhere else in Europe, I can't remember, I think it was Spain. We're behind. We're behind. On this one, right?

49:40And Clonidine? Clonidine, less so. Okay. But it falls under the same sort of class of medication. But if you are an adult not going privately in the UK, you cannot get either of these. You won't get it on the NHS. You won't get it on the NHS. Okay. Because it's not licensed yet. Because it's not licensed yet. Fine. So that's clear. Now, coming back to this, it's often even used in combination with stimulants. Got it. Because stimulants might be better, what we're realising, for the traditional executive functioning, which means attention, concentration, productivity. Organization. That kind of thing.

50:20Yep. Whereas this type of non-stimulant might be better for emotional regulation. Okay, the cocktail. Yeah. And again, in US and Canada, that combo is very common. Is it? Okay. Yeah, it is very commonly used. Again, because it's not licensed here. And then the problem is, because it's not licensed here for adults, there's lack of what's called evidence evidence in terms of there's not many people that are doing it. Okay. Do you prescribe it to your private patients? We do. Privately we do, yeah. Okay. And the results? Can be very beneficial for emotional regulation. Okay. The only side effect is it can make people feel a bit sleepy.

50:59So sometimes people take it at night, but that can be helpful because some people with ADHD have got things like insomnia. Sure, sure. So actually that can be a helpful side effect. Okay. And what was the other one? Guamphocene is the one that's actually more commonly used in these cases. So anyway, that's the medical side. That's the medical. But that is effectively, and just to summarize, Shai, that is using a drug to create a quote-unquote pause. Yeah, to create an inhibition to the emotional response. Yes. That gives you space to rationalize your response. Got it. So now, if we hold on to that, that is basically the technique that we want to emulate in a non-medical way as well.

51:39Yes. So a good ADHD coach would do this. Perhaps a psychologist with some CBT and some knowledge of this may do this. But it's essentially introducing a pause. So how do you do that? So the first step is you'll tell the client, label the emotion when it comes up. We do this in kids. I do this with my toddlers. Yeah? Yeah. Without being patronizing. Yeah. I tell my daughter, happy face or sad face? Sure. Can you recognize them? She's five. Yep. Okay. Colors. Yeah. Colors. Another one. So recognize the emotion in yourself when it comes up. What if you're like me who struggles even to recognize the emotion?

52:22Then recognize the label. Okay. So now if I've told you and explained to you, this is rejections entities for you, and you've read loads about it now. Yep. Right? Because you've gone into your hyper focus about RSD. Yep. At least be able to label this. Now, I don't often believe in labels, but this is where I think a label is important. Okay. Okay. Because when that feeling comes up, you'll say, that's my RSD. Now, it's not going to stop that feeling. You're still going to feel it. This is what I get the feedback from. They can't stop it. Sure. But if you keep saying, hang on, it's my RSD. It's my RSD.

52:58It's my RSD. And you keep mantraing it to yourself almost. By putting a spotlight and knowing what that is, that feeling starts coming down. Because you start becoming aware of this and what this is. Whereas before, you didn't have awareness. Yes. So that's step number one. Yep. Recognizing it. That is also a good pause, right? That is a pause. That is a pause. That will start introducing a pause. Number two, what is the worst case scenario? So you might tell a client, in this situation, because there's always a stimulus, remember? Yes. There is a real situation. Yes. What's the worst case scenario?

53:41What's the worst thing your employer is going to do? What's the best thing your employer is going to do? I'm saying employer as an example. Yep. And then what's the realistic situation here? Okay. Based on your knowledge of your relationship with your employer, for example. Over the last five years, do I generally get good feedback or crap feedback? Maybe I get a mixture of the two. That's probably most people. So what's the realistic outcome? It's probably going to be a mixture of the two. Like it always is. That's starting to rationalize. You've now put the balls in. Now you want to start rationalizing the outcomes because it's the fear of the outcome that you're fearing.

54:25Then the last bit is almost like the bereavement process. It's like the acceptance and forgiveness to yourself. And that's the bit about self-esteem. ultimately have I tried my best and people who are quite conscientious probably have that's my only marker my only marker did I try my best and if I made an F up then I made an F up because that's life because life is imperfect isn't it we're not living in a perfect world no one is your boss makes mistakes they probably made many mistakes before they became your boss so it's that acceptance of ultimately i've tried my best right and therefore if there is feedback maybe this feedback will help me maybe it won't help me yep but i know to myself that i've tried my best and deep down what you really want to start working on then is self-acceptance and your self-esteem okay go back to the cause of the problem so ultimately you want a good coach or a therapist to work on your self-esteem that's that that was the problem in the first place yes because regardless of rsd this is this is back to life that was where the problem be kind to yourself yeah and accept yeah i make mistakes like everyone does yes that's the ultimate treatment in the end you have to go back full circle on life yep where did it come from that's where it came from and when you get to a place where you're like i'm just a human being like everyone else i do right things right do things wrong like the person that's giving me the feedback yeah when you actually get yourself on an equal pegging to everyone else around you not saying above or below just equal that's where you can then really rationalize right yep and stop catastrophizing yes what's the one thing shy that you would love to change or improve about what we know about rsd i think this needs to be part of the diagnostic toolkit in ADHD, in autism, in other conditions.

56:35I think it needs to be part of the diagnostic toolkit. The one thing I want to change is awareness, not really to patients, to clinicians. Because even though this is not currently part of the diagnostic, it will be part of the diagnostic toolkit, because we hear this in conferences all the time by all the bigwigs that are writing the guidelines. This will definitely be part of the future. Probably in the next DSM version, I think. When is that coming out? I think it's in the next few years. Okay. Because until it is, this is going to keep looking like other labels. And just so I'm clear, it's not difficult to introduce an element of RSD detective work within an assessment.

57:23No, it's not. It's not difficult for you to know if RSD is a big challenge for someone. And also, if you keep looking for it and eventually you start to see it, you won't miss it then. Yes. You can smell it from the certain things that they say. Yeah, yeah. Because what you're looking for is actually indicators of low self-esteem as a clinician. Often when you ask that person that question, and I will say, what do you feel about yourself as a person? some people will break down at that point because they're like they've not even been asked that before wow they feel very exposed wow but that is already even that question then is just telling you so much yeah but i love that that ultimately rsd should be included in in the dsm and in your toolkit and then this might not get misdiagnosed for other things which i think it has been for so long yeah thanks shire that was great i feel like we did rsd justice yeah yeah that's very helpful yeah good to keep talking about these things yeah yeah see you for part two

58:38that's it for today's episode of the hidden 20 but just before you go a favor the hidden 20 percent is a charity and we do this to bring you the truth the latest research and the real stories that matter so if this episode spoke to you then please hit subscribe and if you can donate via the link below finally a big shout out to you all for listening and our brilliant team who make this all happen phoebe charlie kristen james john and the guys at tyx studios we'll see you next time

59:19Thank you.