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

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. Welcome to the Hidden 20% on 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 Together with you and an eclectic range of brilliant guests, we can break the cycle of silence by smashing outdated stereotypes, exposing the myths, and sharing the most up-to-date truths about what it really means to be just different, not deficient.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. Enough, Bramble, I'm Ben, your host. Let's get into today's episode. Shoei, how many people do you think you've seen for psychiatric ADHD assessments? Ooh, put about 15,000. At least, yeah. So that's what I've seen, but then I've over-over-seem. Yes. Other people's cases as a clinical lead, right? So I've over-seem 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. This class, I don't have 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. So 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 the whole life, and it's particularly the hyperactive impulsive type, 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. Some people will get into gambling. Some people get into drugs, some will get into alcohol. Some people 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 we're buzz. Sure. Right? Or what we used to call joy writing. Yes. You know, stealing the car in 60 seconds type stuff. So we used to see that kind of thing in the prison population. And when you treat them with stimulants, they remarkably calmed down. So yeah, so that's how I coming back to true and true ADHD fashion, coming back around to where I started. So 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 private least. 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 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. I don't know the right word for that is nowadays. These days are support needs. No, 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. Yes. I don't agree with that. Yeah. I say that as someone who prescribes meds. I think for patients that I see that are definitely on the milder end of the spectrum. Yes, medication might help them by tell them, don't go to medication first. Try things like coaching. Sure. Mindful nurse, CBT. Yeah. Techniques that can help you yourself if you can without the meds. And then go to the meds if you need to. But definitely for the moderate severity, not I mean the chap that's going out the shower with the shampoo in their 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 as RSD come into your work or your assess everywhere. Let's unpack RSD. So RSD stands for rejection sensitive dysphoria. dysphoria 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 an rejection there. None of us likes to be rejected. Yeah. Right. That's no one. 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. Yes. After some time typically or we'll go to friends and family for support, etc. And 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 shown up to a 30% of patients, it's the most debilitating outcome of having ADHD. Okay. More than attention, concentration, deficits. Right. More than being physically rejected 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. Wow. 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. They 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. Sure. A minute. So if you go through your whole life with undiagnosed ADHD, you will often feel misunderstood for the majority of your life. 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. Okay. Actually, 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 a steam focus. Right. Right. So if you then develop low self-esteem, what's your natural reaction to things? Number 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, will 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. Yes. 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. Now 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 just very difficult to get a long way. Okay. 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 suicide or 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 than 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 RST? It can be if you are making it. Okay. So you have to know the nuances and the differences. Right? But to an untrained eye, if you don't know what RST is and you only know about borderline personality disorder, what are you going to diagnose that person with the thing that you know? Yes. The man with a hammer sees every problem as a nail. Yes. Yes. Right? So then you're going to take that person down a completely different treatment path, potentially. Coming back to different responses with RST. 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. Because you're going to go to the GP or the psychiatrist, you're going to say, "No, absolutely, can't stand. I just avoid. I will make up excuses. I'm not going to my work party." Yeah. 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 to try and correct your serotonin levels. You're going to take those antidepressants, you're going to feel emotionally numb. And you're still going to be anxious. Yeah. And still not want to go out. 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. Another coping mechanism to RSD. I don't want to be rejected. So I'm going to become a people pleaser. You don't consciously thinking these things are 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 more complexities to that than that because there's the whole dynamics of abuser and a victim. That's more complicated. They've stayed in maybe saying yes to their employer, "Oh, yeah, I'll do that over the weekend." That other thing. And you didn't want to do it over the weekend, right? Yeah. There's lots of different ways that people end up coping with RSD. 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 experienced chest pain, chest tightness. And then it almost looks like a panic attack. Wow. 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, but it's very hard for them to control it. Yeah. Just tell me about that. And they're okay. Stopping it and controlling it. Yeah. It's really difficult. Let's go into ADHD now. Okay. A little bit here. The definition, what does it stand for? Attention deficit hyperactivity disorder. Yeah. It's not a deficit disorder of it. 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. Okay. A DD. Well, yeah, I don't know what that really would be. We'd have to figure that one out. But it's a difficulty with regulating. Okay. So it's difficulty with regulating attention. Meaning at time, this is where people talk about hyperfocus. Yeah. 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. Yeah. And often it's interest-based, which is someone would say, well, that's isn't that everyone, but no, this is to an extreme. Sure. And 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 one 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. Correct. So 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. Yep. 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, people use colloquially. They will have mood incongruent symptoms. So they might be in a sad situation that we laughing their head off and look very bizarre. Okay. This won't look bizarre. What this will be looking like is, how do you know they're playing a mountain out of a mole hill here? That's what it will 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. Emotional 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, "Shit, 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 crib, just a 20-minute point. No one really likes that. Sure. That's crap for your back, right? 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 rationalisation. 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 long standing RSD, number one, they would don't know what that is. Yes. So there's no label to this. And 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 all just so understand, because you've 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. Okay. Let's come back to shame, though, because this is important, right? Because of shame, you try and hide this from the world. Especially 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 is 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. Yeah. 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. And 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 patronising to the audience. Some of the people are going to relate to this, some of them 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. Or there's no whatever emoji that's from you. Anything. Yeah. 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, their 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 don't want to bring that up because they feel stupid almost. And then from their partners point of view, they'll be like, you're right, something up. And they will be like, yeah, fine. So there's a complete sort of subtitles that's missing to this field now. And then over time, such stupid little things build up in misunderstanding. So the partner who doesn't have the RSD now is like, I, 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. - To 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 reading into like reading their phone. - Yes. - Or looking too much into things that were really quite innocent. - 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 happening in everyone. - No, and this is not like, I just asking my wife where she went today. Because I'm interested in where she went versus like tracking her and interrogating her, 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. I'm 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. Because if you can almost understand what this is at some point, you might be able to have a laugh about this together. Humans are wonderful thing in relationships. There's even channels about this, where with ADHD couples where they laugh about, this is my RSD, this is my ADHD. But I know that's really almost comical. - Sure. - And maybe a bit cheesy. But if you can almost make it a bit more comical, this is happening again. - In naming it. - In naming it. - Yeah. - Naming the emotion, right? Naming the emotion, but not in a shameful way. Not in a like, this is your RSD, happening again, is not that, not in that way. - Yes. - Right? Because then that's not gonna help. - No. - And if you really wanna be there and support, then you don't gonna do that. Understanding naming and maybe initially a bit of reassurance. - Mm. - Yeah. - Until you can get to the point in a rationalization, it's like, listen, we've been together for 10 years, we've got three kids, you know, that's, do you know what I mean? Have I got anywhere? Like, has anything actually ever happened? - Yes. - Let's break it down. - Let's break it down, right? - Yeah. - We've got a good marriage, haven't we? - Yeah. - Everyone has ups and downs. - Yes. - That's again, the imperfect world that we live in. - Yeah. - 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? And now I keep going on about this. But the fact that it's not in the diagnostic toolkit, which most, okay, you average person who's not watching a hundred insta videos and stuff on this subject 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 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 RSD? - I 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 work in this field. If you don't work in this field, I can't see why you would do it this way, 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 like there's the training. - There's the fricking system problem. I mean, now, I don't know, I mean, it's been a long time as 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 in hormones, thinking, menstrual cycle, paramanopause, menopause, how does RSD feature there? 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, typically, therefore. - Yeah. - We definitely see worsening of emotional dysregulation there, so that's where some people get diagnosed with pre-menstrual syndrome. That starts improving about up to a week later when those hormone levels start coming back up. As you move towards paramanopause, and then menopause, you have a declining overall estrogen level, and the other sexual mones, and therefore you're in that phase all the time. And that's where you start getting IC and clinic, for example, women presenting in their 40s and 50s, where they'll say, I was managing before, but now I'm not coping. - Yeah. - That's like a red flag. - Okay. - Now, it's a complicated story here, because some of that can actually be part of menopausal symptoms. - Sure. - So in terms of treatment, you'd want them to get their hormone levels checked. - Yes. - And because HRT might help. - Yes. - 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 worse than dopamine and noradronergic pathways. - Got it. - And serotonin, other chemicals as well. - Yep. - It's quite complex. - Yep. - But essentially that's then makes the emotional dysregulation worse. And you hear the certain words like feeling overwhelmed. - Yep. - Particularly obviously in women. - Yes. - We're talking about hormone or cycles here. - Is there anything good about RST? - 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 neurodiversion 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. - Just think of whether you can channel it. - Yeah, whether you can. - Or whether 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. - And at that level of empath, you will naturally want to then help other people that go through the same crap that you do. - Yeah. - Right, 'cause you just don't want to see that in someone else. - Yes. - And so they can end up becoming fantastic therapists, actually. - Yeah. - 'Cause it's more than passing on, right? - Yeah, 'cause it's more than just, I get what you feel. - Yeah. - I don't want you to feel like that, 'cause I don't want anyone to feel like this. - Yeah. - Right? - Yeah. - And then people become passionate. They take on podcasts and do all sorts of things. They don't want to think 'cause they want to spread a knowledge. - Yes. - So empathy. That's a strength. - Yeah. - And sadly in today's society, you're seeing less than less of empathy. - Yeah, of course. - 'Cause 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 we're going a bit philosophical here, but academically, you're in a competition all the time. - Sure. - Especially in certain schools. - Yeah. - Well, that's a whole different subject, but the school system, education system is wrong. - Yeah. - In my view. Then you go into certain working 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." And that's why the person who's neurodivergent really struggles in this type of society. 'Cause 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. 'Cause you just looked us soft or whatever. - Exactly. - And there are the words for it, but, right? So the advantage, if you wanna look at it as an advantage of RSD, because you feel things strongly, you will be more empathic. - Yeah. - 'Cause you'll 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. - Yeah. - Happiness, fear, et cetera. - You'll be very sensitive to other people's emotion. - Yeah. - And if you're very sensitive, other people's emotions, you're less likely to trod all over them. So you can become a nicer person. - Yeah, yeah, yeah. - Better human being. - Yeah, yeah. - It's quite a big deal. - Yeah, which is a really important thing. Nice, I like that. 'Cause it's a horrible sounding thing, rejection sensitive dysphoria right, and 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. 'Cause 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 other things. - Is a very human thing. - Yeah. - That we need ironically more of. - Yeah. - Can anybody have RST? - 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? Yes. 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. Yeah, yeah, yeah. 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? Pesimist has a general, what we call dysthymia, right? Well, 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. Pesimists often don't look panicked because they are so sure about the crap, the crapness of the future. Yeah, yeah. Yeah, there's less anxiety. There's less anxiety because you 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. Okay. Yeah. Because pessimism is one form of your world view. Sure. 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? Part, 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? Massively. 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. So 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. Sure. You 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? It's 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. 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. Yeah. Come on. School reports will just say, you know, just puts it needs to put a bit more, at least to apply himself a bit. 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 will, you're going to respond to that in two ways. One kid will be like, F off 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 also a rejection of that child to the outside world. Correct. Or if you're another type of kid, you're going to just try and please everyone all the time to your own neglect. Yes, actually. Yes. So, 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, the relationship that you're in. You become the 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 far more incapacitating than that. Yes. 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. But where did that come from? That came from your whole life feeling you're not good enough. Yeah. And be well telling you in one way or the other either politely or not politely that you weren't good enough. So you start believing that. And your place in society, your world view 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 charged in, etc. Yeah. Because underlying all of that, I don't feel I'm good enough. Yes. Yes. That's the point. Yes. You don't feel you're good enough. Well, 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. And actually William Dodson did some work into this as to why this might not be included in the DSM. And one good argument was that this is very hard to describe. So things that are very hard to describe are very hard to study. Yeah. Okay. So if it goes undetected and someone just looks as this is this is my personality type. Yeah. How do you study it? How do you measure this? Things 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 criterion. Emotional regulation isn't either. So therefore, remember I said the man with a hammock and see every problem with a nail. Yeah. I don't have that as part of the DSM, a part of my diagnostic toolkit. Yes. I can only diagnose you with things that are in the diagnostic tool. Yes. Which is not these things, right? So that's why tons of people with ADHD. In fact, if you're a GP out there, this is a good audit to do. And I tell GPs when I go to GP talk to this one. Maybe if you've got a EG a trainee that's got ADHD, they'll do this. Go into your records. 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 still got symptoms. Any of those people who have been diagnosed with ADHD and been on ADHD meds, have they improved? Are they no longer treatment resistant? And I know that there's going to be significant numbers there because I see them. Okay. So there's a lot of 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 big thing. And I know everyone talks about this about overdiagnosis. 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 would it have gone? Yeah. Yeah. From one day to the next. It literally is where 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. Yes. 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 also. 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 a part of that. Dislexia. So no. So dyslexia is a specific learning difficulty. Yeah. Dislexia, you can see in conditions like ADHD and autism. 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. So I said in anxiety that I've catastrophic thinking whether or not you're 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 look at, it will come in that context. Okay. [BLANK_AUDIO] 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. So in children, there's a few diagnoses that get battered around. There'll be very sensitive kids, prone to temper tantrums at the smallest of things. And something called oppositional defiant disorder, where they basically look like they're just difficult kids. That's another way of calling that. And that's that kid that might become the adult that has the externalizing response, which is FU. Right? If I'm good enough for you, then you're not good enough for me. And I'm not going to meet you up with you and I don't want to know you. That's that kid. But the oppositional side is different from RSD. Yeah, but it can look like that. And again, because it's not a diagnostic right in where it's oppositional defiance is, you can only pick up the things that are in the manual, right? If for people listening, this can all be so overwhelming for people, right? A, because we should talk about emotion overwhelming. That's another thing. Yeah, but there's so many of us, there's so many of us that are hearing this all so late, because it can look so different and everybody's individual. And there isn't, it's not a blood test. It's not a biomarker. It's not brain scan. Yes. I know. There's some psychiatry subway to where this is not seen on brain scans, guys. Thank you. Yeah. 100%. If someone's listening, going, this is singing some of my songs. Yeah. 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 molecules? Have you been troubled is that you, you, describe like this your whole life? That's important. Number two, has it impacted you? How have you responded with a breakdown of a relationship? Let's say a romantic one. How bad has it been? Have you not put yourself forward for things that work? How much do you fear your employer giving you constructive feedback? Can you handle constructive feedback? Constructively? Yeah. Or not, right? 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? Do you feel ashamed to tell anyone else about this? And are you in tears right now? Yeah. Because if this is you, and I'm talking about this to you, and you're listening to this 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 ADHD has RSD? 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% is 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. Okay. Right. So I'm, I don't think that's, I'm not sure. I'm not sure that it's, this is more a gender thing. 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, seeing kids, they really don't know how to explain their emotion. Yeah. My kid doesn't know. Yeah. So they're going to have temper tantrums because they don't have 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, they might become more moodiness, but that's hard to differentiate that from teenage or monocomponent. Yeah. And as you get older, this might look like the thing that I was about to mention, which is emotional overwhelm. That I do see more described in women. Okay. Especially you go towards menopause. Yes. Okay. So there's a hormonal component where estrogen levels fall and then it plays a role in that. And it's overwhelm. And the certain buzzwords you be like, well, 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 that that point, that's the time when they're coming to see people like me. Okay. Because they're not managing. Yes. Emotion overwhelm. Another thing depends on your personality type, but another way that it could be described is I could zero to 100 real quick anger. Okay. Okay. Anger outbursts. That you see more in men. Okay. So like that's how it manifests. More in men. Interesting. Right. So they just blow up. Mm-hmm. Although I do see that in women too, but if we are looking at gender differences, there's a slight gender difference may be there. Road rage. Yeah. Road rage. Someone cuts you out. Yeah. Someone doesn't let you go. Yeah. Yeah. Or a cutsy up in a queue. Yeah. Now a lot of people were looking at this say, yeah, but everyone gets in order. Yeah. Yeah. Yeah. But it's just the intensities. Yes. It looks almost abnormal. Like if you saw that other, if you saw the person in the queue reacting, you'd be like, all right, just stay all down. You know, you know, it's that person where you just hear them bp, like constantly and you're like, all right, man, like, just okay. You're going to move. Yeah. Where they can't because that inhibitory response and the cerebral cord at the front, you know, in front of the brain to the emotional response is weak. And so then combine that, I guess, with the impulsivity. That's what that there. It's all the lack of inhibition. Yeah. Basically. And this will come into 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. Okay. 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. Okay. And one is non medical. Okay. Going to both. The medical approach is not actually currently licensed in the NHS. Okay. It'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 to give its kids because we've had, because ADHD has been around for a long time in children. Yeah. Okay. Right. Yeah. Not as a diagnostic. I told you if it's not in the toolkit. Yeah. 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. Guamphacine and Clonody. 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 neurodrenergic, neurodrenerally inactivity, which sounds paradoxical almost. Sure. 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. Of course. The pause. So it works in children, particularly with the very impulsive kids. But similarly, now this is not ADHD medication. It'd be clear. Yeah. It was originally a blood pressure medication. Yeah. It is licensed now for ADHD and 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. Okay. We just don't have enough research yet. Okay. 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. The mind is going on to 100 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. Sure. Quite I'm missing. I've shown some promise in that area. Okay. But I will remind people this is still in early. It's, well, I say that in the US, you know, when I go to conferences, US psychiatrists use it all the time. Yeah. And so we're well behind in the adult's children everything. We are well behind in the UK. Okay. Well, behind. I mean, they use it quite routinely. Okay. They often combine it like stimulant cheese 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 think it was Spain. We're behind. We're behind on this one. Right. And I'm cladding. Cloned in less so. Okay. But it's falls under the same sort of class of medication. But if you are a Guadal, 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. Okay. because it's not license here. - 'Cause it's not license here. - Fine, so that's clear. - Now, coming back to this, it's often even used in combination with stimulants. - Got it. - 'Cause stimulants might be better what they were realizing for the traditional executive functioning, which means attention, concentration, productivity, organization, that kind of thing. - Yep. - Whereas this type of non-stimulant might be better for emotional regulation. - Okay. - At the cocktail. - Yeah. - And again, in US and Canada, that combo is very common. - Is it there actually? - 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 in terms of, there's not many people that are doing it. - Okay. - Do you prescribe it to your private patients? - We do, yeah. - privately we do, yeah. - Okay. - But, and the results can be very beneficial for emotional regulation. - Okay. - The only side effect is it can make people feel a bit sleepy. So sometimes people take it at night, but that can be helpful, because some people with ADHD have got things like insomnia. - Sure. - So actually that can be a helpful side effect. - Okay. - Inundee, what was the other one? - The ground for things that they actually more commonly use. - Okay. - In these cases. So anyway, that's the medical side. - That's the medical. - But that is effectively in just a summarized side. That is using a drug to create a quote unquote pause. - Yeah. - To create an inhibition. - Yes. - 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. - Yes. - So a good ADHD coach would do this. Perhaps a psychologist with some CBT and some knowledge of this may do this, but he'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. - Okay. - I do this with my toddlers. - Yeah. - Without being patronizing. - Yeah. - I tell my daughter, happy face or sad face. Can you recognize that she's five? - Yeah. - 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? - Then recognize the label. - Okay. - So now if I've told you and explained to you, this is rejections introduced for you and you've read loads about it now. - Yeah. - Right? - Because you've got into your hyperfocus about RSD. - Yeah. - At least to 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, "A smart RSD." Now it's not gonna stop that feeling. You're still gonna 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 MarSD. This MarSD is MarSD. And you keep monitoring it to yourself almost. By putting a spotlight and knowing what that is, that feeling starts coming down. - Mm. - 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. Recognizing it. - That is also a good pause, right? - To kind of 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, 'cause there's always a stimulus, remember. - Yes. - So there is a real situation. - Yes. - What's the worst case scenario? What's the worst thing your employer is gonna do? What's the best thing your employer is gonna do? - Mm. - 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 gonna be a mixture of the two. - Yeah. - Like it always is. - Yep. - That's starting to rationalize. You've now put the pause in. Now you wanna start rationalizing the outcomes. 'Cause this is the fear of the outcome. - Yes. - But you're fearing. - Yes. - Then 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. - Yep. - Ultimately, have I tried my best? - Mm. - And people who are quite conscientious probably have. - That's my only marker. - Right. - My only marker. - Did I try my best? - Yeah, I might 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? - Yes. - We're not living in a perfect world. - Yep. - Right? No one is. Your boss makes mistakes. - Sure. - They probably made many mistakes before they became your boss. So it's that acceptance of, ultimately, I've tried my best. - Mm. - 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 in 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. - Mm-hmm. - That was the problem in the first place. - Yes. - Because when you-- - Regardless of RSD, this is back to life. - That was the problem. - Be kind to yourself. - Yeah. - And accept, yeah, I make mistakes like everyone does though. - Yes. - That's the ultimate treatment in the end. - Mm-hmm. 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 to hear them being like everyone else. I do write things right, I 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, Shai, 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 and autism, in other conditions. I think it needs to be part of the dyno toolkit. The one thing I want to change is awareness, not really to patients. - Sure. - To clinicians. - Yes. - Because even though this is not currently part of the dyno, it will be part of the, I'm sure this is going to be a part of the dyno toolkit, because we hear this in conferences all the time, by all the big wigs that are writing the, the diet guidelines. - Okay. - Right? This will definitely be part of the future. It's 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. - No, it's not. - It's not difficult for you to know if RSD is a big challenge to someone. - And also, if you keep looking for it, and eventually you keep start to see it, you won't miss it then. - Yes. - You can get it right. - 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. - Okay. - 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 break down at that point, 'cause they're like, they've not even been asked that before. - Wow. - They feel very exposed. - Wow. (laughs) - 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 the DSM, and I need your toolkit and for the addition, 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 was very helpful. - Yeah. - Good to keep talking about these things. - Yeah, yeah. See you for part two. (upbeat music) - That's it for today's episode of The Hidden 20% but just before you go, a favor. The Hidden 20% 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 T.Y.X Studios. 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