Oxford Psychiatrist: The Fastest Way To Cure RSD! (New Research)

In ADHD, emotion dysregulation is a really massive feature, but is just not in the diagnostic criteria. They are in-pulsivity, hyperactivity, in attention, but the things that adults complain about or say, "I really wish could be changed" is the motion regulation. Dr Jessica Eccles PhD is an ADHD expert specializing in RSD. Oxford and Cambridge graduate in medicine. She's here to share groundbreaking research shedding light on RSD. A lot of neurodivergent people find tolerating uncertainty absolutely painful, possibly being threatened or judged. They are often more likely to use substances or be addicted. Could someone disassociate with themselves because who they are has been criticised so many more times than a neurotypical person? I think that is. Huge announcement just before we start. Tickets to the ADHD chatter podcast live theatre show are selling fast. I'll be joined on stage by three leading psychiatrists and we'll be unpacking all things ADHD, how to process a late diagnosis, or DHD, and of course the dreaded rejection sensitivity dysphoria. I really hope you can join me for a night full of validation, laughs and insights, and one that will remind you that you're not broken just different and that you have always been enough. It's on the 19th of May in London. You can find a link to the tickets in the description. I can't wait to meet you in person. Jessica Eccles, welcome. Hello Alex, it's lovely to be back. You are at the cutting edge of RSD research. Is there anything about RSD that you've learnt that we don't already know? Well, Alex, there's quite a few things. One is actually that we really don't know a lot about RSD. I mean, you would think that we do because people talk about it and it's obviously something that patients and neurodivergent people really identify with, but the actual amount of research on it is really, really small. So we just published this year a paper on the experience of rejection sensitivity, and that was really interesting in that we showed three things that rejection sensitivity was associated with the draw, that it was associated with masking, but that it was an embodied feeling. So my whole sort of work ethos is about how neurodivergent is an embodied phenomena, to whole body thing. Rejection sensitivity, the research that we did suggest that it is a whole body thing. So the people in the research described the threat of rejection or actual rejection as feeling like a punch in the chest as though I can't remember the exact words, but something like the rug being pulled out from underneath them or the ground falling out from beneath their feet, that this experience of rejection or perceived or the threat of rejection kind of changed their actual body temperature. So what we know is that there is actually very little research on rejection sensitivity. That research that we just did shows that it is an embodied phenomena, but the other important thing I think to bear in mind is that the research about RSD shows it's not necessarily particular to ADHD. So there are some papers, very interesting papers about social pain and the carrier social pain in autism and rejection sensitivity, and it's also in the trauma literature and in the esteem literature. But I think it comes back to the idea of possible rejection as a fundamentally painful experience. And I do research about neurodivergence and physical pain. So we've shown that neurodivergent people, as you paper just published last month, more likely to experience chronic pain and fatigue because of having flexible joints. What we know is that if you experience physical pain that lights up bits of your brain and bits of the brain involved in fear and emotion, if you experience social pain, that lights up the same parts of the brain as physical pain. And even more interestingly, if you observe someone in pain, you that may light up the same parts of your brain in pain. So there is this really kind of fundamental thing about the experience of pain. And I think rejection sensitivity is a good example of the brain body nature of pain. I interviewed a number of women when I was researching my book, my rejection sensitivity disorder book. And I spoke to one lady, she's 45 years old, just following on from the physical pain. And she explained that she was getting ready to go out for dinner with a friend. And about an hour before she was due to meet her friend, her friend text her and said, I'm really, really sorry. Something's come up. Can we reschedule? Yes. And she instantly, she said it felt like someone had slid something sharp into her ribs. Yes. And she was catastrophizing in her head. She thinks that her friend doesn't want to reschedule. She hates her, she finds her annoying. She's always only tolerated her. And she almost started, she started trembling. And she replied back with a shaking hand saying no problem, okay. Yes. But she said, masking that. She masked the response. So, and then her knees curled up and she collapsed onto the sofa. And she put her arms over her knees and almost like curled up into a ball on the sofa. And the pain she described was gut wrenching. Is that a typical response to rejection? I think different people experience it in different ways. And in the research that we did that was led by Annabelle Rowney Smith and Beth Sutton and Lisa Quatt and myself. The physical things came up as almost universal in the participants who were interviewed about their experiences of RSD. And the most common physical experience was gut wrenching. Something to do with this sort of very visceral sense of the body. But I think it manifests itself in different ways for different people. So some of my patients and people I know, they might not catch that sort of complete physical feeling. I think it might translate in slightly different ways. So the woman you describe interviewing, you know, she she felt dreadful, she curled up and sounds as though that was quite paralyzing. I think for some people, and that that was a very inward experience, that for some people it turns outward. And that this emotion regulation issue can be, could probably lead to flashes of anger. You know, I think sometimes when I talk to patients who have emotion regulation difficulties and we know that emotion regulation difficulties are massive in neurodivergence even if they are not in the diagnostic criteria. It's like this idea of going from 0 to 60, the sort of red mist descending. And that for some people that feeling of being possibly rejected or slated or judged can actually translate into anger. And that anger, can that turn into a best verbal abuse or can it transition into something worse? I think it could, I think it can transform into several different things, actually. So I think it could, especially when you think about neurodivergent people having issues with impulsivity. So, you know, your filter has sort of come off slightly, that you may in conjunction with this feeling of emotion dysregulation, the perceived rejection or slight or judge that this may lead to, yeah, impulsively, you know, shouting or, you know, making comments, but it could lead to, I think it could absolutely lead to physical violence or at least the fear of violence in and of yourself. And it might be that if you were the sort of person who thinks, "I am on a hair trigger," and if I am activated, I'm going to react and I am terrified of my reaction, that means you're probably walking through the world quite, you know, scared of your own self. But I also think that that sense of rage, or one type of a better word, might be translated differently, so not into anger. So I have a thing whereby myself, I'm, or ADHD, have, I wouldn't say I experience typical RSD very often. There are a couple of circumstances and people who can bring it out, but I wouldn't say it was a very common experience, but what I do get is quite activated on behalf of feeling that my patients have been rejected or misunderstood, and that that leads in some ways to a feeling of anger, but not that I was going to hit the patient, but a feeling, a desire, like an actual desire for change, a desire for making a difference, a desire to validate people's experiences. So for me, that, that flair of anger is actually very much associated with a desire for change. And a little while back, I was involved, I mean, I'm sure you're aware of, you know, there's all these discussions, is ADHD being overdiagnosed. And I was invited to a prestigious debate about it. And I had a sense of what I wanted to say, but I hadn't particularly scripted it. And I, in the moment, when I was in the room, and there were people in the room who were, you know, there because they were neurodivergent, and I could see their reactions on their faces to what the counter argument was that, you know, that was sort of dismissing or invalidating their experiences, seeing their faces and that feeling of invalidation and rejection sort of fired up something in me that I was probably even more fiery, verbally than I would have been normally because it felt so much more important because I could see how it was hurting people in the moment. Just rowing back a second. Yes. You mentioned that there were two things that could trigger RSD and you. What would those be? In me. Well, I think, I mean, it's sort of ironic because I am a associate professor of brain body medicine that I am naturally quite unknown to myself. And I think that this is quite true in some ways of a lot of medical professionals. So when I was my first year of medicine, like a lot of medical students, I spent three days a week in the dissection room. Did I learn? Really? Do I remember any anatomy from my dissection days? Not really. I think that was fundamentally an exercise in dissociating and disconnecting. It was a way of teaching you distance. And also as a doctor, you are often medical doctor, often dealing with quite difficult situations on the end of the telephone or in the hospital in the middle of the night. And there is a degree to which one has to distance yourself from your emotions. So I think in general, I am probably, like a lot of neurodivergent people, quite disconnected from my feelings. So I am probably less. I mean, it's a bit of a paradox because obviously we are saying neurodivergent people are more prone to RSD. I am saying that in myself, I think I am quite mass from it. But when I do experience it, it feels very, very significant. But it would be in the context of something pretty that felt fundamental to my identity, I think. With RSD being a very emotional experience, as well as a physical one, but we will talk about it being a very emotional one for now. And surely, therefore, if you have an ability to disassociate from your emotions, that's almost a shield from RSD. I think it's a double edged sword. So I think, yes, in, so there is a degree to which masking or disconnection is adaptive. And it must be from an evolutionary perspective. You know, you're running away from bears and things or bears are making you run. You don't want, you know, prey smelling fear and all of that sort of thing. So there is a degree to which we all have to mask in order to get through the world and to do the things that you know, you're expected to do. But at the same time, I think that although masking can possibly protect you from RSD, we have done some quantitative research. So looking at numbers, we haven't published it yet, but this is with our student Rebecca Gazzett, that we have shown that rejection sensitivity leads to dissociative experiences. So disconnecting neurodivergent people and that that is altered by the presence of masking. So I think if you, if you mask, you might be protected a little from experiences of rejection or if you can reframe them, you know, kind of cognitively appraise them. But at the same time, this could lead to dissociation, which could potentially be implicated in, you know, severe mental illness. So could we talk in the RSD paper about the overlaps with the fact that this phenomenon led to people feeling disconnected and how feelings of disconnection and dissociation may be driving experiences in things like bipolar disorder or what some people describe as borderline personality disorder and also in complex PTSD. Could someone disassociate with themselves who they really are because who they are has been criticised so many more times than a neurotypical person? I think that that is absolutely true. So, you know, I talked to some patients and I have some friends who say, you know, when I was at school, I was the class joker, I was the life and soul of the party. But that wasn't me at all. That's what people have said to me that, you know, they basically put on a mask in order to survive. And if you do that for so long, how do you know who you are? So really, so really difficult question. And I think, you know, some people do that professionally. I mean, if you choose to be an actor or a comedian, possibly even a politician, you are putting on, you are inhabiting that mask. Perhaps because it is safer to do it [BLANK_AUDIO] in that kind of dozed way. I will, for that moment, be masking someone else's emotion. And that is my way of feeling it, but keeping it at a distance. And there is, I remember when I was, I mean, I'm a, you know, I'm a neuroscientist. I'm very much a firm believer in the sort of biological elements of neuroscience and human experience. But I remember being struck when I was revising for my membership exams about a psychological defense. So, you know, people talk about, you know, psychological defenses, you know, minimization or catastrophization or projection, you know, all of those sort of things. One of them was called incorporation, which is where you have, for one to the better word, a, like an unstable sense of self, and you take on the identity of other people. So a bit like being a chameleon. And I found that, I found that fascinating because it's not something that we think about, we'll talk about a lot, but that your own sense of identity is so fragile or distant from yourself that you kind of have to become someone else. But I suppose we all, you know, we've all been different people and, you know, we're never the same person, aren't we? I'm sure, I though part of me thinks, I'm exactly the same person as I was when I was six, as I was when I was 13, but all of our cells and everything, they're all changing all the time. - Sometimes I come out of the cinema and I adopt the personality of the lead actor in the film. - Well, this is interesting. What about the accent? Do you adopt the accent? - Sometimes, yes. - Yeah. - Yeah. - Or from a social event. And I will lie sometimes in order to fit in, like football, for example, I hate football. But if someone starts talking about football, I will say I support whatever team, Manchester, - Do you have a reserve one in your head, ready to? - Yeah, but then I always get stuck because they ask follow up questions. I use your favourite player, and then I have to go, I don't know. - Well, I think what you were talking about is absolutely fascinating. So what I find fascinating is what you're talking about in terms of the accents, in that we think about ADHD, and we think about autism, but we often forget about ticks and Tourettes. And ticks and Tourettes are very important part of neurodivergence. And as we were talking about the anger, that's sort of impulsivity. In Tourettes, you have, or you have this combination of impulsivity and compulsivity. So this idea of being compelled, it's almost as though you don't have a choice. And it's also in the impulsive in the moment. And one of the features, so people think Tourette is swearing. I mean, that is actually the vast majority of people who have Tourette do not swear at all. But what they may have is stuff called, I think it's a great word, echo phenomenon. So this is where you might start mirroring someone's body language completely subconsciously. You might start mirroring, you might start doing the same, you might start mirroring accents. So if you're in a conversation with someone, and I have this sort of issue, sometimes if I'm talking to maybe someone from Australia suddenly developing an Australian intonation, and it's really embarrassing. But that kind of contagious element is really interesting. And I, that echo phenomena, so body language accents, it can also, I think, apply to people's moods. So you can kind of have this feeling, and this happens sometimes on psychiatric wards or in schools, that there is almost like, people mirroring other people's moods, which as I was talking about, you know, you can see the bits of the brain when you're mirroring. So that is a very, I think that we just don't talk about a lot. Though it does crop up on social media sometimes mimicking, and I think mimicking is a form of echo phenomena. But what was really interesting is we have a clinic in our NHS service, the neurodivergent brain body clinic. And most of the people in that clinic have an autism or an ADHD diagnosis or both. But we looked at the data, and we found that almost all of those patients, they actually had significant features of ticks and terets, and that the features of tics and terets predicted emotional regulation problems more than the ADHD or autism features. But yes, the other interesting thing about terets is that there is, there's this, people often, you know, they think about it as swearing, but there's this really interesting phenomenon. I used to experience it. I actually have a terets diagnosis. I used to experience it in chemistry lessons where you would see a beaker of acid. I would see a beaker of acid, and I knew I didn't want to die. I absolutely didn't want to die, but I would become overwhelmed by the feeling of I should drink that clear acid. Does that make sense, Alex, in terms of, it feels compulsive? And you get that too, people might look out of windows, I think I should jump from it. They don't really want to jump, but just looking out the window makes you think you should. Same with train tracks, cliffs, and when you combine that with the motion regulation difficulties, trauma is a recipe for making it difficult to make predictions about risk. What would have to happen for somebody who experiences that compulsion to jump, but they don't want to? What would have to happen for them to actually take that leap or for you to drink that acid? Well, that's the interesting thing for a neurodivergent person is to what degree can you be filtered, and to what degree can you put your own breaks on? And that, as we all know, in a neurodivergent people, can be incredibly context dependent. So one day, that might be absolutely manageable, but say you had a number of stresses, including I don't know, mixed social messages, feeling rejected or loss of routine or predictability, that could make that experience much more compelling. I know a woman who told me her heartbreaking RSD story, and she had been sober for seven years, and she explained how last weekend she relapsed, and she told me she was sat in the office it was Friday afternoon, five o'clock, ready to clock off for the weekend, and then her email pinned, and it was from her boss. And it said Bethany, that was her name, "Have a lovely weekend, can we have a chat Monday morning?" That's all it said. And she instantly catastrophized with thoughts, such as everyone in the office has finally figured out that I'm useless, they all hate me, I'm definitely gonna get fired. And on the way home, she picked up two bottles of wine and got absolutely drunk Friday night. She drank again Saturday, she went into work Monday morning, trembling, shaking, and she sat down in her boss's office, and her boss said, "Bethany, I would like to offer you a promotion." - Wow. - It sort of has a happy ending, that story, but is a reaction that big, relatively common with ADHD women? - I think, I'm not sure it's some just women. I think that what that story does is illustrate a sort of the kryptonite nature of tolerating uncertainty and potentially perceived rejection in a neurodivergent brain, that for a number of brain body reasons is more likely to potentially be addicted to substances. So I can, I wouldn't necessarily say it was incredibly typical, but it's totally understandable in terms of how neurodivergent people can be in the world. So we know that a lot of neurodivergent people find tolerating uncertainty absolutely painful, just in the same ways we've been talking about. RSD is being painful, that things not being predictable are painful, that this sense of possibly being threatened or judged is painful. And we also know that neurodivergent people, you know, maybe for various reasons to do with impulsivity and compulsivity, they are often trying to take the edges off a brain that is worrying and probably hoist to spot danger and pattern seek. And for those reasons and also, you know, lots of bodily things that we study to do with inflammation and the autonomic nervous system, that substances are a means of trying to cool that down. So I think it's a really under explored area, and we need to do some proper research into it. Why is it that neurodivergent people are more likely to use substances or be addicted? Because you can be addicted to lots of things that aren't even necessarily substances. But I also wonder, Alex, if, you know, what you describe, you know, this sort of feeling of imposter syndrome, the unpredictability I called it kryptonite, that actually that led, you know, that feeling of things being out of control, that sense of unpredictability meant that the person you described actually reached for something very predictable, even though it sounds dangerous and self-destructive. It's actually a sense of certainty. She knew what the outcome would be if she started drinking. And was that self-sabotage or what you think of a self-sabotage actually a form of trying to have control? Well, I guess it was the antidote, at least in her mind, to the deep emotional pain that she was experiencing. The pain, it is pain. Yes. That came with the thought of that Monday morning meeting, which was the ultimate rejection, going to get fired when in fact she was going to get promoted. And it shows how we can be exquisitely sensitive to something. And we think it's danger, but actually it could be reward, that you've made this sort of sense that there's something in the water and you think the worst, but actually it could be, it could be really good, but I think there's a protective factor because if you think, if you always think in the worst, then you never disappointed. Does that also mean that you won't reach your potential? You won't apply for that promotion. You won't stand up to your friend who is walking over you. Maybe you'll stick in that abusive relationship. Like, can it make you vulnerable? I actually think it probably can make you vulnerable because it means that you're probably less likely to break outside of your patterns because it seems more terrifying to do something different. And I think that feeling probably does hold people back. But I think also for some people, it may do the opposite. That feeling, they might be like, I'll do it anyway. But I think in the workplace, it is important for managers to realise that it's perhaps not best practice to send such emails at five per block. And often, if possible, to include an agenda, so that there is a sense of context, because I think a lot of people, but particularly in your diversion people, do struggle with that idea of the unexpected meeting. If you ask someone like Bethany and many of the people who listen and watch this podcast, you're sort of living your whole life constantly feeling like you're about to get told off, like you're about to disappoint someone, you're about to do something that's going to annoy someone. And that's a constant fear. What coping strategies do you put around yourself to protect you from the extreme emotional pain of criticism? Do people please? I think some people do. I think, and this came up in the research, the RSD qualitative research that we did is that people withdraw. So they might avoid situations. And I think in that work, some of the people that we interviewed said that they even missed out on career opportunities, because they were afraid of, or they feared rejection, or that they would sort of hobble themselves, so like hand in essays, late knowing that they get a lower mark in order to make that feeling of possible rejection less. But in terms of people pleasing, I think that that is also another mechanism is to put your own needs aside in order to make sure that other people to try and control a situation by people pleasing. But that you get into a vicious circle, they don't you, which is not very helpful. So sorry to interrupt your hyperfocus, but I finally found an app that actually works. I've been using Timo way before they became a sponsor and it's changed me as a person. I've got organizational skills that even make neurotypical people jealous. Let me explain. Timo wasn't named app of the year in 2025 for no reason. 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Just a note though, this code is only applicable on the web browser and not the smartphone. Back to the episode. We talk a lot in the RSD conversation about being triggered. Yes. And this is the trigger that is so painful and therefore you people please, you're a perfectionist or you avoid conversations. But what is actually being triggered? Is it as William Dodson theorises that it's the 20,000 extra micro rejections we received in our formative years and that cumulative tibley is a trauma? What is being triggered? What is causing the pain? Well, I don't think we completely know and we could hypothesise and we do it does seem that neurodivergent people are more likely to experience trauma and the work that we are doing, particularly at Brighton Sussex Medical School, about the sort of neurodivergent brain body type suggests that maybe perhaps because of these flexible hypermobile joints, that neurodivergent people experience trauma differently because they have a, and we talk about this in the earlier ADHD chatter episode, they have this trigger happy autonomic nervous system. So you're constantly your propensity to go into flight or fright, I always say that wrong, sorry, fright or fright, is so much, that's on a hair trigger. So if you combine that with having loads of triggering experiences or microdromers and the propensity to feel physiologically in flight or fright, and then you maybe combine that with what we talk about on, I have the Bendy Brain YouTube channel on the Bendy Brain episode four, I think we talk about unusual sensory experiences and people having this very vivid mental imagery. So if you combine trauma neurodivergent, the brain body type that is hair trigger in terms of flight or fright and a very vivid mental imagery, That is going to be feel traumatic and you're going to feel that in the body. What's the other thing that I think is that a lot of neurodivergent people, and we've done research into this, or we're doing research at the moment, this idea of Alexa Thymia, this difficulty understanding, describing, or recognising emotions. We also know that neurodivergent people have differences in something called interception, which is the innocence of what's happening in the body. If you combine difficulties working out what's going on inside the body, and difficulties recognising or describing or distinguishing emotions, in a body type that maybe because of hypermobility and very connective tissue is primed for fear. We did these brain imaging studies showing differences in parts of the brain that were involved in fear processing. And because you're neurodivergent and maybe ADHD, you're not able to put the brakes on in the same way. This is a recipe potentially for feeling awful. And if you've got that cookbook with that recipe in it, and that's you, when you are living in fear all of the time and you anticipate rejection and criticism around every corner, or if someone benignly responds to a text message with a thumbs up emoji and you instantly recoil. If that's you, can you retreat socially and can that create loneliness? Oh, yeah, I am sure. And that's what in the paper with the interviews of people talking about their rejection sensitivity, that is precisely what they said is that it can lead to social withdrawal, or only socialising with other people who understand the phenomenon. Yes, and that can lead to loneliness and a sense, a lack of connection. And my colleague, Brighton Sussex Medical School, Lisa Quatt, who is also on the rejection sensitivity paper and is, you know, she and I work very closely together. She did this really quite groundbreaking study in autism, where people assume that autistic people, you know, don't want friends or can't socialise. And she showed that actually autistic people experience a lot of loneliness. And fundamentally, we do want connection, but it's about being able to regulate that. So that's sort of myth busting about loneliness, but I think rejection or emotion dysregulation, which is a really massive feature in ADHD and other neurodevelopmental conditions, but it's just not in the diagnostic criteria. I mean, they are impulsivity, hyperactivity, in attention, but the things that people, especially adults complain about or say, you know, I really wish could be changed is the motion regulation problems. But I also think that they are potentially amenable to intervention. I think there is hope in that, recognising it, that you describe this idea of seeing the thumbs up and kind of thinking, I'm not sure what this thumbs up mean, and withdrawing. If you can at least recognise the pattern, then you are in a position where you could potentially revise it. But I think the problem for a lot of neurodivergent people is integration. So not only sort of brain body integration, but also time integration. And you know, you've talked with Hallowell and Dubson and this idea of now and not now. I think applies to the neurodivergent emotional experience, that it's actually sometimes quite hard to integrate the past and the future. And I see this a lot in our NHS, neurodevelopmental service. We only, well, we see a lot of patients who are in patients or have had mental health crises. And for many of them, actually in the moment being able to say, well, you know, actually the past, you know, to integrate the past and the future when something emotionally catastrophic happens is such a hard task. I speak to a lot of ADHD adults. At events and a story I just hear time and time again is they'll go to a party. They'll go reasonably well, socially, they'll meet new people, but then they get home. And then the overthinking starts. They'll start saying to themselves things like, I laughed weirdly at that joke or that conversation was awkward. And they'll ruminate and they'll stay up all night. And can this create a degree of patty recognition, which then you'll say to yourself, well, I know now that social event equals weeks of anxiety. Therefore, I will just withdraw from all social events. So you mean like a form of conditioning, like Pavlov and his dogs, sure, that you basically associate social situations with turmoil and rumination and mental recrimination. And so you actively avoid them. I think that certainly happens for a lot of people. But I think it's also there's a lot of overlap with ADHD and autism. And we know that they're just as almost just as likely to occur together as they are singly teasing apart what is an ADHD social difficulty from another neurodivergent social difficulty. I think it's very hard, but that experience is very, very common for neurodivergent people and also the sheer exhaustion that that can generate. But I think we were talking or I was talking about, you know, this, you know, we were talking about the accents and taking on other people's accents or taking on other people's body language, this kind of compulsivity. And it's just as though sometimes we are compelled to replay those situations. And it may also be that some neurodivergent people are not necessarily accurate, but they have a very high level of recoil. Sometimes we talk about I get to memories or photographic memories. I think of it as like being an elephant, you know, this idea of remembering everything. And when when you are compelled, when you remember everything and you are compelled to try and read patterns into it, you can, you can see how that that could just end up being exhausting. Absolutely exhausting. William Dodson, who coined the phrase RSD, he described RSD, the emotions as catastrophic. But I wonder from your experience and your research on RSD, is there a way to objectively measure the emotional response to criticism? Well, that is really interesting. So what is RSD? We don't really know. People have described it. It definitely seems to be something that resonates with people. In the paper, we asked people, you know, to describe their experiences. But that's not necessarily generalizable. And also our participants, although they had ADHD, some of them also autistic or had other neurodivergences. But what we can do is we can ask people questionnaires. And we have done some questionnaires studies that show that rejection sensitivity is linked to emotion regulation problems in the context of neurodivergence. And it would be really interesting. And as you are, you know, as you and I are talking about it, I'm kind of thinking about how this could play out is you could devise a series of experiments, I mean experiments in the scientific way. Whereby you take brain, brain measurements, you know, you could do brain imaging. And at the same time, and this is where my mentor Hugo Critchley has been really pioneering is in combining those types of brain imaging with physiological monitoring. So heart rate, blood pressure, what you think of is the lie detector test, you know, galvanic skin response, we could put all of that together. So we are we are measuring all of these things. you could. You could get people, some people with ADHD, some people without ADHD, and you, people have done this in the psychological literature over the years, you could make them do something in the brain scanner or in the, you know, just around it or in a virtual reality kind of scenario in a headset where you experimentally induce feelings of rejection. So there is a paradigm, I'm not sure, I mean, I'm sure it would elicit RSD, where you basically say to someone, you have 10 minutes to give a, to prepare to give a speech and people think this is called the "trier stress test." And so people think that that's actually really going to happen to them and you measure their physiology and you can see their heart rates and all of that. And so I imagine you could, you could, you could absolutely adapt something like that to RSD. And what would be interesting is not only to adapt it to look at the difference between neurodivergent people or non neurodivergent people or, you know, people who seem to have a propensity for trauma versus those who don't, you could also, if you had the money and the research funds and the resources, you could have an intervention to try and reduce it. So interesting, just you saying about though, you got to do a talk in 10 minutes, my foot started tapping at a faster rate. So there's an objective measurement right there. Well it is and this is a really interesting thing. So I remember being fascinated years ago at a conference where people talked about self-harm and imaging self-harm. Not, yeah, imaging people who undertook self-harm. So these people had a diagnosis of borderline personality disorder, which is a very contested thing. Could be ADHD, could be neurodivergent, could be trauma, could be complex trauma. Who knows. But the, what they did is they took people who harm themselves and people who didn't and they put them in the brain scanner and they looked at their pain thresholds. So you might be thinking, well, what point is that? But they showed that at baseline, their people with the pro, who would self-harm actually had slightly higher pain thresholds. So that means they are more disconnected from their bodies potentially. And what they did was they stressed them out and you think, well, what was the stress? Was it the tree of stress test? Well, they told that they were going to have to give a speech where they told that a loved one was going to abandon them. No, the stress they underwent, which is a reliable stressor of the autonomic, the involuntary nervous system, was minusing sevens from a thousand. So mental arithmetic. And that caused people's pain thresholds to become even higher. And their heart rates to become higher and their activity in parts of their brain involved in fear to increase. And it really shows, I think to me, that you can conceptualize these difficulties as a sort of brain body disintegration, that they literally lead to dissociation and that stress could be performance stress, but it could also be social stress. It could be mental math. And a really interesting thing that we did, you know, I was telling you about how social pain is experienced in the brain in the same way as physical pain. But there were some interesting experiments not done by us that showed that a single dose of paracetamol in the brain scanner. So paracetamol is a pain killer for the body, actually reduced feelings of social pain. We did an experiment whereby we showed people in the brain scanner a sort of a virtual reality, we're not quite a virtual reality, but sort of avatars and things. There's a game where people get excluded. So you're supposed to play a game and it's like, you know, three people passing a ball and you're supposed to feel as though the ball is never coming to you. It's a reli- it's called cyberball, it's a reliable inducer of feelings of social pain. But what we did is we had you watch someone else be in social pain and that activated the same areas in the brain. So just to push that to an extreme example, if you took a shot of morphine and then you got an email from your boss asking for a quick chat, would you be immune to the emotional pain? I don't know. You mean for my paracetamol example? Well, I don't think we should speculate or encourage people to take painkillers before emails, but I think it speaks to the, what we were talking about in terms of neurodivergent people being more likely to end up taking the edges off through addictive behaviors, but it also suggests that no one, I mean often people think, oh, you know, that some drugs have uses that are not what you think they are. I'm not saying that paracetamol is the key to social pain, but it makes us think are there things that we could repurpose? Is it something to do with this brain body type that means you're slightly inflamed or your nervous system is, as I said, you know, trigger happy. If we reduce your heart rate, for example, would that help with some of those feelings? So Hugo, who I worked with, he did this really elegant experiment, we put people in the brain scanner and they played them, they showed them pictures and they played into the participants ears, they were told that it was their heart rate, so that they were hearing their heart beating. So they look at all of these images, they're hearing their heart rate and sometimes without knowing that sound was sped up, false physiological feedback. And when people thought their heart was racing, they rated emotional images as more intense even if they were neutral. So basically the body is a context setter for our emotions. So if we were able to regulate the body and we've done research, you know, that shows that for neurodivergent people, emotion regulation is linked to a sense of sort of uncertainty about where you are in space, which is more common in people with flexible joints. But if we were to improve the body, we might be able to improve emotion regulation, which I think is quite encouraging because some of the narrative sort of feels, we know sort of, you know, doomed to always feel this way. And I think there is actually hope that we might be, that there are things that people can do that can improve their emotional experiences. So interesting Jessica, I want to carry this on with the audience questions, which are in the washing machine of work. Of course the washing machine of work. So there's a little announcement for anyone who's got clothes stuck in the washing machine right now. I do use the TMO app, which reminds me to empty my washing machine. But this week, Jessica, somebody has written in, you've got three questions actually. And there's a bit of a trigger warning, we do reference suicide in this section. But the first question is, my daughter is six and she gets very emotional when criticised. Do you think this could be early RSD? Um, I think that it is the daughter have ADHD, or is this, is this just out of the blue? How, it's not specified. So I suppose if it was specified, how would that change the answer to the question? Um, I suppose I'm thinking about it in terms of the sort of support that you would provide. So I don't think you would necessarily dash to think, ah, my child has RSD, but you would notice that as a pattern and think, is there something else going on? And is how are they, um, you know, is there some trouble at home at school? Is there something that can be adapted? Might they? have, are there any other signs suggestive of neurodivergence? And if that was the case, might it be worth evaluating so that the child can get the support they need to thrive and learn more about themselves? So I saw this thing on Instagram, which I actually thought was quite wonderful about how to explain to a child that you want them to have an assessment for a neurodevelopmental condition. And I think for a lot of people there is a sense of sort of judgment or stigma. And what this person who I think is called neurowild said was, all plants are different. Some plants need lots of light, some need darkness, some need lots of water, some need to be dry. And what we're trying to do by finding out whether you as a child are neurodivergent, is to try and work out what sort of plant you are. And when we know what sort of plant you are, we've got the, we've got the operating instructions. And I actually thought that was a wonderful analogy. What's the fastest way to find out what type of plant you are? That's so tricky. Well, in patients, yeah. How do we work that out? I think by being curious or a neurodiversity affirmative assessment by recognising the pattern and also not punishing the fish for not being able to climb up a tree rather than swim in the sea? Is it hard though? Because if you are different and you're criticised so many times because of it, don't you try to be a different type of plant than what you actually are? Well, yeah, and we know that that comes at a huge cost. And I think that that brain body cost of being different is hugely underestimated. But the chicken and the egg is also an important thing. So we showed that children with autistic or ADHD traits age nine had higher levels of inflammation and that that was related to having fatigue problems when they were 18. But it's a sort of chicken and an egg. What was causing the inflammation is hard. But clearly, neurodivergent children, there is a sort of difference in this brain body profile that predisposes to certain strengths, but also certain challenges. I'm going to move on to the next question, Jessica. This is where the trigger warning comes in too. This one does reference suicide. In horrific circumstances, do you think the RSD could lead to someone dying by suicide? I think that suicide is a very complicated thing to try and predict. But we know that autistic people, ADHD people are more likely to die by suicide than others. And I wouldn't want to say one thing. I think it's a intersection of a number of factors. But that type of emotion regulation difficulty could be a factor. It could be in a sort of intersecting storm. It could be a trigger. I don't think I don't think that's, I wouldn't want to catastrophise, but I think appreciating the degree of difficulty that some people experience with that. This profound feeling of dysphoria, dysphoria is shouldn't be underestimated. And it's impact. I saw a heartbreaking stat last week and there's a utilisation clinic. I think Sweden, and they're able to put demographics of the people that come to them for that service. And the highest group is autistic women that come to them to be utilised. Well, there are an awful lot of awful statistics about autism and women. And also, well, as I said, autism and ADHD, unfortunately more likely to die by suicide also reduced life expectancy. We were talking about vulnerability. I remember reading a really horrible French paper, or paper that was written by some French scientist showing that autistic women, the majority of them had been subject to some form of interpersonal violence, that there is this relationship between neurodivergence and trauma. But I think I hope that that is not the answer. I mean, and that there are that the more we understand about the neurodivergent brain body, about its challenges, but also its strengths, we can make a difference to people's experiences. And that is, you know, we were talking about desire for change that I think is a cause for hope. Many of the viewers and listeners of this podcast are late diagnosed women who very much relate to the RSD conversation. What message of hope or closing advice would you have for the listeners? For that, it is neurodivergence is a complicated experience that it is ultimately so many paradoxes that there is a terrible pain, but there can also be pleasure associated with neurodivergence in our last, when I spoke to you last on the previous podcast, we talked about the sort of joy of neurodivergent on neurodivergent conversation, that sort of mental dancing, and there are strengths and challenges, and I think recognising your own spiky profile. So what are the things that you need help with? And what are the things that actually go well for you and getting support for the things that are not going so well and making the most of the things that are, is kind of hacking your own system. Amazing closing advice, thank you Jessica. Just finally before we go, I've got a letter to deliver to you. And it is one where the previous guest wrote a letter to their younger self, and if you could kindly read it to us. Yes, I will. There we go. Here we go, to the next guest. You were always loved even when you thought you were not, and you were always beautiful even when you thought you didn't fit in. So that was written by the previous guest, that's a lovely note. Definitely, a very fitting actually. On the topic, we were just closing on too. Yes, exactly. That you are enough. You are enough, absolutely. Jessica, thank you so much. Yet again for bringing wisdom to the ADHD chat to podcast. Thank you, and please check me out on my YouTube channel, Bendy Bray.