The Hidden Storm of ADHD: Emotional Dysregulation & RSD

[music] Hello everybody and welcome to Taking Control, the ADHD podcast on True Story FM. I'm Pete Wright and I'm here with Nikki Kinzer. Hello everyone, hello Pete Wright. Hello. Over there in Portland, Oregon. Sick as a dog. Still sick as a dog. It's still snowing, so my spirits are bullied. I have food spirits. We're going to talk about this is the third in our trilogy of ADHD symptoms. And oh my goodness, here we go. It's emotional dysregulation day on the ADHD podcast. And we, man, I learned some stuff. We've been talking about emotional dysregulation a bunch, but reading all these articles. I learned some stuff. And I am moved to talk about it. Before we do that, head over to TakeDrollADHD.com, get to know us a little bit better. You can listen to the show right there on the website or subscribe to the mailing list. And we'll send you an email each time a new episode is released. You can also catch up with us on Blue Sky or Instagram, Facebook, Pinterest at TakeControlADHD. 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You get early access to every episode that we produce in this pocket in your very own personal podcast feed. And those episodes include bonus content, the beginning and the end. I mean, how special could it be? It is very, very special. So special. So, please visit patreon.com/theADHDpodcast to learn more. I'm very sick today and I am on the precipice of a coughing fit to beat the band. Do you know what your patronage through Patreon buys my medicine? What do you think about that? Look, you're healing the sick with your membership to the page. Yes, you're healing me. I can't, I can't take myself seriously at all. But thank you so much for being a part of this community. And now let's talk about emotional dysregulation. Emotional dysregulation and by extension, RSD, that's what we're going to talk about today. So let's start. We've talked about emotional dysregulation a bunch over the years. Let's back it up. Back the truck up. What is it? Back it up. What is it? What does it mean? So emotional dysregulation is the decreased ability to effectively manage and regulate emotions and behavioral responses. So that's the formal definition, right? So what does this mean? So you could be watching something, you could be in a conversation with someone and they say something, you could be just feeling something when you woke up in the morning, right? And for some people, your reaction to whatever it is that you are feeling or sensing could be unexpected and could be disproportionate to how maybe somebody else might react to that situation. So mood swings, you could be very hot and cold, you could be very annoyed by something, impatient, angry, hurt, anxious, like the emotion that you're feeling is elevated 100%. Right. Yeah, you're operating at the extremes at the extremes and it's not only negative emotions, it can also be very, you can be very excited about something. You could be really motivated to doing something because you're just so into it, the hyper focus, right? High energy, your joy, feel, you're happy, you're in a great mood. So it can go both ways, it doesn't have to be positive or it doesn't have to always be negative, it can also be positive. Yeah. Yeah, so it presents an all ADHD subtypes, but most pronounced in combined type ADHD, that's something that you added. Yeah, I have a comment about that. What did you learn, Pete? There are some really interesting things that are coming out of the research right now and I did put some links to some of the journal articles that we're talking about. I got a list of about 40, so I'm trying to nail it down, but the thing that was most interesting to me is that emotional dysregulation does have a noted presence in combined type ADHD where it is not so in inattentive or hyperactive. So it's more if you're in the middle, if you have a combination, then you're, which is interesting, because I think most people are combined. Yes, right. So that's why it is such a common. Exactly. Yeah. Now, here's the thing that really that really blew my mind. There is a, there is research to say that the reason this is happening is because those of us who live in this space with emotional dysregulation have reduced surface area in the right inferior frontal gyros in the brain. There is a physiological neurological correlate to this. Your brain is fundamentally different. And as a result, that's why emotional dysregulation is not fully addressed by men's right. It is not dealing with that neurological component sufficiently enough to address emotional dysregulation. Wow. What, what, with the brain, you weirdo, I think that's fascinating that you have a smaller, essentially frontal lobe. Right, right. And it really is interesting to bring up the point that it's, it's not fully addressed by the medications. Yeah, for sure. Right. So I have some things I want you to read from a resource that I found that I thought explained it really well of what causes emotional dysregulation. And it goes into what you're just saying here with this frontal lobe. And I'm going to have you read it because there are, yeah, I think you're going to do a really good job. Okay, here we go. And I'll say I added a coda at the end from a separate paper. So here we go a couple of passages. A couple of recent brain imaging studies shed some light on the causes of emotional dysregulation in people with ADHD. The ADHD brain oftentimes has an overactive amygdala and an underactive prefrontal cortex. The amygdala is a small almond-shaped structure located in the temporal lobe of the brain. It plays a crucial role in the processing of emotions and emotional memories. In ADHD individuals, recent, there I did it. In ADHD individuals research suggests that the prefrontal cortex might be underactive, which can lead to difficulties in regulating emotions. This underactivity might be caused by lack of dopamine and neurotransmitter associated with attention and motivation in the prefrontal cortex. When dopamine is low in the prefrontal cortex, it may not be able to effectively modulate the emotional response of the amygdala, which can lead to emotional dysregulation. So that's the first part. And then in the paper, emotional dysregulation and right-pars orbitalis constitute a neurophysiological pathway to ADHD. We go on an analysis of data from the adolescent brain cognitive development study. That's right, ABCD, adolescent brain cognitive development study. I love that too much for words. I found that emotion dysregulation mediates the association between a smaller surface area. Of the right-pars orbitalis region of the inferior frontal gyros and ADHD symptoms a year later in the research and across a year-long study with a lot of people. This finding suggests that emotion dysregulation is a core component of ADHD. This is not just a potential symptom. It's a core foundational element of the lived experience for most people with ADHD. I think that's fascinating. Yeah, I do too. I need to have the evolution of the research, too, where we know there's a dopamine connection. And now, as of late last year, early this year, we're already finding that it actually has, because of a physiological difference in the brain tissue. That's fascinating to me. This is another one of the papers that actually broke down the clinical and social implications in the form of functional impacts and developmental trajectory of people living with emotional dysregulation. And I think it's really interesting, too, so functional impacts. People experiencing dysregulation are 2.1 times higher risk of mood disorders and 27.4% anxiety comorbidity. They face workplace challenges, emotional outbursts, impair professional relationships. I don't know anything about that. Interpersonal strain, 60% of people report chronic relationship conflicts, links to emotional reactivity, developmental trajectory under the developmental guidelines, emerges in early childhood predicting persistent ADHD symptoms. You've got a kiddo with severe outbursts that can be predictive of ADHD, fascinating. 21% of severe ADHD cases lack cognitive motivational deficits, but show pronounced emotional dysregulation. What? And then, of course, we have the impact of emotional dysregulation. Right. Well, and it's so interesting because we were talking about workplace challenges, and it's the relationships with other people. Whatever that relationship is, whether it's a spouse, a partner, boyfriend, girlfriend, whatever family members, friends, co-workers, colleagues, neighbors, you know, the person at the grocery store. I mean, it could be anybody, right, that this can have that high impact because it's how you relate and get along with others and how you're interpreting those conversations and that relationship. And what I see with clients is they tend to take the blame for a lot of things, right, or they, there's so much negative self-talk that they can find themselves either isolating themselves or really like on guard, right, because they're not really sure how these relationships are going to go. And so that emotional dysregulation is huge, yeah. It leads to a lack of trust because emotional dysregulation leads to intermittent outbursts with an unpredictable signal, right, because you don't always know how you're going to respond. And when you respond, you might have an outburst all over somebody else, which leads them to trust you less because they don't know when you're going to have an outburst or be unpredictable. That's really hard. The next thing I want to talk about impact is something that I don't think we ever talk about, at least not on the show or even just in general, like I don't think you see this in the books around ADHD. Your task list gives you a lot of, it provides a lot of emotions and can definitely provide some emotional dysregulation and it's so interesting because you hear people talking about like I've got too much to do. I know where to start. Everything is important. I'm avoiding things. I'm procrastinating. And if we get to the root of, okay, let's look at your task list. Let's look at these avoided projects. So many times it is tied back to some kind of emotion that you're feeling about this task. And it could be that it's boring and you don't want to do it. It could be that you're embarrassed and you don't want to have to send this email because it's past due. It could be some kind of shame, some kind of fear. There are so intense, the feelings are so intense that it causes you to keep avoiding and to keep shutting down. And so it's just, I think it's an interesting point to bring up is that, you know, it's not just about the relationships and getting along with people, but it's also just how you look at your work and the things that you have to do. And of course that wraps into self-esteem because again, I see so much blame being put on people on themselves and these negative messages from the past and just the fear of what's ahead. And so there's such an impact. And I don't think you can talk about ADHD without talking about emotional dysregulation. It's so a part of it. Yeah, it really is. And such an important piece of it, which does lead us to the RSD connection. Yes, and there is a difference. I mean, well, RSD is part of emotional dysregulation, but they are, yeah, let's talk about that because I want to be clear. Rejection sensitive dysphoria. Dr. Dotson first came on our show to talk about rejection sensitive dysphoria. And it's not a formal diagnosis, but it is common and very disruptive part of emotional dysregulation. And particularly in adults with ADHD. So with what's going on in RSD is it's characterized by an intense, but short-lived emotional pain triggered by a distinct event that could be real perceived of or it could be real or perceived rejection, criticism or teasing. And a perfect example of this is getting a review, a performance review at work. Sure. You could be, you could have 100 things on that review that are just glowing about you and how wonderful you are and all your strengths and how valued you are to this organization. And then there's a couple of sentences about constructive feedback of some things that you could possibly work on. And that's what the person is going to be holding on to. And that's the trigger is it is this one particular sentence that has set me off into feeling the rejection, the criticism and feeling like I'm going to get fired. There is nothing here that's saying that I'm going to get fired, but that's how I, you know, that's the feeling and it's really intense. Really intense. And it can happen in that kind of relationship. It can happen in a romantic relationship where you're feeling attacked or whatever. It's there. It's very, very real. There are, there are three elements that distinguish this from a normal, just sort of mood swing, RSD for moments. So the first one is physical pain, right, 72% of people who experience RSD report bodily sensations, like chest stabs during episodes of RSD, right, they have physical nerve pain, somehow, right. The speed of onset is the second one mood crashes occur in under 90 seconds. It is an immediate deflation of your emotional experience. And third is context independence context independence says there is no social history required in an engagement. You could, like you're talking about a review, but it could be a stranger looking at you with a completely neutral glance and you could just completely fall off the rails and so, you know, physical pain, speed of onset and context independence are three elements that distinguish RSD from other mood swings and they're important. Yeah, absolutely. Less than 90 seconds. That is not a lot of preparation. Not a lot, not a lot. And I was, I was looking at this, the RSD emotional dysregulation feedback loop, and I think this is an interesting way to build it like step one, you have this perceived rejection, which leads to intense emotional pain. You attempt to regulate it, but you fail, which leads to shame and self criticism. You anticipate feeling that shame and develop anxiety, which leads to essentially rewiring yourself to be hyper vigilant around future rejection. And then you create in yourself new, avoidant behaviors, which reduce your social practice and make your emotional skills, your ability to take social risk worse because back to step one of your perceived rejection. That cycle, I think, is fascinating and it's really, I loved putting words to this because I did not have a sense of how I was behaving that emotional dysregulation is triggered by various situations, anything. RSD is triggered by perceived rejection or criticism, right? And I do that. I live in that sort of fantasy space, where I make up things that people are mad at me about, and I get very, very sad about them. I'm sorry, you're sad. I'm not right the second, but I'll know. Yeah, but you know, I think you brought up a really good point. It's naming it and understanding it. I had a conversation recently about RSD with someone, and I was explaining that, you know, it names it, right, it at least gives you an explanation of why this is happening to you so that you have a better understanding. And that was part of our conversation with Dr. Dodson is that naming it and knowing that it's part of it, there's some comfort in there in that just knowing that we can talk about it and relate to it that, yeah, this is, this is true. So what do we do? That's a good question, because there is not, we are going to talk about things that you can do, but I think it's also really important to understand that this is a, this is an ongoing conversation and process, and there is just not an answer, right, that just gets you to, oh, I'm going to all of a sudden be regulated all the time with my emotions. So I just want to be clear about that. The first kind of area that I would look at as a coach is your basic self care, and are you taking care of yourself, and when I say basic, I know it's not, it's not easy. We're talking about exercise, sleep, nutrition, your whole body, how you're taking care of yourself, because we know, and there's evidence and behind this that exercise is going to help your ADHD, getting a good night's sleep is going to help manage your ADHD, what you put in your body is going to help manage your ADHD. These factors are also going to help part of this emotional desirculation. If you're, you know, your whole self is being taken care of, that makes a big difference. Same thing with like stress management, again, exercise, walking, taking a break. A lot of, when you look at emotional desirculation, what are some things that can help you, mindfulness, meditation practices, right, because that's helping you center, recenter that nervous system that is going a little haywire right now breathing those kinds of things. So we start with that those self care things that you have some control over, you can start making a difference, you know, right away. In my research, I found CBT and DPT, cognitive behavioral therapy and dialectical behavioral therapy. And those are two things that I found really common, like every article I read, everything that talked about strategies for emotional desirculation, these two types of therapies came up. I definitely think that this is an important piece to look at if, if you're really struggling with this is to find a therapist that that specializes in one of these two kinds of therapy to really help identify and change those negative thought patterns. It just, it feels like it was repeated too many times to not have something be there that is clicking for people. You know, I think one of them that we found together, which is called somatic anchoring, which is developing an improved awareness of how you feel in your body, right, noticing what do you need right now? Do you need to walk away? Do you need space? Do you need fresh cold air? Do you need a glass of water? Putting words to it, right, labeling how you're feeling in a given moment, take your, do your box breathing, take three long deep breaths, like do do the practices, because as we said, when you only have less than 90 seconds, you've got to be ready with these tools immediately. They have to be instinctive, because you, you know, you don't want to, you don't want to get caught, right, even knowing the skills, being able to talk about the skills, if you can't put them into practice in under 90 seconds, you're going to get caught in an RSD episode. Well, and this is where coaching can come into play too, is that talking through different scenarios can make a big difference. I've worked with clients before in this, in this capacity where we'll talk about specific situations where they felt like they were emotionally dysregulated. And one of the things that was really interesting in one conversation that I had is that the client had a really hard time figuring out like triggers, because he said like I, I could be triggered off of anything, like it isn't anything specific, right, as we're saying, we, we have less than 90 seconds to figure out if something is going to, you know, put you in this kind of episode or not. And so it was less about like identifying the triggers and more of talking about past experiences and okay, how would, how would you deal with this now looking back and what are some things that you might want to think about when this kind of conversation comes up again. And there's a lot of value in figuring out like what is your goal, like do you want to be less reactive, do you want to catch it earlier, but like really putting intention behind, I want to work on this thing because it's really uncomfortable and it's causing problems in my relationship. And so, you know, talking to a therapist and talking to a coach through those kinds of scenarios can be really helpful. And, you know, we like to talk with other people because ADHDers process that way when you're talking out loud about a situation, you can see it from a different perspective, they can hear it and see it from a different perspective. But of course, you want to be processing with those you trust, right, like we have to be careful and make sure that who we're talking to is not going to give that emotional, yeah, trigger. So, one of the things I found so interesting is the overlay between how we can address RSD and how we address anxiety, right, and specifically specific phobias and specific anxiety. So, the two pieces that I think come out of the dialectical approach are, you know, dialectical is much more focused on, or not much more focused, but it combines CBT, cognitive behavioral therapy with a sort of mindfulness presence, like let's engage in reality kind of an approach and reality testing, having someone help you through cognitive drills to differentiate between perceived and actual rejection is really important, right. You're saying, look, I'm making up a story right now, am I living in fact in truth and sometimes you need somebody else to talk through it with you so that you can judge if this is really real, or if it's a simulation that your brain is creating on your behalf. And the other is related exposure therapy, oh my goodness, gradual practice, facing things that otherwise would be triggering with low stakes criticism. It's the exact same thing and the same way I got over my needle phobia, like it's exactly the same, the same testing of stressors, and I thought that was a really interesting way to factor the RSD experience. Absolutely. So I think that, you know, with the things that we're talking about, they all, for the most part, require some kind of professional reaching out and getting some help and some guidance about how to do these things and definitely encourage folks to get that help and talk to your doctor, talk to your therapist, talk to each other about the experiences that you're having in your community. And it's just as important to talk about it, right, because we know with anything, once we shed light to it, it starts to lose its power a little bit. And so definitely want people that are listening to know that they're not alone and there's help and definitely take care of yourself. There you have it. That's that's optional dysregulation. Yes. And thank you all for hanging out and listening to us and putting up with my voice and our links that are rogue. They'll be in the show notes. We've got lots of stuff in the show notes. Check them out on the website. We appreciate you downloading listening to this show. Thank you all for your time and attention. Don't forget, if you have something to contribute about this conversation, we're heading over to the show talk channel and our discord server. And you can join us right there by becoming a supporting member at the deluxe level or better on behalf of Nikki Kinzer, I'm Pete Wright. And we'll see you right back here next week on taking control the ADHD podcast.