“Always respond with THIS when someone calls you ‘too sensitive’” - Harley Street psychiatrist shares RSD management secrets | Dr James Kustow
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January 28, 2025
TLDR: Expert Dr James Kustow discusses Rejection Sensitive Dysphoria (RSD), experienced by many with ADHD, its manifestations, triggers, and coping mechanisms.

In the latest episode of the podcast, Dr. James Kustow, a Harley Street psychiatrist and expert in adult ADHD, shares valuable insights into the complexities of Rejection Sensitivity Dysphoria (RSD). This condition frequently accompanies ADHD and manifests as intense emotional responses to rejection or criticism, often causing significant distress in personal and professional relationships.
What is RSD?
RSD can feel like an emotional tsunami, overwhelming individuals with feelings of shame, anxiety, and anger. Dr. Kustow describes it as a cycle of intrusive thoughts that can last for hours or even days, making everyday interactions feel like high-stakes situations.
Key Characteristics of RSD:
- Emotional Responses: Varying ranges of shame, anxiety, and controlled anger.
- Physiological Reactions: Rapid heart rate, muscle tension, and feelings of being overwhelmed.
- Cognitive Disturbances: Looping thoughts and ruminations focused on perceived rejection.
Effects of RSD in Daily Life
In Relationships:
- Interpersonal dynamics can become strained as those with RSD often interpret neutral comments as negative.
- Family events, such as gatherings, can be triggers, particularly when historical tensions exist.
At Work:
- RSD can prevent individuals from engaging fully due to a fear of criticism, leading to procrastination or avoidance of responsibilities.
- Comments from colleagues, even if benign, can evoke a feeling of dread and subsequent spirals of negativity.
Strategies for Managing RSD
Dr. Kustow emphasizes the importance of proactive measures for managing RSD symptoms:
1. Education and Awareness:
- Understanding RSD can help individuals contextualize past experiences and recognize their patterns of emotional dysregulation.
- Sharing insights into RSD with family members can foster understanding and support.
2. Self-Care Practices:
- Ensuring sufficient sleep, balanced nutrition, and mindfulness practices reduces the emotional load one carries daily.
- Techniques such as movement meditation can help process and regulate emotions effectively.
3. In-the-Moment Responses:
- Use humor, engage in grounding techniques like deep breathing, or excuse yourself briefly to regain composure after being triggered.
Insights on Vulnerability
Dr. Kustow discusses how allowing oneself to be vulnerable can be an essential part of healing while managing RSD. Vulnerability invites connection but can also evoke fears of judgment and hurt. The conversation emphasizes striking a balance between self-protection and genuine interaction to foster healthy relationships.
The Connection Between RSD and Alcohol
Dr. Kustow elaborates on how alcohol can worsen RSD symptoms by lowering inhibitions, leading to impulsive behavior and emotional outbursts. This emphasizes the need to understand the synergistic effects of substances on emotional regulation, especially for those with ADHD.
The Future of RSD Research
While RSD is currently not recognized as a formal medical diagnosis, it is increasingly acknowledged in psychiatric discussions, with experts like Dr. Kustow advocating for further research. Understanding the mechanics of RSD through research could someday validate the experiences of those suffering from it.
Conclusion: Embracing Sensitivity
With RSD, the key lies in balancing sensitivity and resilience. By fostering awareness, maintaining self-care, and developing effective coping strategies, individuals with ADHD can significantly improve their emotional regulation and overall quality of life. Dr. Kustow’s blend of professional insight and personal experience offers hope and practical methods for managing RSD.
Key Takeaways:
- RSD is a profound emotional response often felt by individuals with ADHD.
- Understanding and education surrounding RSD is critical for self-management.
- Techniques for grounding and humor can alleviate immediate emotional responses.
- Acknowledging the positive aspects of sensitivity can lead to personal growth and deeper connections.
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to being successful with ADHD. One of the big keys is following your heart when it comes to vocation. And once you've found it, it will let go of it. James Cousteau, the Harley Street psychiatrist and author of How to Thrive with Adult, ADHD. RSD, is that more concentrated within people that have an ADHD diagnosis?
I think it is probably more common in ADHD and the experience people describe is that their thoughts are looping. It can last for hours, sometimes even days. The reason you mask is to protect against criticism. By presenting this, I'm in control and everything's fine facade. It's a lot of work to carry around the facade to keep it going. And actually, when you realize that it's generally a really good thing to be vulnerable, it becomes part of a real healing process.
So if someone has a shield that is ultra thick, compared to someone who, say, the other end of full extreme, has no shield. They're completely vulnerable. They're exposing themselves to everything. How do you know if your mask is too thick or too thick? Well. This episode is dedicated to anyone who has 50 tabs open right now on their browser. How RSD feels in our body can be difficult to articulate.
Can you describe what it feels like to an audience that might not have experienced it? I describe it as an emotional tsunami. In the presence of rejection, criticism, whether it's real or perceived, being slighted or sidelined,
People with ADHD experience an overwhelming, intrusive emotional response. Usually characterized by one or more of three main features. The first is shame, top of the list. A sense of shame being exposed and having messed up. The second is anxiety or panic in some situations.
And the third is anger. And very often the anger can be turned inwards. I'm such an idiot. How could I have done that? Like, I'm obviously rubbish. I messed up. They've rejected me. I've messed up. But it can also be projected outwards and often takes the shape of rage and controlled rage.
Now, when you get into this, it feels like you've been hit by lightning and it's incapacitating. If someone tries to talk to you when you're in the state, often you don't hear them. You're distracted, you're absorbed, you're preoccupied. And the experience people describe is that their thoughts are looping,
and they're ruminating and they're stuck in an endless cycle of thinking through the event, trying to make sense of it. They can last for hours and sometimes even days. And it's really impairing.
It's painfully relatable what you just said. It shows up in my life almost every day. The extremity of the experience can vary. But even on the minor end of the scale, the lesser end of the scale, it's still a visceral response that completely derails me in that moment. And it's not the big things
that set me off, that derail me. It can be the tiniest things, the tiniest little comments that often it's I find when I'm expecting a particular response to a bit of work or something that I've done, and that hasn't been met. It's the expectation of a positive response, and if it's a neutral response, it doesn't even have to be negative, if it's neutral,
it can trigger me and that internalised rage and I try and keep it internalised when it does happen. Do you have any visual analogies that might represent this horrible thing for someone who doesn't recognise what it feels like?
Well, I've got a few that I'm thinking about, but the experience of it is like a punch in the gut or a slam around the face. Good analogy would be if you were sunburned.
Everyone's had the experience of being sunburned at times, and your skin is just super sensitive. And a touch that would previously, you know, feel like nothing feels so intense. It's the same thing if you have a little cut on your fingertip. Every time you touch anything, it's like extreme sensitivity. I think that sort of captures what it's like. So something that would otherwise be
regular sensation or regular experience is amplified. I think people can relate to that height. I mean, people with ADHD are as a group more sensitive often than others, heightened sensitivity.
as higher rates of sensory processing issues. And although it can be various things, one of the features of that is sensory overreactivity. So responding in a heightened way to your environment or inputs like other people's comments or looks or tones of voice
And interestingly, it doesn't have to be negative. It could just be neutral as you described. And the mind starts playing games. Why didn't they respond with a positive smile? Or was their tone of voice? Were they angry with me? Are they upset with me? Mind starts playing games. And I think it's something to do with the fact that in ADHD, there's a problem with the breaking system inhibition.
most of the executive function symptoms. In fact, all of the symptoms of ADHD can be explained by the brakes not working properly. And when the brakes are not working properly,
What was previously a fleeting thought is latched onto and built on and suddenly becomes much bigger. And it goes completely in line with my model of understanding ADHD, which is as an issue of regulation. And those 10 domains of dysregulation, domain four is emotion.
by far the characteristic emotional dysregulation in ADHD is linked to this rejection sensitivity. And in your patients, how do you see RSD presenting itself both physiologically and mentally? Well, they describe those features that I mentioned before. So they'll talk about these strong emotions and they'll talk about death thoughts cycling and looping and
And interestingly, when our system feels overloaded or overwhelmed, there's a tendency to try and protect us by shutting down or flipping a switch. It's called dissociation. And dissociation often happens in RSD. So someone who talks about zoning out or going elsewhere or getting stuck somewhere else. So that's sort of a mental side of things.
Within that category, I would add in all the stuff about self, self-deprecation and self-doubt, all of those thoughts of how I've messed up. And catastrophization is all going to fall apart. My whole life's a mess. And then a few hours later, or the next day, you can't even remember what it was that triggered you. On a physiological level,
with those emotions that I mentioned, particularly the panic and anxiety and the anger, they all fit into the arm of the autonomic nervous system that we refer to as the stress system, which is the sympathetic nervous system, the fight or flight response. So when you're triggered with a rejection sensitivity moment, immediately you'll feel a surge of adrenaline
which rushes through your bloodstream and causes you to feel hot and feel your heart start racing, your muscles to tighten up and it can feel extremely physical and that's the links with the body really. The autonomic nervous system and the sympathetic nervous system and its balancer, the parasympathetic, they innovate all the major organs of the body.
And you can see if there's an imbalance there, you're going to get symptoms of a stress response and a crash afterwards, an exhaustion afterwards.
Going back to the point where it might not be a negative comment, it might just be a neutral one or not the positive one that you were hoping for. The comment didn't meet the expectation that you had in that particular scenario. I had a guest on here who said that he cleaned the kitchen and his wife came in and he was hoping or expecting a thank you for cleaning the kitchen. But she said nothing and that triggered him.
Do you think there's a relationship between the general life experience of someone who has been made to feel that they are different and not enough? To one's sensitivity to rejection sensitivity? It's a really good question. So I think what you're asking is, can this be explained
physiologically, like biologically, something to do with the ADHD, or is this a product of experience, life experience? So living with ADHD and potentially having ADHD, family members, taking more risks, drinking more alcohol, you're going to face a number of setbacks and notbacks and criticisms and tellings off and detentions and all of these things over the course of your life.
And you learn that you don't like that feeling. You don't like the feeling, whether it was biologically primed from the ADHD in the first place, which I do think it is. As does William Dodson, who described it, he says, he believes it's much more a biological, physiological, neurological glitch.
And that makes sense completely, doesn't it? Because the system is dysregulated, everything about the system's dysregulated, not just the mental health components, not just the attention, but activity levels, sleep cycle, inflammatory status, the whole of the system's dysregulated. So it would make complete sense that how we deal with attacks. This is going back to survival, isn't it? How we deal with attacks is going to be dysregulated.
I've spoken a lot on the podcast. I've told the story a million times when I was six, someone in the playground said to me, you could be one of the cool kids, Alex, if you weren't so weird. And, you know, thousands of comments similar to that. At the time, I didn't think that I was unusual, but comments like that compounded over years to create an adult who has to mask in order to feel like he's normal.
And then when someone makes a little comment that suggests otherwise, it's almost like they've, in that moment, seen through, seen straight through it, and my efforts are in vain. And that makes me incredibly sad because.
I'm working so hard internally to hide this version of me that I've been convinced is weird. You think if people are listening and they relate to that, that feeling of years and years of feeling different, feeling weird, feeling like they have to shape shift and adjust who they are.
Is that feeling and that effort that is required to maintain that version of themselves? When someone sees through that, could that cause this internalized feeling of sadness? Absolutely. It's like one of the drivers of this is exposure in some way. I would even go a step further to suggest that the reason you mask is to protect against criticism.
that you set your life up to avoid anyone criticizing or rejecting you by presenting this, I'm in control and everything's fine for SARD. Not just because you're trying to defend against being different, but I think you're trying to defend against
feeling really, really awful. And you've learnt that by people pleasing, by putting on a smiley face, by a whole load of other little strategies that we use, you don't encounter that feeling as often.
It's interesting you said about the autism connection at the beginning, because I'm considering going for assessment for ASD. I feel like there's this, this like internalized version of me. There's like this child within me that has never grown up. And I'm having to sort of put on this character of an adult. And what age do you get stuck at? Gosh, you know, somebody who doesn't know how to
get leave the house on their own without being very scared. So when someone pulls me up on something that I've done wrong,
It's in those moments that I get triggered because it's bringing the child to the surface and all of that effort to camouflage the child is being tossed to one side and is made to feel like it's been a waste of time. Do you hear stories like that from your clients, this sort of contradiction between this
Internal version of themselves that might not be as mature or grown up or whatever, and is a contrast to the external version of themselves that they're putting on. Yes, I think that when we experience traumas, whether they're big tea or small tea traumas, big events or even comments in the playground.
And that charge remains in us. And when you have a charge and you try to avoid activating it, something gets stuck. I mean, that's the nature of trauma. It doesn't get integrated. So any mention or reminder of that issue activates the trauma, activates the charge, and you feel rubbish. And when those events take place, particularly significant events,
I feel we leave a part of it. Our part of ourselves doesn't move forward and mature. I see our self as made up of a number of different parts and different aspects and that certain aspects will have got stuck at the age of seven, at the age of 12 when this happened, when that happened. And integrating those parts through therapy, through the different approaches to processing trauma.
I think is a big piece of the work in ADHD because then these ADHD and trauma strongly overlap. And I think to optimally manage your ADHD, you need to go back and process some of these things that got stuck. And the idea is that those younger parts of you get integrated rather than shunned and left on the side because you're too sensitive and you called me too many problems and we're going to keep you away.
The way I like to see it is seeing that child part of yourself. As a child that was a bit stuck and lost, what would you do if you had a child that was stuck and lost? You'd come in, you'd bring them in, you'd make them feel safe. And I think those aspects of development, they get a bit stuck.
are what make you feel like your younger self. I often think, how do I feel? And I always go back to 17, for some reason. So I really relate to what you're saying. And I'm sure the view as well as well.
Yeah, no, it's fascinating. I'm trying to close that gap between my internal age or persona and these sort of external versions. I think that when we start to become more vulnerable and we open up about our difficulties, I've very much been through this myself over the last couple of years because as we talked about last time, I recently published a book.
on how to thrive with adult ADHD. And in the book, I open up about my own ADHD. And that whole process of coming clean, being vulnerable has been the most unbelievable, freeing process for me. Because it's a lot of work to carry around the facade to keep it going. And actually,
When you realize that it's generally a really good thing to be vulnerable because the person in front of you responds and opens up and connects with you, it becomes part of a real healing process.
But I think the vulnerability is countered by the rejection sensitivity. Can I be vulnerable enough? Or is it going to hurt me too much? And actually, when you do it a little bit, you start to realize that it's a really positive thing in the right environment, in the right setting.
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They're all at different stages of that journey. Some of them are actually quite advanced, that they're able to be very vulnerable. But the trouble that they report is when they have to go back to their family, their family unit for events, family dinners, birthdays, whatever it is, they fill that mask coming back because there's a massive distinction between their vulnerable self that they've
discovered through finding their tribe, this group of friends, compared to how their family portrays them or how they feel they need to portray themselves in front of their family. So my question is, if someone is feeling RSD significantly when they reunite with their family, say at a dinner, and there's Uncle Barry, who's had too much wine, and he says,
You're 40 years old, you should be married by now, and that triggers them. What advice would you have for that person? What could you say to Uncle Barry in that moment? I think the thinking needs to take place in advance. Families are really complicated things, so there's often
history wrapped up in all of this, charges being activated all the time. So it might be that there's a story behind some of these intrusions. But where I would think I'd approach that is if this was a pattern that was going on, an uncle Barry was regularly triggering your rejection sensitivity. I would think through it in advance, I would probably try to visualize in my mind's eye
how I would like to manage his intrusions that are likely to happen, but to visualize myself being calm and cool, and not responding with a shocked, angry, upset, anxious face, but responding with a little smile, with a little humor, and perhaps bouncing it back to Uncle Barry and saying, OK, Uncle Barry, so are you an expert in long-term relationships? And how's it going for you?
Deflect, humor. Sometimes that works and sometimes it doesn't. And sometimes what one needs is to just put down a really clear, not angry or aggressive boundary. One that says, I'm not comfortable to go there. I don't think it upsets me when you talk like that. So can we talk about something else? Just put a really clear boundary in place.
And the other thing I would say is once you are triggered, it's about how to add a ground, how to bring yourself down. Now, sometimes you can ground before it's too late, nip it in the butt. Sometimes that's possible. First signs of stress coming into your system, you might go, OK, I need to just take a moment.
going to get some fresh air, state change, and then in that space, whether it's outside or in the bathroom,
Do whatever technique helps you the most, whether it's breathing, some mindfulness. For me, it's tapping. We mentioned it last time. Emotional freedom techniques. It's a really excellent way of regulating quickly. Take a few deep breaths and then go back in confidently. And it might be in those situations that a mask is necessary just to get through the bump. But the idea is not to get fully triggered.
to avert it, to preempt it, and then if necessary to manage it. I like that so much. There's so much messaging about the need to unmask, but I think sometimes it can be such a good protective defence to have a mask in the short term as a tool. What if you do push back to Barry, Uncle Barry, a little bit? And Uncle Barry says, all right, I was only joking. Don't be so sensitive.
What would you say to an ADHD naive person like that who doesn't understand the complexities and nuances of RSD?
I probably wouldn't have that conversation there in the moment because the likelihood is I would be just on the edge and I'd probably slip into getting angry. So what I would do is let the situation calm down and then later have a little chat with Uncle Barry and say, look, I have ADHD and one of the features of ADHD is for me at least is heightened sensitivity.
When you make these comments, it upsets me and it triggers me. And I just want you to be aware of it. And if you don't mind not doing it so much, that would be great. Dealing with these things, not in the heat of the moment, is often the way forward. And listen, if some people will just laugh back at you and say, whatever, here he goes again. And then I would detach and I would say, fine, well, I'm not going to talk to you then until you start respecting me more.
And maybe Uncle Barry is self-medicating his own ADHD unknowingly. And this is the journey to his own assessment. You're right. Listen, I've always been taught that when someone goes on the offensive of the tackle, starts teasing or criticizing, it's very, very often about them, about jealousy, about something that they're struggling with, projected into you. How does alcohol interfere with a person's emotional regulation and have a knock-on effect onto their RSD?
I think given the fact that we're in the Christmas or just after the Christmas period, it's probably a very appropriate question. It's an alcohol disinhibits. It reduces inhibition. We know that. We say things we shouldn't say. We're more impulsive. We make decisions and poor judgment calls around things. And it's important there to recognize that
ADHD is an issue with regulation and inhibition. So the self-control really takes a hit with alcohol. It might be that people seek out, well, it is the case that people seek out alcohol and substances more because of all sorts of interesting reasons. To manage trauma, to dull sensations that feel overwhelming,
just because they are chasing sensations because they're sensory seeking or maybe they're sensory under responsive. And when you're sensory under responsive, you might try and seek out and grab sensation because it's nice to feel something. So the combination of alcohol, alcohol, which obviously has increased in ADHD and the preexisting ADHD
comes together to reduce self-control and to make it more likely to find yourself in a situation where your RSD or rejection sensitivity is triggered because someone else has been drinking and they say something they shouldn't say and you respond in a certain way and before you know it you're spiraling.
Do you think someone with ADHD who's had a few alcoholic drinks could start an argument, not necessarily because they have an issue with someone, but because they are looking for stimulation? And if so, and that person claps back, how could that trigger their RSD? I think the first part of the question, absolutely yes.
unconsciously we seek out dopamine or noradrenaline to bring a sense of regulation to the brain and if we don't feel it we will find ways of getting it and we talk a lot about ways of getting it through
You're drinking and alcohol and all sorts of other things that promote it. But certainly getting in a conflict is one way of getting it. We talked last time about that calm after the storm. If you enter into that conflict, there's a reasonably high chance that the stuff that comes back at you is going to trigger you. Christmas has just happened. We're into the new year. There's probably
Lots of people listening to this who are on the other end of a big flare-up. They've perhaps been triggered, they were triggered over Christmas, and now they're sort of sat at home feeling very shameful or embarrassed about how they responded to something. If someone finds themselves in that camp, what advice would you have for someone who's on the other end of it, who's in that post-trigger stage?
I think normally a day or two is gone, usually. I mean, if something dramatic has happened and, you know, someone said something that they can't retract or you can't rationalize or make sense of it's gone too far. It might be different, but on the whole,
The impaired working memory of ADHD means we forget things. It's actually quite protective in some ways sometimes. Until you move on, it feels like your whole world's falling apart. And as soon as something, I mean, I'm just amazed. I struggle with LSD a lot. And, you know, when I'm in that, oh my God, I feel so angry. I just want to, I just want to sort of vent. And then I decide
I catch someone's eye and there's an opportunity to both smile at each other. And the message is, are we really going to go there or should we just let this go? And that smile and that giggle, it just dissolves it within a second. So I'm increasingly looking at an easy out.
And the easiest out is to just laugh and just to say, oh God, you're triggering me again or like, I'm gonna get out of here now, otherwise I'm gonna be a real mess. I don't tend to see the rejection sensitivity in the moment stuff dragging on for a long time in most cases. I think when it does, you're into the realms of trauma, a trauma reaction.
I think ISD is a mini trauma reaction, but I think this is something that's happened that sort of left that charge in place. We want to try and get rid of these charges before they set in.
From my experience, and speaking to people in the community, when they're triggered, the feelings are disproportionately intense to the event, and therefore the emotions are heightened, and the things that they can say in retaliation to the perceived comment can be quite drastic, sometimes mean, like horrid.
If someone's on the other side of Christmas and they've said something nasty to a family member that they didn't mean on reflection, how do you go about explaining that to the family member who might not understand the complexities of RSD? Well, first thing is that you need to be out of it. You need to be completely OK in your own right. You have to go into that discussion without any heightened emotion. And that means you've got to go and do a bit of work on your own.
And I think going through the, I think whenever you're going to have a heavy discussion, I think it's important to create the setting, the right setting and frame it and explain. I'm going to be telling you some stuff that might be difficult to hear. I want you to listen rather than come back at me and plenty of time for you to give me your thoughts, but I want you to take me seriously. And I don't want us to get in an argument about it.
because there's no point in doing that. And then I think to give some honest feedback depends whether the individual knows you have ADHD, but assuming they do, it's explaining that I have ADHD and the features of ADHD include dysregulation, an emotional dysregulation, and this particularly sensitive to rejection.
When I get triggered, this happens. I feel it really strongly. And sometimes I can sort of lash out with a knee jerk reaction. And I did that the other day. And I want to apologize. I don't want to excuse it. I just want to explain it. And that in itself, regardless of what the other person says,
is discharging your responsibility as long as your heart was in it, and you did it for the right reason, and you did it honestly. So I'm real believer in owning my mistakes, and if necessary, apologizing, and then moving on. And it's now their job to decide how they do that. We're in January. All of the parties are finished. It's very dark.
Can loneliness be a trigger for RSD? Absolutely. The lack of connection is perceived as rejection.
So without a doubt, when we fill our lives with busy things and structured work, if we're working, and we have lots of interactions with people, we don't leave much space to allow these things to percolate and ruminate in our minds. And so loneliness, even if loneliness is perceived as rejection and
Particularly around this festive period, if people don't have good, loving friends and family to go to. It's a time of heightened social comparison.
So and so is going to their family, and you're going to your friends, and I'm here on my own, and I'm really bored. I think in that situation, you want to bring structure into your time. I think dedicating your energy to helping other people, getting involved in community stuff, homelessness stuff, bringing and maybe working in a creative project, massive mural on the wall, a painting, a video, a video diary or something to something to occupy you, because it's in the space.
where some of these unhelpful thoughts and ruminations and sensitivity, oh, no one likes me and my life's falling apart. It's in the space that this happens. So you want to sort of limit the amount of unstructured time and connect with the people. The worst thing to do when you're feeling lonely is to go, I'm going to retreat to my bedroom and stay in bed and cut off from everyone even more. Actually, it's the time you want to reach out, but reach out to people who care about you.
And maybe show that vulnerability you got a balance you don't want to be the one who's completely moaning and drawing every sucking sucking the energy out of other people the whole time but when you need to you need to reach out and ask for help. A good friend will help you will arrange to meet with you will pop round.
RSD isn't well studied or studied at all. It's definitely not an official medical diagnosis. Why do you think it's not an official medical diagnosis? And do you think it ever will be? I don't think it will be a diagnosis, but I think it will get studied. I think it's not just not been studied because it's a relatively new concept.
It's probably quite challenging to study. When you're studying a drug medication, you can give a placebo. And so it's very difficult to study these things. But I think it can be studied and it will be studied. And I think it will become a thing in time. I've no doubt about it. It's face validity, as we call it. It's strong. I mean, people resonate. You resonate. I resonate. We're talking about it. It's real.
So I do think it will happen in time, but I don't think it will become a diagnosis. I think it will become like a symptom cluster. And I think it would sit as it does now under the emotional dysregulation of ADHD, which extends beyond RSD, but RSD is without a doubt central part of it.
My mind's whirling, trying to think of ways you could study it, which is ridiculous. Like you said, it's almost impossible. You'd have to give like a thousand people a notebook and say, journal your emotions when you are triggered and put data points together, very difficult. One of my colleagues, Professor Philip Ashison, he and his team, he's retired now, but he's done quite a lot of studying on emotional dysregulation.
One of the studies involved giving participants, so there were two groups. One group had ADHD, and the group didn't, and they had this little buzzer thing in their pocket. Every time they became dysregulated in any way, they'd press the buzzer, and it allows a comparison between the groups. You could do a similar thing with rejection sensitivity, and maybe at those times,
as well as pressing the buzzer, maybe record and capture the scenario, what happened and what you felt. So it would be a mixture of quantitative and qualitative research. So quantitative is like how many buzzers in a day, and qualitative is what was the experience. And I think it needs to be looked at from both of those angles.
when we look at things like medication, we look at symptom scores, it's numbers, it's like how many numbers as a go down. But we must have forget that quite a lot of research, useful, helpful research is descriptive, clustering into things. And I think this needs both. I can kind of see how you could potentially easily
study a group of people's response to criticisms. How would you measure whether those criticisms were perceived or if they actually had some merit? That seems to be like the almost impossible thing to measure. Well, that's why you'd capture the scenario at the time. And then you'd have to cluster those into, was it appropriate or not appropriate? You know,
Again, subtleties of study design, but there will be ways of capturing those, answering those sorts of questions. But it needs, you know, it needs a good study. If there ever is one, sign up. What social interactions do you think might trigger RSD within someone that a neurotypical person might just be able to brush off, ignore?
So the thing that comes to my mind is when you used to get selected for teams for sports at school and each captain would choose someone for their team and then slowly the numbers would dwindle down until you were left there. I think someone with heightened sensitivity finds that horrific, whereas perhaps other people who don't
would just go, yeah, whatever. I don't know. Maybe that's not the case. Maybe actually everyone doesn't like that. I'm not sure. But that would be a scenario. What would be another situation? I suppose a neutral comment. Most people would see a neutral comment as a neutral comment. Someone with heightened rejection sensitivity will interpret the neutral comment in a negative way. And why do we go towards the negative more?
I think it's because that our evolution has led us to look for danger. It's much better to look for danger and get it wrong than not to identify it and then get hurt. I think we're primed to look for attacks. And if that system that does that is a bit dysregulated for the reasons we've discussed,
I think you will interpret it in a different way. And there's many different situations. I'm trying to think of ones in my own life. I will often, through, and hyper focus is actually part of this because individuals with ADHD who hyper focus will not miss a thing. They will catch the subtlest movement in someone's face or tone of voice
Whereas other people might not do that. It's like if you are checking a document that ADHD individual with hyper focus won't miss a single dot. And it's a similar thing in a social situation. So it's not just the response, but it's the sensitivity to anything that might suggest danger.
It's amazing, isn't it? It's like in the absence of positivity, you default to extreme negativity. It's like if someone replies to a text message without five emojis or a full stop, you think that they're going to break up with you. Or if your boss asks for a quick chat, but doesn't give you any context.
You catastrophise and think you're going to get fired. That's not the thing, sir. I felt my gut going just then and you said that. I mean, I agree with you. That sort of open-ended thing, leave it to you. You want you to work out what it's about. It's not good in ADHD. I suppose normally, one's mind might go, oh, they could be asking to fire me and then it would get closed down. Oh, there's no evidence for that.
and the inhibition would kick in. But you remove those breaks and that thought goes here, there, and before you know it, you know, you're resigning yourself. Yeah, you know, you think your world's going to end. It's amazing. The shifts that can take place in how extreme you feel from one minute to the next always puzzles me. It's amazing. Do you think RSD and people pleasing are connected? A hundred percent.
took last time about how the personality shapes over time to accommodate the RSD, to stop it happening, to reduce the chances of it triggering. And there are different categories on there. So people pleasing as one of them. Over extending yourself.
to compensate to make it less likely that someone's going to criticize you, which essentially translates to people pleasing, taking on too much, volunteering where you don't really want to do it, agreeing with people when you don't agree with them. And there are other things that patterns that form such as avoidance and perfectionism. And all of them are there to
mitigate, protect in some way. And again, it's like the mask. Can RSD manifest itself in more subtle ways, less physiological ways that we haven't mentioned before? So I think chronic perfectionism is a clue, as is someone who's a very high achiever,
who just pushes forward and tries to be the best all the time. Someone who doesn't take on projects at work, the fear of getting it wrong and being criticized, makes a step back, is sitting at the end, on the outside circle, doesn't make eye contact. Those sorts of things are clues, slightly more subtle clues.
People who will never agree as, I call them, agree as, who will just go along with whatever you say. In all of these things, it's like creating a shield between that person and the possibility of them encountering a criticism. Yeah, the shield is there to protect you, but it also inhibits connection. The flip side of the shield, when you protect yourself too much, you don't connect.
vulnerability equals connection. So the shield is actually quite damaging. And I think as we develop and grow older, our challenge is to try and shed these layers, these protective layers, so that we can connect more, we have more nourishing relationships, not just with other people, but with ourselves, because when you
When you mask a lot and when you people please and when you work really hard to perfection, you get burnt out and you suffer long term. It's never enough. You're a perfectionist. It's never enough. You're only as good as your last thing and then you have to keep on improving on it. And actually the aim is to feel comfortable and content and secure and enough without any of your achievements. It's a life's mission.
It's all the stuff we're talking about. It's being aware of it. It's communicating. It's regulating both in the moment and as part of your normal day-to-day routine because how easily you trip.
or you switch or you get triggered, depends on your level of resilience in the system and your level of resilience is made up of all sorts of factors. How sleep you've got, how sleep you've had, whether you're nutrition's good, whether you do any form of mindfulness and grounding, whether you have good tools in the moment, there's so many different factors that, and you really wanna work on both. You wanna work on the reactive stuff and you wanna work on the
Preventative stuff. Preventative is always better. That's why I put so much weight on self-care and movement and breath work and mindfulness. But it has to be the thing that you have to work for you. Not all approaches work for everyone.
So if someone has a shield that is ultra thick, i.e. they have a mask that's ultra thick, they struggle to put boundaries in place, they say yes to everything, they over commit. Compared to someone who say the other end of the extreme has no shield. They're completely vulnerable. They're exposing themselves to everything. How do you know if your mask is too thick or too thick?
Well, if your mask is too thin, you're going to get hurt easily. And then you're probably going to develop a thicker mask or find some other way of managing it substances. And you know, it's a bit like a mask, isn't it? When you drink alcohol, smoke or joy, it's like putting a protective layer, cotton will lay around you in some ways, protecting you a bit. And so I think
Too thick. Mask means that you don't know yourself.
You don't connect with people. You can't relate to people if you can't, if it's too much of a barrier. And if it's too thin, then you're sort of being thrown around like, you know, in a fairground ride without a seat belt when you're being thrown around continually. And it's not nice. And at some point you'll do something to stop that happen. One of the things that we talked about.
like everything in life. It's about finding a balance. You need to protect yourself a little bit, but not too much. You need to go and have fun and nights out with friends, but not too much. You need to
You need to be able to vary your diet and mess up a bit and break some rules, but not too much. Everything's about balance. I don't know any answer to any question that involves personal development or growth. It doesn't involve someone having to get the balance, re-establish a better balance.
I want to talk about how RSD can show up at work and in people's relationships, but first I want to draw attention back to the item on the table. Could you explain what that is and why it represents RSD? So it's a glass, thin glass orb, which I am imagining is the individual's sensitivity
and when rejection or criticism comes along it's like bringing a small hammer to this glass orb which then immediately and dramatically shatters the thinness of it that shatters into lots of pieces and just the idea of someone
everyone's attention being drawn, the focus coming in, the scattering of glass shards all over the floor, attempting to try and clean it up, but just making it worse and just the shame of people watching you scrambling around and on the floor trying to sort of recover things made me think of RSD, the impact of it. How dramatic the impact is and how vulnerable ones
Sensitivity is really captured by this thin glass. And it can all feel like it's fallen apart.
Yeah. No, it's amazing analogy. I mean, it's so stunning and amazing to look at. But to prove how fragile it was, I actually did crack it. Did you? I tried to place it here. It fell. It was about two inches. I know. We want to keep it on the shelves, though. Not just an amazing object, but a two-inch fall that it's completely cracked. It has brilliant sensitivity, vulnerability, yeah.
James, I want to do the ADHD agony art section, which is cool, the washing machine of woes, because I always leave my laundry in the machine. That's my ADHD item. Although I am using the TMO app, so I'm getting a little bit better at remembering the washing. This week in the washing machine of woes, somebody has written in and asked,
I can't stand family gatherings. I'm creative and all my family are business-minded, so they don't understand my pursuit to be an author. Everything they say is so demeaning, but I'm not sure if I'm just being paranoid or if they are being really patronising. How can I stop myself from feeling such intense hurt and rage? Not uncommon that people project. Family members project.
into people what they think is what they should do. Actually trying to work out what to do with your life with ADHD is such an important thing and if you do have found direction and you found something you're passionate about, extremely lucky and that's one of the big keys to being successful with ADHD in my experience is
following your heart when it comes to vocation, finding the thing that you're passionate about. And once you've found it, don't let go of it, regardless of what other people, how other people judge it. Again, it has overlaps with the conversation we had about Uncle Barry a little bit earlier. I think it's about being very clear in your own mind where you stand on something. And once you've made your mind up,
to be quite boundary about what you'll accept and not accept as an adult. It might be different as a child. Your parents and family members are there to help guide you and challenge you and steer you. But as an adult,
You take the responsibility for that yet when you go back into a family gathering family environment is very easy to slip back into old roles to regress back into that childhood part of yourself and the parents perhaps assuming. The role of a guide or a judge but actually things have changed and.
Clearly, assertively say, making it quite clear that this is your decision, it's not for anyone else, and maybe once and for trying to nip it in the bud. Obviously, if it triggers you and you go into the spiral that we've talked about before, then all the stuff that I discussed earlier is relevant. It's about
removing yourself, judging whether or not you want to go in the first place. And if something's really, really uncomfortable, you have a right to say, I don't want to go. But I think feeding back your views and feelings clearly without getting angry is important. And maybe discussing the fact that
If I was to take a similar career line to you guys, I wouldn't be happy. Things would not be good. And you should be celebrating the fact that I found my path and encouraging me. No, it's brilliant. Thank you so much. And then you mentioned there, when someone with ADHD, it's important to find or to put the energy towards something that you're passionate about. How does someone figure out what they are passionate about?
It's that inner feeling, that excitement inside when you encounter that thing. I'll never forget. So my journey into psychiatry wasn't pre-planned. I trained as a doctor. I worked two or three years as a doctor in emergency departments and various different wards of the hospital.
And then when I was, I decided I was at that stage going to train to be a GP. And as a GP, you used to do six month jobs in a variety of different things. And one of them had to be psychiatry. And so when I was applying for the psychiatry post, my gut feeling told me that this is good. I'm excited. So rather than getting on a six month job,
I impulsively decided to apply for a four-year training program to become a psychiatrist, not a GP. And my instinct was right. I never looked back. And that was how I got into psychiatry. I literally didn't go through the left brain, pragmatic, pros and cons. In fact, I'd actually ruled it out. But my instinct led me that way. And I learned
at that stage to follow my instinct a little bit more. Not always, because it can lead you down dangerous paths, but to listen to what my gut is telling me. If someone listens to what their gut is telling them and they make their passion, their work, how does RSD show up? Or how can it show up in someone's work?
in so many ways. I find lots more people with ADHD choose not to work as part of a larger system, like the big organization, where there's lots of rules and regulations and protocols and
Security this and swiping in this, you know, it's a nightmare. The punctuality, the remembering logins, the sense that you're constantly being monitored in some way, doesn't go well for ADHD. And you do have slip-ups and then you sort of get called up on those slip-ups. And that really...
that really activates the RST. Am I going to lose my job? Am I going to be shamed in front of everyone? Is that whole feeling of going and standing outside the headmaster's admissions office? In other ways, it can show up. I think in not wanting to volunteer or take on projects, being like you want to slip into the background and not be judged on things, procrastination,
I don't produce a finished product. I won't be judged on it. But when I actually get something done and deliver it, we judged on it. So that's a level of exposure. I think the comments by colleagues in the office that perhaps we're just fleeting can be misinterpreted and certain looks when people are stressed at work for all sorts of different reasons.
One can register it as a personalized thing, get quite paranoid about it. And of course, you're struggling with your executive function. So you're running slow for a project and you're worried about getting criticized. So all of the executive function difficulties of ADHD that can play out in a work setting potentially lead you into this cul-de-sac. And in romantic relationships, how can RSD show up in that arena?
most commonly by the individual with ADHD, misjudging or perceiving something that was neutral, or maybe it was slightly irritated or slightly this that wasn't a big deal.
happens with my wife and I all the time. I'll say, oh, don't give me that look. I wasn't giving you a look. I knew she was giving me a look. She didn't even realize she was giving me a look. And then that dynamic of you did this, no, I didn't. And then suddenly you're in this spiral. You know, we need our
We need our partners to be able to feedback and give us guidance and advice. In fact, it's an amazingly effective tool to have some sort of subtle communication with your spouse to help guide you when you're talking too much, or eating too much, or drinking too much, something to help regulate you from the outside. So again, that fine balance between welcoming that,
Again, if you ask for something, if you ask for that sort of input, sometimes it takes away the intensity of it. It's often when it comes, it's unpredicted or like unpredictable or unanticipated.
It hits you hard, whereas actually you say, could you tell me if you think I'm talking too much? Or being a little bit direct with people. Let's have a little sign. Yeah, a little whatever it is, the sign. So I think bringing the partner on board and then in addition to yourself learning about this thing, the sensitivity and working with it. So when it does happen,
Now, I will turn to my wife and say, I've been triggered. I know you didn't mean to. And I know you haven't done anything wrong, but I've been triggered. And so let's talk about this afterwards. I think there's a lot. So listen, every time you mess up, you turn up late, you book the wrong holiday.
drop the bars at two o'clock in the morning, whatever it is, you know, you're opening yourself up to a, what would seem to be a natural response as people get angry or get upset in a brief moment.
that you might be left there going, it wasn't my fault, I didn't mean to drop the vase and you're having to go at me and then suddenly it gets into this out of control thing. When your wife triggered you and you said, you've triggered me, let's talk about this later, what do you do in that interim? I'll go and state change, I'll go and blow my dog, I'll go outside, I'll breathe, I'll tap.
I will try and open a conversation about something else with someone else. I'll make a phone call. I will try more increasingly now. Like I said before, I will try and make a joke out of it.
some light-hearted, flippant comment that doesn't self-denigrate, but it just captures the silliness of the whole thing. And the moment you give that forward, you both smile, you both laugh, you hug, you move on, it's literally just lifting it away. It's quite powerful, that feeling. You know it, don't you? That must be a switch. Yeah, no, definitely.
If something that's fascinated me is, do you think RSD presents differently between the sexes? In other words, is there a difference between how the sexes are triggered? So I can only answer the question anecdotally, because again, we don't even know who RSD is. But I would imagine that when we do have the evidence, we'll probably find a general theme of women internalizing more
and perhaps going down the perfectionism route, the self-doubt, the internal ruminations. Whereas I would imagine men would probably, on the whole, externalize more, be more in touch with their anger, maybe avoid more.
But there's such variability between these reactions and very much influenced by societal expectations and cultural things. So I don't think there's a clear-cut answer there.
We had a guest on here, James, who explained the heartbreaking scenario where they were triggered so badly that in that moment they actually considered taking their own life. I appreciate that there's no evidence to back this up, but do you think RSD really gets that bad that someone might want to in that moment take their life? Unfortunately, yes, I do. The intensity is off the scale.
You know what it's like. It's like being knocked down and then so full of emotion or cut off that it just feels like your life is falling apart. There's no way out. There's no solution. It's completely overwhelming. And with someone who has is quite impulsive
Maybe has a history of hurting themselves because they don't know how to manage emotions. Maybe has a history of other mental illnesses, might be depressed or have anxiety issues or have trauma issues.
I suspect if we were to go back and look at the suicides of people with ADHD, you might find that there's a pattern that they happen at times when that individual for whatever reason is even one of these episodes. So I don't know the answer to it. My gut feeling is it's a higher risk period. Do you think RSD can dip into the realm of paranoia?
Yeah, I mean, the paranoia is on a spectrum, really, from a sort of vague paranoia, overwearing, overinterpreting, and then going into the realms of illness in terms of psychosis and persecutory delusions and so on. So I'd say in terms of the former, overinterpreting things, making links and connections that aren't necessarily there,
Don't forget, we get a bit of information, a look, or a tone of voice. And in our minds, it's like, that look meant this. And if that means this, then they actually really don't like me. And if they don't like me, then this is going to break down. If this breaks down, I have to move out. And if I move out, then I will be on my own. It spirals. That's the lack of inhibition. You're taking the breaks off. Normally,
That look, as I said, would get closed down quite quickly because there's no real evidence. So, yeah, in terms of a paranoid flavour, a themes, I think that's really common. I wouldn't go as far as to say it triggers a full blown paranoid psychosis. And on the flip side of all of this, do you ever treat people that don't get affected by rejection at all? And is there an official diagnosis for people like this?
But there's no official diagnosis and it's so common rejection sensitivity. I'd say it's, you know, it's, uh, with the, it would definitely be the majority of people that don't forget that ADHD comes hand in hand with other mental health problems or neurodevelopmental problems, which include autism.
which one of the features of autism is it affects your ability, theory of mind, your ability to put yourself in someone else's shoes. And then there's a symptom called alexithymia. You may not register your own emotional reactions. I think in those two situations, I'd say it's less likely, but certainly really common.
People with the community, James, I speak to who have ADHD. They report this sense of heightened intuition. Do you think people with ADHD have heightened intuition? And if so, should we believe everything our super sharp intuition tells us? So the answer to the first part, the question is absolutely yes. And it's easy to understand why, because when you start thinking about the regulation model,
The frontal part of the brain is the brain's regulator or conductor, or better to understand the inhibitor, the breaks of the brain. So without that frontal part working fully, the brain can go too far. It can, you know, those thought cycles and they can go on, but the frontal lobe will
Regulate will dull down, will pull in, will organize. Now, the fontal lobe in ADHD isn't working in the same way. So there's less inhibition. And so when you take those breaks off, all of the functions are expanded in some way. So your ability to sense things and feel things is not dulled down. It needs to be dulled down.
to be able to function well in normal life because otherwise you were responding too impulsively and there's no limits, there's no balance. So I do think intuition has increased. I do think the ability to sense and feel, often feel other people's emotions, often get a sense of what other people are thinking. So I think that's a very real thing.
And I think that when there's emotion involved, it will shift or taint or influence those intuitive thoughts. So the emotional intensity will distort. And I think in that situation, not sure you can trust on your intuition as much. When the emotion is
Rises and particularly if there's stress in the system stress has the effect of shutting down the frontal lobe literally switching offline which is taking the ADHD problem and exacerbating it is why we in a crisis we we don't think through things we just act animalistic way we just go for it.
And so I think when the emotions and upset is involved, it certainly influences our ability to accurately perceive. Gosh, I'm listening to you, James, and I'm just so much relatability. The calm and the crisis thing is overwhelmingly relatable. And I'm excited by how many people this episode is going to help. And ultimately, James, have you got three tips on how we can manage RSD? Yeah.
I do. The first one is to learn about it and to understand it, to understand reinterpret
many past situations where you've beaten yourself up for acting in a certain way and actually realized, oh my God, that was RSD. And what you'll find is that there's a scattering of these RSD moments that it can explain many of the crises or breakdowns or problems you've had in your life. And it can go a long way to changing the way you relate to yourself
And that awareness allows you to intervene earlier and to prep your system in such a way that you don't get triggered as much as I mentioned before. So the first one is learning, understanding, awareness, and sharing that awareness with loved ones so that they really understand it as well. The second one is the preventative. So this is
self-care, making sure you get enough sleep, making sure you're nutritionally balanced as much as possible. You don't drink too much alcohol or use drugs and that you take care of yourself and that you don't allow those charges, those mini traumas to collect on you. You don't gradually build up these heavier and heavier bags that are weighing you down. And the way I approach that is a daily practice of
mindfulness. But I mentioned last time we spoke, I can't do the regular mindfulness thing, I just get distracted. So I developed the solo soma practice that I mentioned, I think there'll be a link. I mentioned last time it was almost done and that was just me misjudging how long it would take to finish it. It actually is finished now and it will be available on
the Grove Practice website. And it's essentially a 20-minute movement meditation that integrates a number of different emotional regulation or trauma processing techniques, or at least the potent elements of each of them, and weaves it into a flowing movement meditation. And I find that it clears the stuff that's built up over the last 24 hours and makes me feel resilient
such that when I get into a situation, I'm far more likely to, you know, bat it off, laugh at it. Whereas before, I might, because of the general load in the system, I might just trigger. So that's the second one. The third one is when it happens in the moment, using one of a handful of strategies that we've discussed, whether it's humor,
time out, um, deflection, um, or, or other things and taking yourself off and in the moment regulating with breathing, tapping, fresh air, green spaces, talking to a friend, all of these things. So there's, there's three different elements to the question, information, preparation or prevention and reaction or, you know, how you respond in the moment.
Brilliant. I'll put a link to the Sosoma as well as to your brilliant book, How to Thrive with ADHD in the description of the episode. Adult ADHD. Adult ADHD. It's so good. No, thank you very much. That's great.
Just finally, James, I've had a couple of guests on who have claimed the opposite of RSD is a euphoric response to praise. But if we focus on RSD, do you think there is a way of framing RSD to be a positive thing? I mean, specifically RSD is a positive thing, possibly not, but what underpins RSD is heightened sensitivity. And that certainly is a double-edged sword.
Because, and I know that from a personal point of view, about 10 years ago, while I was traveling on a lecture tour, I got a tick bite, I got Lyme disease, and it shifted my immune system in the way that I would never realize would have such an enormous impact.
And then subsequently I struggled with mold toxicity, probably because my immune system was vulnerable. And as a result, over the last few years, my sensitivity, which was already pretty high, has just ramped up. And it's been the most awful few years and the most
Unbelievably growth promoting few years because that sensitivity is intrusive it sounds and lights and smells and chemicals and everything will just Consistently floor me and make me feel ill yet intuition that connectedness that
positives of sensitivity, the ability to feel where to go and actually trusting it more has gone up.
And so I think this, although maybe not to that extreme, although I think this sort of immune dysfunction is much more common in ADHD. And that's a whole separate discussion to have. So I don't think I'm alone in this. I think many people will relate to heightened sensitivity, which may be a lifelong sensory processing issue or maybe a exposure linked
Heights and sensitivity like multiple chemical sensitivity or other names for that thing. And sensitivity is neither a good thing or a bad thing, but it needs to be managed. Yeah, gosh, I mean, we're going to have to have you back for a third time now. It sounds really fascinating.
Today, truly, I mean, overwhelmingly helpful for me personally. As I said at the top, RSD has been the most problematic aspect of this whole experience for me. And I know many listeners, if not all of them, will agree. So thank you so much for sharing so much wisdom today. We have a closing tradition, James, on the podcast where I deliver to you a letter written by the previous guest. They wrote three rules to live by.
I've got an impulse to smash the orb, by the way. I don't think I should there, because they won't find its place on your shelves. I think I'll leave it. I'm going to deliver the letter to you, James. If you kindly read out the last guests, three rules to live by. OK. Listen to your knee-jerk reactions. They are best indication of your true beliefs. That's what we've been discussing, really, or intuition. Number two, don't beat yourself up about things you said when you
triggered. Again, very relevant. Say sorry and recognize it wasn't your fault. Okay, very good. Again, themes we talked about, really important. And the next one is celebrate the winds, especially the small ones. Your subconscious will become stronger. That's great as well. The idea of
filling your airwaves with positivity and future thinking and rather than rumination, negativity, because ultimately what we fill our airwaves is what we become.
I was laughing when you were reading those because I recognised them and I remembered that they're mine. Because you were sitting in the sea. I was before you, yes. Great. Well, excellent. James, again, thank you so much. Thank you very much indeed.
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