One of the toughest parts of ADHD is left out of the diagnosis

ADHD diagnoses are on the rise in the United States, but what if professionals are missing a key part of the disorder? In the 1970s, some clinicians recognized a lot of their ADHD patients had trouble with emotional regulation. But because it was easier to measure behavior rather than emotions, the criteria eventually fell off the radar. Today in the U. S., emotional dysregulation is not a part of the ADHD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Dr. Sasha Hamdani thinks that needs to change. In today’s episode, she talks about her book Too Sensitive, and explains what is going on in the brains of people with Rejection Sensitive Dysphoria. Interested in more mental health science? Email us your question at [email protected] mailto:[email protected]. Support public media with NPR+ and enjoy perks for over 25 podcasts like this one. This show’s perks include sponsor-free listening. Learn more at plus.npr.org http://plus.npr.org. Wender, P. H. (1971). Minimal Brain Dysfunction in Children. Wiley-Interscience. https://pubmed.ncbi.nlm.nih.gov/4581984/ Barkley, R. A. (2015). Emotional dysregulation is a core component of ADHD. In R. A. Barkley (Ed.), Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (4th ed., pp. 81–115). Guilford Press. https://www.guilford.com/excerpts/barkley2.pdf?t=1 Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014). Emotion dysregulation in attention deficit hyperactivity disorder. American Journal of Psychiatry, 171(3), 276–293.https://doi.org/10.1176/appi.ajp.2013.13070966 Faraone, S. V., et al. (2019). Emotional dysregulation in adults with attention deficit hyperactivity disorder: Validity, aetiology, and clinical implications. Neuroscience & Biobehavioral Reviews, 107, 132–142.https://www.google.com/search?q=https://doi.org/10.1016/j.neubiorev.2019.08.021https://doi.org/10.1016/j.neubiorev.2019.08.021 Bondü, R., & Esser, G. (2015). Justice and rejection sensitivity in children and adolescents with ADHD symptoms. European Child & Adolescent Psychiatry, 24(2), 185–198.https://www.google.com/search?q=https://doi.org/10.1007/s00787-014-0560-9https://doi.org/10.1007/s00787-014-0560-9 Cleveland Clinic. (2022). Rejection Sensitive Dysphoria (RSD): Symptoms & Treatment. Cleveland Clinic Health Library. https://my.clevelandclinic.org/health/diseases/24099-rejection-sensitive-dysphoria-rsd See pcm.adswizz.com https://pcm.adswizz.com for information about our collection and use of personal data for sponsorship and to manage your podcast sponsorship preferences. NPR Privacy Policy https://www.npr.org/about-npr/179878450/privacy-policy

• 0:00Speaker 00

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• 0:17Speaker 01

  I went to med school with the full intention of being a pediatrician. I think it just sounded so amazing that I was like, this is a superhero job.

• 0:26Speaker 02

  Meet Sasha Hamdani, a doctor, but not a pediatrician.

• 0:34Speaker 01

  When I was ready to get my letter of recommendation, I walked to the door of my attending and she stops me at the door and she's like, I hope you're not coming in here for a letter.

• 0:46Speaker 01

  And she was like, you cry all the time. She's like, you cry during patient interviews, you cry when you're checking out, you stick around with the families, you make them cry more.

• 0:57Speaker 02

  Sasha wanted to jump in and defend herself, but she could already feel the tears building.

• 1:04Speaker 01

  She was like, you know, if I write this letter for you, you're going to burn out. Like, this isn't a career you can sustain.

• 1:10Speaker 02

  In hindsight, as a psychiatrist, Sasha learned that pivotal moment was so hard because she had rejection sensitive dysphoria, or RSD.

• 1:20Speaker 01

  Rejection sensitive dysphoria is this incredibly robust emotional, sometimes physical, but mostly emotional response to rejection or criticism. And the rejection or criticism can be real or even perceived. It can be the threat of it that sets off this neurological cascade.

• 1:39Speaker 02

  RSD was popularized in the 1990s by the psychiatrist William Dodson. And it was something he noticed a lot in his ADHD patients.

• 1:48Speaker 01

  Now, the problem is, is that I really, really want to say, I know that it is extremely uncommon in ADHD, but because RSD is not part of the diagnostic criteria, emotional regulation is not even a part of ADHD criteria. We're just so behind. We don't have those actual studies and data to say exactly how prevalent it is. But for a lot of people, and even what I've seen anecdotally, and even in myself who has ADHD, I would say that RSD is the most limiting part of my ADHD.

• 2:18Speaker 02

  And so Sasha wrote the book she'd been looking for to give meaning and resources to herself and to her patients.

• 2:27Speaker 02

  Today on the show, the emotional dysregulation of ADHD. From what's happening in the brain to why many people have never heard about it. I'm Regina Barber. You're listening to Short Wave, the science podcast from NPR.

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• 4:11Speaker 02

  Okay, so Sasha, in your book, you write that brains with RSD and how they're wired differently when it comes to emotional pain. What does that mean?

• 4:20Speaker 01

  Well, I think in order to get to that, you need to first get to that emotional threat processing. So initially, when you're looking at the brain, you look at two big areas of the brain. The first one is that emotional threat detector, which is the amygdala, which is this tiny little almond shaped structure deep in the brain, which tells you like, this is a problem, this is not a problem. And so for people who are highly emotionally sensitive, this area is hyper responsive.

• 4:46Speaker 02

  Yes.

• 4:46Speaker 01

  Like on alert. Then you look at the prefrontal cortex, that area directly under your forehead. And that is in charge of judgment and decision making and processing. It's that logical side of your brain. And this is underresponsive. And what makes it worse is that the connection between the two is weak. So now you just have this delayed communication. And so what that means is that you are perceiving a threat and you're actually experiencing the chemical cascade that goes on before that logical side can step in. So when you get into that chemical cascade and your brain is already assessed, like something weird is happening, let's do something about it.

• 5:27Speaker 02

  Yeah. RSD is not in the diagnostic and statistical manual, the DSM, which is the authoritative text for diagnosing and treating psychological disorders. I was surprised to learn that decades ago, early in describing ADHD, and before we even had words for it, some clinicians did really key into troubles with emotional regulation and this sensitivity we've been talking about. So why do you think this aspect of ADHD fell off of people's radar?

• 5:56Speaker 01

  Dummies, all of them. I hate it. And I think what happened was that we started to favor observable symptomology. Like, this is hyperactive behavior. I could see it and it's easy to measure. But the problem is, when you're dealing with the brain, there's so much that you can't measure because so much of this is internal.

• 6:14Speaker 02

  Yeah.

• 6:15Speaker 01

  And so it is so limited in our understanding of ADHD. And as a result, since we don't have the emotional side of this in the diagnostic criteria, what happens is clinicians are only as good as the tools they're given. If this is, if this is what they're saying is the diagnosis, then they're like, okay, surely it can't, if you're having emotional dysregulation, it can't be from ADHD. This must be from anxiety. This must be from depression. So what happens?

• 6:40Speaker 02

  Because it's not in the manual.

• 6:41Speaker 01

  Yeah. So you get into these situations where people are incorrectly diagnosed with something that might not be happening and as a result, incorrectly treated.

• 6:51Speaker 02

  So if someone were to go to their doctor or their counselor or their psychiatrist, their mental health professional right now with any of these issues, how likely would it be for that professional to know about RSD and could help that person?

• 7:05Speaker 01

  It's tricky because I think depending on who you see, it's really varied. Again, it's not in the diagnostic criteria. So it's really, and I, even as a psychiatrist, it took me a second to get to the spot where I was researching. But I think it's becoming more part of the just public knowledge. People are talking about it more. And I think that is trickling into like more discussions with physicians. So people are becoming better educated. I think if you were to look at the spectrum, if I were to put primary care doctors on one end of the spectrum and then like people specializing in psychiatry, like a psychiatrist

• 7:46Speaker 01

  or a therapist or some other mental health professional, I think that side would probably be better educated because they're more exposed to that, that kind of, they've just seen it more, not only just, you know, in research and academics, but also anecdotally, they've seen it in their practice. And I think the further you get into the practice, the more irrefutable it becomes. You know, the more you see ADHD patients, the more you recognize how deeply important the emotional side and context is in the whole picture.

• 8:19Speaker 02

  What do you think it'll take for RSD to be added to the DSM?

• 8:23Speaker 01

  Oh, my God. I love this question. So let me tell you, my whole sneaky agenda with this book is I literally wrote it. With the hopes that it would shift the tides and at least get people talking about it. Like, Europe changed their criteria for ADHD in 2019 to include emotional dysregulation as a core component. That, like, the US is just behind. So I'm like, what is this? So the person who wrote the foreword of my book was William Dodson, the psychiatrist who coined the term RSD. And he told me, he was like, listen, I have been fighting this battle my entire academic career. The true way anything in psychiatry changes is

• 9:05Speaker 01

  public outcry. If the public wants a change, then it escalates the ranks and it adds urgency. So I was like, all right, let's create a book that at least creates a little bit more dialogue and at least gets it in the public view enough. And so that was kind of my underlying goal. Whether or not that happened, I don't know. But I think it's a good start.

• 9:27Speaker 02

  So if diagnosis is hard and treatment is an extra step, what does the landscape look like for treatment right now?

• 9:36Speaker 01

  I think the best way to look at this diagnostically is, number one, pattern recognition. Because i-if, as a patient or as a clinician, if you are recognizing, okay, we have these deep emotional episodes that are triggered by rejection, by criticism, by disappointing someone else. If we're looking at that and we can tie together and piece together that this is a pattern of behavior, then we can start to say, okay, this isn't a one-off thing. This isn't just due to hormones. This isn't due to anxiety. This isn't due to, like, something situational happening. This is truly a longstanding pattern that could be neurological in nature.

• 10:14Speaker 02

  Mm-hmm.

• 10:15Speaker 01

  Then, once you have that data, you can start moving into a direction which is, okay, well, what do we do about it? Medications can be so helpful for this condition. But I want to also pair that with skills. And so that's why I started with the skills first, because access to care in general is such a nightmare.

• 10:33Speaker 02

  It is.

• 10:34Speaker 01

  But I wanted to give people these usable skills that they can pick up the book, open up to a page, start using them literally right in that moment, instead of waiting months or years for an evaluation, have this discussion, and possibly, because it's not in the diagnostic criteria, get a serious response back on how to address it. So I started with the skills. And I was pulling from every area of psychiatry and neuroscience and psychology. And I found 12 tools. And literally, everyone, Regina, you've heard before. But the difference in this book is that, or, I mean, for me, you know, someone tells me, like, take a deep breath, and I'm like, I'm gonna punch you in the face. Like, I don't even know how to breathe right now.

• 11:12Speaker 02

  Exactly.

• 11:13Speaker 01

  Like, it doesn't help me. So with this book, I think what helps me is, like, when I tie that tool to what's happening in the brain. Like, here's what's happening in the brain in that moment. This is why that tool works. This is how to use that tool at the right time, at the right place. And then this is how to practice it when you're not dysregulated. So you know how to do it for when you need it later.

• 11:37Speaker 02

  Yeah. Can you give me just an example of using one of those skills?

• 11:41Speaker 01

  So some of them that I really like are, you know, those mindfulness things, like the deep breathing. There's cyclic sighing, which is a specific and pretty easy to grasp type of breathing. Because, like, when someone tells me, take a deep breath, I realized up until, like, five years ago, I was like, I'm not even taking a deep breath properly.

• 11:58Speaker 02

  Yeah.

• 11:58Speaker 01

  So I didn't know that. Some of them are, like, when I'm in a spot where I'm feeling these emotional waves. And it's not like I'm just sitting here and I've zoned out. I'm so agitated and restless and pacing. During those times, I would love to take a deep breath, but it's not happening. So sometimes I'm so restless that it's like, okay, well, I just need to lean into this. So let me do some squats. Let me do some stairs. Let me walk around the building. Let me, let me take some of this weird energy and funnel it in a way that's gonna get resources to my brain. But again, you know, when someone is like, let's go take a walk, sometimes if I'm hearing that, and depending on the mood I'm in, that just makes me mad. Like, I don't want to take a walk. I want to fix this right now.

• 12:42Speaker 02

  Yeah.

• 12:43Speaker 01

  And so it's interesting, being in that non-threateninged position when you're reading this stuff, that you're like, oh, I understand now why this would work for my brain. Okay, well, that means that maybe next time I'll use it, if it's my own idea. I'll use it. And so those are some of my favorites.

• 13:03Speaker 02

  Sasha, thank you so much for talking with me today.

• 13:05Speaker 01

  You're welcome.

• 13:06Speaker 02

  Sasha's book, Too Sensitive, is out now. We'll link it in our show notes.

• 13:17Speaker 02

  If you liked this episode, check out our episodes on inner monologues and how ADHD shaped the movie Everything Everywhere All at Once. This episode was produced by Burley McCoy and Juan Diego Ramirez. It was edited by showrunner Rebecca Ramirez and Tyler Jones checked the facts. Jimmy Keeley was the audio engineer. I'm Regina Barber. Thank you for listening to Short Wave, the science podcast from NPR.

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