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

Regina Barber (0:00)

You're listening to Short Wave, from NPR.

Sasha Hamdani (0:05)

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.

Regina Barber (0:14)

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

Sasha Hamdani (0:21)

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. 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.

Regina Barber (0:44)

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

Sasha Hamdani (0:52)

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.

Regina Barber (0:57)

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

Sasha Hamdani (1:08)

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

Regina Barber (1:27)

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

Sasha Hamdani (1:35)

Now, the problem is that I really, really want to say, I know that it is extremely common in ADHD, but because RSD is not part of the diagnostic criteria, emotional regulation is not even 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.

Regina Barber (2:06)

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

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?

Sasha Hamdani (2:42)

Well, I think in order to get to that, you need to first get to that emotional threat processing. 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 shape structure deep in the brain, which tells you this is a problem, this is not a problem. For people who are highly emotionally sensitive, this area is hyper-responsive, 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. This is under-responsive.

What makes it worse is that the connection between the two is weak. Now you just have this delayed communication. 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. When you get into that chemical cascade, your brain has already assessed like, something weird is happening. Let's do something about it. Yeah.

Regina Barber (3:50)

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?

Sasha Hamdani (4:18)

Dummies, all of them. I hate it. I think what happened was that we started to favor observable symptomology. 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.

So it is so limited in our understanding of ADHD. 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.