Leading Psychiatrist: How To Process A Late ADHD/AuDHD Diagnosis, Grief Is The First Stage!

1. 0:00 – 1:09

   Trailer

   1. ARDr. Asad Raffi0:00

      The female presentation of ADHD doesn't even resemble what it says in the NICE guidance or within the DSM-V criteria. So how is a clinician who is effectively using a checklist going to be able to diagnose any woman? What we have with regards to assessment tools, with regards to the understanding, is all based on a male-centric presentation

   2. APAlex Partridge0:21

      Dr Asad Rafi is a leading psychiatrist who's assessed thousands of women for ADHD and autism. He's here to explain how to process a late diagnosis and how to reach your untapped potential.

   3. ARDr. Asad Raffi0:31

      Individuals with ADHD are constantly striving for validation from the outside world. And I'd say before you can get that validation from others, you've got to seek it within yourself, and I think that's one of the toughest elements of this particular condition. When someone says to me, "How would you describe someone with ADHD?" I say they're emotional people.

   4. APAlex Partridge0:48

      Why do you think women have been missed for so long in the ADHD space?

   5. ARDr. Asad Raffi0:52

      If we look at...

   6. APAlex Partridge0:58

      Dr Asad, welcome back.

   7. ARDr. Asad Raffi1:00

      Thank you for having me back, Alex.

   8. APAlex Partridge1:02

      Huge privilege to have you back. And before we start, I want to address the elephant in the room. I'm gonna put you on the spot a little bit to start.

2. 1:09 – 3:52

   Is it OK for men to talk about female ADHD

   1. APAlex Partridge1:09

      One of the criticisms that many people in the ADHD space have had in the past is that it's not okay for men to discuss female ADHD. What's your stance on this? Is it okay for us two men to sit here today and discuss the struggles that women have with ADHD?

   2. ARDr. Asad Raffi1:26

      It's, it's a recurring conversation that I see in forums, I see it online, and men like you and I, you know, do attract that criticism. What's... And, and, you know, what's the agenda? You know, what's, what's behind this? Is it a commercial agenda? Is... Are they doing it for the likes? But I think we've got to be really clear about what that agenda is, and certainly from, I can only speak for myself, certainly from my perspective, it's sharing that knowledge, it's sharing that understanding with people who have been misled, who have not been understood, who have not been validated for, for decades. And ultimately, no man should claim any form of authority on, you know, women's mental health or women's health in general, and we should act as advocates in the best possible way and not be virtue signaling. You know, we need to be using these platforms in the best possible way to help others.

   3. APAlex Partridge2:31

      The late diagnosis crisis that is happening with so many women having been let down for so long, I truly believe, having spoken to so many women on this podcast, is heartbreaking. Being misunderstood, being othered, being genuinely feeling like they're broken for most of their life is truly heartbreaking. In your practice, do you see many patients that stick with you as being truly heartbreaking?

   4. ARDr. Asad Raffi2:59

      Abso- absolutely. And the... There are, there are common themes. People who have not been listened to, they've not been heard, they've not been understood and, as I say, they've not been, they've not been validated, and that leads to almost a chronic distrust of doctors like me. And the first piece of work I've got to do is to try and rebuild that trust. And I often say that there's nothing new that I'm gonna tell you today. My job is to join those dots up, is to help you to understand how everything connects and ultimately to help you to understand yourself better. So yeah, absolutely, you know, we're, we're in a situation where we're seeing many women who come to our practice who, who, who seek out that help and support because they've not been given the right answers

3. 3:52 – 6:50

   Dr Asad’s most heartbreaking patient

   1. ARDr. Asad Raffi3:52

      in the past.

   2. APAlex Partridge3:53

      If you were to think of one standout patient who you saw and you were truly heartbroken by, could you think of one?

   3. ARDr. Asad Raffi4:00

      I can, I can think of many. And I think one of the most recent cases that I'd seen really brings home to roost a lot of the issues that women, not necessarily with ADHD present with, but just women in general, um, tend to demonstrate, which is significant sacrifice. And this particular case has sat with me on a personal level for, well, since, since the moment that I met this family, and it was a, a young boy who'd, who, who had been brought to clinic with, with mum and dad, um, to understand whether or not he had ADHD, which, which he did. And Mum, mum kept intimating to me that she wanted some time by herself, and I wasn't sure as to what that conversation was likely to be about. I thought it might... may well be about, um, something at school. Um, what she did say to me was, when I did have the opportunity, was that she was in a situation where she may not be here for much longer. She had a terminal illness. And I think what was really obvious at, at that point for me was understanding that sacrifice that she was making, and she wanted her child to be in the best possible situation. And I think what she really encompassed was motherhood and women, and ultimately that they have those dual roles in life alongside their work, alongside everything else, there's constant battles, and ultimately her biggest worry and concern wasn't herself, it was for her child. But then also had a partner, also had a husband who was really struggling, and I suspect also had ADHD. For him to understand himself-And his child, whilst at the same time facing potentially losing a partner, was absolutely heartbreaking, and it, it's difficult to even talk about it now. Um, and dare I say, I've had that permission, um, you know, from, from the, um, the patient themselves to be-- well, the patient's mother, for me to share this with you 'cause I thought it was really important for me to, to bring that home to you today and, and to talk about it.

   4. APAlex Partridge6:34

      Truly heartbreaking, Asad. Thank you so much for, for seeking permission and for sharing that. I can see you, you're getting emotional just sharing that story, and it's truly heartbreaking. And when you experience devastating stories

4. 6:50 – 10:14

   Dr Asad’s mission

   1. APAlex Partridge6:50

      like that, how does that tie into your mission, your personal mission within the ADHD space?

   2. ARDr. Asad Raffi6:57

      I think I've been blessed with the opportunity that my own parents gave me, which was they educated me. They gave me that platform to be able to learn, to understand, and I have a duty to share that with others. Got to educate people, got to empower people. And my ultimate mission, again, which came from my mother, was to help those that were less fortunate. Not everyone can afford private services, and one of the, you know, small things that we will do is to, is to give back. We all need to give back in, in whichever way we can. We have a not-for-profit service for children who can't afford ADHD assessments, and ultimately what I'm trying to do there is to, to help level up that disparity that exists. But we'll also see any of the teachers within that particular school as well. And for me, any provider needs to follow suit, and I'm more than happy to hear from anyone, you know, to collaborate on a, on a, on a mission like that. And I'm gonna use this opportunity to share that with, you know, with, with the wider audience.

   3. APAlex Partridge8:08

      You're truly doing incredible work, and I share so much of that mission with you. You were absolutely incredible last time you came on, I think it was about eight months ago, onto the podcast, and I think it's important to ask, have you had any epiphanies since you were last on about ADHD and some of the challenges that come with that?

   4. ARDr. Asad Raffi8:27

      I think I have a, an epiphany almost every day. There, there is so much information that is, is being shared and, you know, we're constantly looking at new research. We're constantly trying to understand how these different elements start to intersect with one another. And we keep going back to understanding how do we frame ADHD from that traditional typical model that we all have an understanding of, and coming to a point where we start to understand it as a brain-body condition. Super complex, and invariably we look at seven or eight different elements, and we can almost build a profile, especially when it comes to, you know, ADHD in, in women. We can almost build a profile by looking at their physical health symptoms because we don't see that pattern existing anywhere else. Also, we see the connection with sensory sensitivities, and this is, this is the element which really captures my imagination because we see that bridge between physical and mental. I see it as, as being that sensory element, especially something called interoception. I'm not sure whether you've come across that term before.

   5. APAlex Partridge10:04

      No, I haven't.

   6. ARDr. Asad Raffi10:05

      So if we think about... Typically, we think about sensory sensitivities with respect to our five senses. And when we look

5. 10:14 – 12:10

   Alexithymia in ADHD adults

   1. ARDr. Asad Raffi10:14

      at the, the wider scope of understanding sensory sensitivities, uh, there's something called alexithymia. Okay, so please don't feel flattered that they've named it after you, Alex, right?

   2. APAlex Partridge10:25

      I have heard of that.

   3. ARDr. Asad Raffi10:25

      Yes, you have influence, but not to that degree.

   4. APAlex Partridge10:28

      [laughs]

   5. ARDr. Asad Raffi10:28

      Okay? So alexithymia is certainly very much prevalent within neurodivergent individuals, and it's when you struggle to understand or recognize your emotions. You struggle to process them. You struggle also to articulate them. Interoception is when you struggle to recognize bodily signals and correlate with emotions. So it's things like knowing when you're hungry or knowing when you're full. It's knowing when you're tired or fatigued. It's even knowing when you need to go to the loo or when you need to hydrate, or even when you're in pain. So lots of these signals can often be delayed or not even picked up in many neurodivergent people. So when we start to see challenges like obesity, type two diabetes, disordered eating patterns, starts to make sense. You see that correlation. You start to understand more about sleep issues. Then you start to understand, is that child actually being disruptive in the classroom who wants to... who's, who's always putting his hand up and asking to go to the loo, or does he truly have a difficulty? Okay? So these are the things that we're understanding more and more, and they become so much more relatable for people away from that traditional model. So we incorporate a lot of this understanding in, in, you know, in, in our approach to assessment, and I think it's really important people start to understand that 'cause they'll relate to it a lot more then.

6. 12:10 – 13:57

   How to manage ADHD stress and sleep

   1. APAlex Partridge12:10

      How does that tie into stress and other necessities like sleep?

   2. ARDr. Asad Raffi12:14

      If we think about Alexithymia and the concept of stress and, and how that might manifest, there's lots of different elements to how, um, stress, stress, um, presents. People may not be able to recognize it. They might not be able to detect it or even process it, let alone communicate it. If we look at stress physiologically, and we look at a physiological measure like heart rate variability, that's your heart's adaptability between consecutive beats, and that correlates... It's probably the best, as I said, it's the best marker of stress that we currently have. And for many people with ADHD that I see, we will ask this question, if they track, you know, u- using wearable trackers, we'll often see that they have lower HRV, which indicates that your body is in a state of stress. Where they get really confused often is, and, you know, we see this anecdotally, is they'll say, "Well, you know, my, my phone's telling me that actually my metrics are really good, but I don't feel that way." And I said, "That probably reflects that delay that occurs due to interoception." They say, "Right." There's almost a lag of about a day or maybe even two days before that occurs. So that's a really interesting, um, finding that we're, we're seeing on a, on a regular basis. So by looking at the metrics, you can almost predict what, what's happening or what's about to happen.

   3. APAlex Partridge13:51

      So interesting. I had a brilliant psychiatrist on from America, Dr. Jacob, and he said,

7. 13:57 – 14:07

   ADHD women are the most stressed group on the planet

   1. APAlex Partridge13:57

      "ADHD women are the most stressed group of people on the planet." Do you agree with that sentiment, and why do you think that might be?

   2. ARDr. Asad Raffi14:04

      Women with ADHD,

8. 14:07 – 17:26

   Why ADHD women were missed

   1. ARDr. Asad Raffi14:07

      it's not just ADHD by itself. And if we look at the number one factor that we certainly saw from our research, we, we examined responses from over 1,300 women from the age of 18 all the way up to 65. And the independent factor that drove ADHD symptoms getting worse and subsequently increasing mood, emotional symptoms, but also addictive behaviors was stress. We've got to understand why women face lots of challenges, lots of transitions in their life, further complicated by the hormonal impact as well. If we think about their role in society, and if they're working on top of that, they finish work, they're at home, they're the matriarch, they're, they, they are the leaders of that household, and it never stops. They never complain. They just manage. They just cope. They just survive. And yeah, I, I don't know how they do it. I, I can't relate to that. I can't do it. And, and, and I have to admit that. You know, I can, I can go to work, I can, you know, can be there for hours. Managing the household, doing everything else is where I'll struggle, and, and this is where there's a fundamental difference. So absolutely would agree with Dr. Jacob.

   2. APAlex Partridge15:41

      Likewise, and you made the point incredibly well. 85% of the people who listen to this podcast are women, and I feel like they listen because after too many years of being let down and missed, they are finally hearing people like yourself explain their lives and adding color and context to so much of their past, which without that is just a void of any understanding. Why do you think women have been missed for so long in the ADHD space?

   3. ARDr. Asad Raffi16:13

      If we look at ADHD, the way it's presented, the way we as doctors and, and professionals are taught this particular subject, it's, it's archaic. Look, look at the diagnostic classification systems. Look at the guidelines. Respectfully, well, it, it's not respectful. It's... I'm being very disrespectful here now. The female presentation of ADHD doesn't even resemble what it says in the NICE guidance or within the DSM-5 criteria. So how is a clinician who is effectively using a checklist going to be able to diagnose any woman? They're gonna struggle. You know, we've got these preconceptions, these misconceptions. What we have with regards to assessment tools, what we have with regards to the understanding is all based on a male-centric presentation. Does not apply to women. Certainly doesn't apply to people of color either. So we've got a lot of work to do.

9. 17:26 – 20:38

   ADHD women deserve an apology

   1. APAlex Partridge17:27

      Do you think women deserve an apology from the medical community?

   2. ARDr. Asad Raffi17:31

      I'm going to answer that in quite a controversial way, which is to say no, because I think words are cheap, and we need to demonstrate action. Can talk about things all day long, but actually what we need to do is to engage as a community. We're a very fractured community within the neurodivergent community, I have to say that. We have to unite, and we have to have a common goal and a common purpose, and therefore, action is far more important. I think that's the best way of demonstrating any form of remorse.

   3. APAlex Partridge18:10

      I spoke to a woman at an event recently, and she said she was incredibly angry, incredibly resentful, because she felt like she had wasted so many years to feeling misunderstood. People just didn't get her. She looked back after her diagnosis, and she understood why that relationship was so bad. She understood why that particular job wasn't right for her, and she felt so mad at-One of her doctors called her crazy, she, she shared with me, and she was so angry at... She got to 55 years old and, and, uh, numerous appointments, anxiety diagnoses. She was so resentful. Do you think generally women should be feeling resentful? Do you think they have... They deserve to feeling resentful?

   4. ARDr. Asad Raffi18:52

      They have every right to feel resentful for, for the reasons that you've just described there, because their condition and their presentation hasn't been understood. And I think we're putting a lot of pressure on people like teachers, parents, even if we look at primary care, GPs, who, dare I say, are tasked with trying to understand. They don't realize this. You know, I've had a cohort of GPs that I've just trained recently, and the first question I ask them is, "How many people do you think you see with ADHD on a daily basis in a clinic?" And out of 40 people, let's say for example, on average they'd say about two or four. Once we'd done the training, once we'd helped them to understand the emotional presentation, the physical presentation, by the end of those two days, they were like, "Oh my God, this is more than 50% of our caseload." That's how significant it is. Now, they are the people who are ultimately the gatekeepers. That's where ADHD needs to sit. We need to be investing that time in helping them, and that resentment is gonna come from the fact that their condition's not been fully understood. Um, they don't present typically, as I said before, as the DSM-5 criteria describes it. It's more internal. It's more emotional. It's more physical in its nature, and therefore misdiagnoses happen, the wrong treatments happen, and therefore there's going to be that chronic distrust, and therefore resentment.

10. 20:38 – 23:41

    A lifetime of missed opportunities

    1. APAlex Partridge20:39

       In your last episode, Dr. Asad, one of the top comments on YouTube was that they felt, this woman felt like she had a lifetime of missed opportunities because of how late she was diagnosed. Do you see that sentiment in your practice when women come to see you?

    2. ARDr. Asad Raffi20:57

       We do, and I, and I think I, I can understand that particular comment. However, what I will say is this, many of the people that I see, many of the women that I see, have actually been really successful. But it's important how we define success. Success doesn't always come from, you know, your bank balance or it doesn't come from your occupational achievements or your academic success. Look at your relationships, look at friendships, look at yourself as a parent, and stop giving yourself such a hard time. You know, those of us who have ADHD have huge, huge expectations of ourselves. Forget the wider world, and there's huge expectations there as well, but we have huge internal expectations of ourselves, and we've got to manage those. But going back to that question, yes, many people will say, "You know, haven't achieved my true potential. I haven't achieved what I felt that I was capable of achieving, and I need to understand why." And that's how we frame the reason why they come to see us. And, and that certainly becomes the starting point to that conversation.

    3. APAlex Partridge22:15

       I think what's heartbreaking is I speak to many women with ADHD and they say often that they feel like they can do, they've got the skills, they've got the capabilities to start a project, but it's this fear of criticism, this fear of putting themselves out in the world that exposes themselves to a potential rejection. So it feels safer in the moment to not even bother, to not even buy that domain, to not even apply for that job.

    4. ARDr. Asad Raffi22:40

       Mm-hmm.

    5. APAlex Partridge22:40

       Because if they just stay at home, it's safer and, and it's, it protects them. When you hear ADHD, do you sometimes think untapped potential?

    6. ARDr. Asad Raffi22:49

       There is, and I, and I say it, it, th- there are inherently super capable individuals. ADHD comes with significant strengths, and I, I hate it when it's framed as a superpower as such. I don't see it like that. I don't see it as a disorder. I see it as a state of dysregulation. It's, it's more, it's more like this. It's inconsistent, it's variable, depends on the context, depends on the situation. And the problem that we then have is, you know, that untapped potential, that ability is certainly there. It's not being channeled in the right direction at the best of times, and this is what we've got to help people understand, you know, that they inherently do have those skills. They do have those abilities. Actually, they've not been given the opportunity

11. 23:41 – 24:52

    Tiimo advert

    1. ARDr. Asad Raffi23:41

       to demonstrate them.

    2. APAlex Partridge23:42

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12. 24:52 – 32:11

    The most debilitating ADHD traits (Dysautonomia)

    1. APAlex Partridge24:52

       Back to the show. What are the most debilitating parts of ADHD for women?

    2. ARDr. Asad Raffi24:56

       I'd like to say there isn't one single feature. It's a combination of things.And dare I say it, on that long list, the core ADHD symptoms are usually right at the bottom. As I said before, the number one element seems to be the physical challenges and the physical difficulties. That combination of challenges with hypermobility, connective tissue disorders, dysautonomia, and there's one feature that really stands out with dysautonomia, and this is the part that really hits home. And I'll say to, I'll say to a lot of the women that I see, "I can almost predict that you've got ADHD when I ask you this question." I say, "What happens when you go from sitting to standing or lying to standing really quickly? Do you feel dizzy or lightheaded?" They're like, "Oh my God, yes." I say, "Do you bruise easily? Do you have cold or heat intolerance? Um, do you have Raynaud's type features, you know, cold tips of your fingers or toes?" And they'll say, "Yeah, absolutely." I say, "Well, do you realize that a lot of those features, especially the going from sitting to standing, that s- slight feeling of dizziness which corrects within seconds or microseconds, correlates almost directly with that internal sense of inner restlessness?" Which I say is that somatic internal hyperactivity, which a lot of people think is anxiety. So, you know, we, we see a lot of the dysautonomia features, but also the hallmarks of stress, chronic inflammation, histamine hypersensitivity, which is the whole plethora of symptoms, a constellation of symptoms like skin-related issues. And women will say, "It just, it flares up from time to time." Psoriasis, eczema, acne, itching, respiratory issues. You can see it, you know, from, from their history. Um, asthma, hay fever, allergies, headaches, migraines, brain fog, fatigue. "Oh, I've been diagnosed with fibromyalgia." I say, "Have you? Okay, let's, let's try and understand this in the context of everything else." And then the, the heavy periods, the cramps, you know, even, even down to visual challenges and difficulties. Um, you know, they, they will, they'll talk about gut health problems, IBS-type symptoms. We see all of those elements. That then takes precedence over everything else. And let's be honest, when it comes to a hierarchy credibility-wise, physical health symptoms trump mental health symptoms. That's what happens in society, doesn't it? You can measure them, you can see them. Can't measure or see mental health issues, so therefore the most debilitating element becomes this whole constellation of physical health symptoms, but alongside that then the emotional challenges and the emotional difficulties, which are then significantly linked to addictive behaviors. They then become the headlines. And as you can imagine, you're looking at those three elements alone alongside then independently hormonal fluctuations, sleep, stress. They tick ev- well, and it's not a box-ticking exercise, but we're going into all of that detail and understanding all of those things. And I often say, "We've not even talked about ADHD yet." So you can imagine all of those things, you know, we will, we will address, then we'll talk about the ADHD, and it's like, "Wow, now it makes sense."

    3. APAlex Partridge28:52

       So interesting. How does it all tie into emotional sensitivities? Because I feel like so many people with ADHD, they hear comments like, "Why are you doing it like that? Stop doing that. That's a weird way to do it," even though the way that they're doing something might be right and effective, but it's just different.

    4. ARDr. Asad Raffi29:10

       Mm.

    5. APAlex Partridge29:10

       How might exposure to so many corrective messages like that have an effect on someone's emotional sensitivities?

    6. ARDr. Asad Raffi29:18

       Th- th- these are some... What you've described there, um, are often what I frame as, you know, these microtraumas that continue to accumulate over a period of time, you know, from childhood all the way through to, to the rest of your life. And, and, and, and it evolves, it changes. First it's in the classroom, then it's in a relationship, it's in friendships, um, it's at work. And you've got that external criticism, which is significant. I think one of the things that is certainly even more powerful is that internal sense of self, and individuals with ADHD are constantly striving for validation from the outside world. And I'd say before you can get that validation from others, you've gotta seek it within yourself, and I think that's one of the toughest elements of this particular condition. When someone says to me, "How would you describe someone with ADHD?" I say, "They're emotional people. Don't tell them what to do." You know, and, uh, many parents will ask me this question, partners will ask me this question. Say, "Here's a tip for you. Don't tell your child or your partner what to do if they have ADHD, because they see it as a criticism." Even if they were gonna go and do that particular task, at that moment in time, it was their idea, the minute you say, "Go and empty the dishwasher. Go and empty the suitcase," whatever it might be, tell you what, they're not gonna do it. They'll do it when they're ready.

    7. APAlex Partridge31:01

       Is that related to demand avoidance? Is that just another way of framing pathological demand avoidance? Could it actually be a, a, a trigger or a response to a perceived criticism?

    8. ARDr. Asad Raffi31:12

       The, many people will look at terms like PDA and relate to it. Now, we can relate to so many conditions. I, I will often show people the criteria for Alzheimer's dementia, young people, you know, children, and say, "How many of these features do you have? You forget your keys, you forget, you know, names," whatever it might be. They'll say, "Yeah, I've got all of those." I say, "Well, that's Alzheimer's dementia." And I think we've got to be really careful because we can align ourselves to these particular explanations or, or conditions and, you know, there, there, there can then be a, a bias, but certainly demand avoidance or, and avoidant behavior I see within the emotional challenges that people with ADHD present with, what we would um- badge under that umbrella of rejection sensitivity.

    9. APAlex Partridge32:05

       I was thinking of my weekly hunt for my car in the multi-story car park that still takes place every week after I come out of the

13. 32:11 – 37:46

    Rejection Sensitivity Dysphoria

    1. APAlex Partridge32:11

       gym. The criticisms that many people with ADHD are exposed to, though, we talk a lot, and we mentioned this in your first interview, rejection sensitivity dysphoria, it's a horrible emotional response, pain to real or perceived criticism. How does the topic of rejection sensitivity dysphoria show up in your practice? How do people explain it to you?

    2. ARDr. Asad Raffi32:34

       In, in lots of different ways. Th-this is the element that I call the penny drop moment. This is the part of the assessment where people realize exactly, you know, what's been happening over the last few years, how it relates to the ADHD, and, and certainly having ADHD, the impact of not meeting your own expectations, not meeting the expectations of others, starts to take its toll. You're not achieving your true potential. Life is stressful. Becomes unsustainable. And what people will often say is, "I feel different. Don't feel good enough." They're, they're not able to, in, in some respects, qualify it further from there. And as we start to frame exactly what RSD looks like, because again, this is a term that's synonymous now with the neurodivergent community, you ask most doctors, most clinicians, most people within the healthcare field, they don't even know what it is. And what we will then find is, yes, those are the features that will dominate.

    3. APAlex Partridge33:52

       It feels like your brain can convince you 100 times per day that everyone hates you and thinks that you're a piece of trash for no other reason other than vibes. You sense a tiny shift in tone of voice or a slightly heavier footstep, and you think that they're mad at you, and it can be really debilitating. I walked through a train station the other month, and I saw a man. Um, he recognized me, and he said, "Are you the guy who talks about ADHD?" And I said, "Yes," and we shook hands. Really well-spoken, looked confident, well-dressed, great posture. You know, you wouldn't think he was struggling on the surface, and we ended up talking about rejection sensitivity dysphoria, and he explained how it's controlling his life, how his marriage is about to break down because of it.

    4. ARDr. Asad Raffi34:39

       Mm.

    5. APAlex Partridge34:39

       He's really struggling at work. He's drinking in the evenings. Do you think rejection sensitivity dysphoria shows up in men differently than it does in women?

    6. ARDr. Asad Raffi34:51

       To a degree. The, the, the framework is exactly the same. As you say, it's, it's how it, how it manifests. And the gentleman that you described there, and, and, and I think this is, this is a reflection of the society that we now live in. It's not necessarily just about ADHD. You know, we, we, we live in a society due to social media and everything else where we, we seek that validation externally. And when it comes to the male presentation, it is difficult because they're told showing emotion is almost akin to being weak, and there's a certain shame in that, shame in disclosing things, talking about how you feel. And what we, what we tend to see is that when it, when the RSD does start to become more apparent, for a lot of women, it's more internal, and it's more emotional. For the men, it's more external, and it often manifests as being angry, you know, overworking, overcompensating for things. Almost, again, going back to the conversation about avoidance, they will avoid thinking about what's the root cause of the problem and will rather do things that, you know, prevent them from having to face that reality. But ultimately then, it also manifests with how they manage those moods and emotions by use of substances, by use of certain behaviors, and again, that addictive profile can differ between women and men quite significantly.

    7. APAlex Partridge36:41

       Rejection sensitivity dysphoria, I feel like the pain is so intense. Like, the, the... When you are triggered, the emotional tsunami is so brutal. You, it can turn you into a massive people pleaser. You're so terrified of putting yourself first, or it can turn you into a p- a perfectionist. It-- How can someone possibly criticize me if the work is so perfect? And that looks like staying in the office five hours later than everyone else.

    8. ARDr. Asad Raffi37:05

       Yeah.

    9. APAlex Partridge37:05

       That looks like working tirelessly through the night, and that's all people see. They just see the brilliance. They see you handing in that assignment, and you might get a great mark, or you might get a promotion, but they don't see you getting home at the end of the day, the door slams-You fall to the floor and burst into tears, or-

    10. ARDr. Asad Raffi37:22

        Yeah

    11. APAlex Partridge37:22

        ... you have a huge row with your partner. It's that invisible behind the scenes struggle that is invisible to so many people, and it's completely overwhelming. The topic of overwhelm, for me, in the ADHD space is huge. I think it's those highly caffeinated squirrels I mentioned. That's how I describe my brain, and it's such a soft word for, I think, incredibly serious topic.

14. 37:46 – 40:48

    What ADHD overwhelm can look like

    1. APAlex Partridge37:47

       What exactly is ADHD overwhelm? What can it look like?

    2. ARDr. Asad Raffi37:54

       I would say that when I describe ADHD, it's a condition where you're all or nothing. Right? It's, you know... When are you gonna do that particular task? It's now or not now. They're the two options. You know? All or nothing type individuals, we struggle with balance, and when we are at 100 miles an hour, we don't usually leave much fuel in the tank. It usually takes an unexpected curveball. That's what life brings at you, you know, an, an, an acute trigger, an acute stress, and you've not got the capability to be able to manage it, and it almost kind of tips you into that overwhelm. So you're either here, where you're lacking motivation, struggling to get going, or it tips you all the way over there, and that becomes unsustainable. So that overwhelm, however, then results in, you know, the, the, the human body almost c- you know, saying to you, "You need to stop. You have to stop," and those defense mechanisms kick in. That manifests as, you know, bodily shutdown, physical symptoms, and, you know, we talked about how that can, that can manifest in terms of, um, y- you know, that, that presentation, but also from a, from a mental health perspective, what happens, the mood issues, the emotional issues, and it's then resorting to try and manage that with substances, behaviors to, to, to compensate.

    3. APAlex Partridge39:29

       Can there be a quite, a fast spiral downwards? Because if you are so overwhelmed, and you alluded to, I think, a, a paralysis, a body shutdown, and you might not be able to do anything in that moment, despite the fact that you know you've got 10 million things to do, but you can't put them into any order in your mind. So you don't know where to start, so you end up doing nothing, and I suppose the optics like that can expose you to comments from perhaps a partner-

    4. ARDr. Asad Raffi39:56

       Mm

    5. APAlex Partridge39:56

       ... who might not understand ADHD, like, "Well, why can't you just start the task? Why can't you just empty the dishwasher," like you said earlier. "Why are you so lazy?" And that perpetuates that internal critic that is constantly shouting at you, "You're useless, you're a POS, why can't you just do stuff?" How fast can that spiral take someone down to a dark place?

    6. ARDr. Asad Raffi40:17

       I, I think very quickly. Y- you know, within seconds, but it's... I think it's understanding the mechanism behind it because I don't think it's as simple as A equals B. You know, the, the rejection sensitivity results in a certain outcome. Think about that explanation or that description that you've just provided there, and how much of it is that inability to be able to even articulate how you're feeling? So going back

15. 40:48 – 43:16

    Alexithymia and RSD

    1. ARDr. Asad Raffi40:48

       to the... Bringing, bringing alexithymia now to RSD, bring those two t- elements together, yet you're emotionally driven, yet you can't even recognize or communicate that emotion or that distress. Now, that's gonna be problematic, isn't it? Coupled with the fact that you can't even pick up with the bodily signals, with the interoception problems. You're never gonna recognize that your body's going into shutdown until it's too late. So you're, you're on a hiding to nowhere with it really, aren't you?

    2. APAlex Partridge41:18

       What can that look like if someone does have alexithymia and they are also in that moment triggered, and they feel these intense emotions, sadness, rage, but they don't know how to articulate it and let off some steam in a safe, communitive, communicative way? What can that look like? Can that be quite explosive? Can that be violent?

    3. ARDr. Asad Raffi41:38

       That can be significantly explosive and, and, and violent and, and that aggression can often be internalized, and how that can manifest... Yeah, and we, we see it, we see it a lot, is in terms of self-harming behaviors, self-injury. When we're asking people who engage in cutting or, um, self-injury, they'll often say, "It's n- my intention isn't to end my life. It's not a suicidal gesture." I said, "Tell me more about it. You know, what was the intention there?" Firstly, they'll often say it's impulsive, and what we, what we get... You know, the, the, the ultimate explanation then w- we, that we reach is that it becomes a manifestation of trying to articulate internal emotion. Feeling that physical pain is like a release of that emotion, and often, the intention isn't there to hurt themselves. They come across that inadvertently, and they see that release. It almost has an addictive or compulsive quality to it, and when it's described in that way, many people can, can relate to it, certainly those who engage in that. The problem you have there is those types of behaviors could inadvertently end up in you doing something which, you know, causes catastrophic consequences, and that's where the risk profile starts to increase quite significantly.

16. 43:16 – 45:28

    Advice for late diagnosed ADHD women

    1. APAlex Partridge43:17

       What would you say, Dr. Asad, to the undiagnosed or the late diagnosed women listening who might have felt forgotten about? What closing advice or words of hope would you give to them?

    2. ARDr. Asad Raffi43:30

       It's never too late, and I understand that there is a distrust of clinicians. You may well have been told that you're depressed, you're anxious, you've maybe got bipolar disorder, borderline personality disorder, you know, even autism. I see so many women who've been diagnosed with autism who actually present with ADHD, lots of physical health symptoms. The answer isn't go and book an assessment. The answer is look for, first and foremost, educate yourself, understand there's lots of resources, podcasts like this and other podcasts. Read them, listen to them. Also look at community, connection, fundamentally important, identifying with others, then being in a position that you understand you're not alone. There are many others, and that is a travesty. It's an absolute travesty, something that, you know, we're tirelessly trying to address. But it's never too late, and at this point, if you do, you know, you come to that realization that ADHD could be the explanation for your challenges, seek an assessment, okay? But only seek that assessment if you're going to do something about it meaningfully. The label, the diagnosis, you know, is, to me is irrelevant. It's the explanation behind it that's critical. That's the key thing.

    3. APAlex Partridge45:15

       It's really powerful advice, Dr. Asad. Thank you so much-

    4. ARDr. Asad Raffi45:18

       My pleasure

    5. APAlex Partridge45:19

       ... for, for sharing that, and generally for the interview. I mean, again, it's been overwhelmingly insightful, and I can't thank you enough for, for coming back and being so generous with

17. 45:28 – 49:20

    Audience questions

    1. APAlex Partridge45:28

       your time. I wanna move on to the ADHD Agony Aunt section, which is Audience questions, and it's called the Washing Machine of Woes because my ADHD item is a washing machine, because for me it represents memory loss. And I think I asked you before, do you, do you relate to that? Do you leave your clothes in the machine after the cycle's finished?

    2. ARDr. Asad Raffi45:48

       Not sure how to answer this question now, Alex.

    3. APAlex Partridge45:50

       [laughs]

    4. ARDr. Asad Raffi45:50

       You've really put me on the spot, because I'm so useless that I don't even know how to use a washing machine, never mind leave-

    5. APAlex Partridge45:58

       [laughs]

    6. ARDr. Asad Raffi45:59

       ... the clothes inside it. So hands up. Yeah, I'm, I'm the least domesticated human being you'll ever meet. So yeah, it's not even a washing machine of woes, it's a whole household of woes for me, I think.

    7. APAlex Partridge46:10

       [laughs] I have been using the Tiimo app actually, which has really helped me to remember. But, uh, yeah, we're, we're, we're getting there, one smell of damp at a time. This week in the washing machine, Asad, someone has written in and asked, "I've been on a waiting list for a diagnosis for months, and I think it's not being taken seriously, which I'm finding hard, more so than the ADHD itself. Do you find a lot of distressed women in your practice who are frustrated with not being seen sooner?"

    8. ARDr. Asad Raffi46:40

       I think this applies not only to women. I think it's society in general, people who are seeking diagnosis. There is, over the last five years, certainly a lot more awareness, a lot more understanding of ADHD, and there are pros and cons to that, dare I say it. Um, a lot of what we've talked about in terms of misdiagnoses, the explanations that haven't, the narratives that haven't quite fit, and certainly even the interventions that have been provided, the treatments, the medications, the therapies, have been ineffective. Many people are now understanding and certainly relating to ADHD a lot more. The demand on the system is significant, uh, to the point where there is, there is no more capacity. And again, I'll go back to what I said before. What will a diagnosis give you? If it's the label, and I know that many people will say, "It's not about the label, it's about the narrative, it's about that validation," but there's a lot that you can do before that. Okay? Look at credible sources of information. Look at educating yourself. Look at coaching techniques. You know, these are things that all of us, regardless of whether you have ADHD or not, can benefit from. Look at optimizing things like sleep. Look at stress. Really important. Look at tracking your hormones. Look at getting some support around understanding hormones. Look at your gut health. I refer to them as the four brain amplifiers. They will make your ADHD better or worse, and believe me, those people who even take medication, they probably need less of that medication if they managed stress, sleep, hormones, their gut health more effectively. That's where I think we're going wrong. So let's try and reframe this and say, if you're waiting for a diagnosis, those are the four elements. There's a fifth one as well, should I say. It's movement, it's exercise. Get out there. Okay? They're all interconnected. If you can actually address that, would you even need an assessment?

    9. APAlex Partridge49:10

       Fascinating, Dr. Asad, and incredibly helpful. Thank you so much.

    10. ARDr. Asad Raffi49:13

        My pleasure.

    11. APAlex Partridge49:13

        And if anyone's listening-

    12. ARDr. Asad Raffi49:14

        Thank you so much

    13. APAlex Partridge49:15

        ... or watching who wants to submit a question for the washing machine, there will be a link in the description underneath.

18. 49:20 – 50:16

    A letter to my younger self

    1. APAlex Partridge49:20

       One more thing before we finish. I want to deliver you a letter that was written by the previous guest, where they wrote a letter to their younger self.

    2. ARDr. Asad Raffi49:28

       Okay.

    3. APAlex Partridge49:29

       If you could kindly read this, Dr. Asad.

    4. ARDr. Asad Raffi49:32

       "Dear me, thank you for all of your experiences. It molded me as to how I am today. Remember one thing, you'll come across obstacles, lots of boulders on your way. Don't be disheartened. Manifest what you want to achieve, and it will happen. You'll enjoy the journey. Stay strong. Your old version."

    5. APAlex Partridge49:56

       A lovely letter, and a lovely finish to the episode, and if you could, after the cameras stopped rolling, kindly write your letter to your younger self, and the next guest will read it out. Dr. Asad, on behalf of everyone watching, listening, grappling to understand their ADHD brains, thank you very much.

    6. ARDr. Asad Raffi50:12

       Thank you. [outro music]

Episode duration: 50:16