The Science of Rejection Sensitive Dysphoria (RSD) | Dr James Kustow

Dr. James Kustow 0:00 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, don't let go of it James Cousteau The Harley Street psychiatrist and author of How To Thrive With Adult ADHD

Alex Partridge 0:13 RSD, is that more concentrated within people that have an ADHD diagnosis?

Dr. James Kustow 0:18 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 and sometimes even days. But 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-

Alex Partridge 0:37 [laughs] Yeah

Dr. James Kustow 0:37 ... and 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.

Alex Partridge 0:47 So if someone has a shield that is ultra thick 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 thin or too thick?

Dr. James Kustow 1:02 Well-

Alex Partridge 1:04 This episode is dedicated to anyone who has 50 tabs open right now on their browser. [upbeat music]

Alex Partridge 1:12 How RSD feels in our body can be difficult to articulate. Can you describe what it feels like to, to an audience that might not have experienced it?

Dr. James Kustow 1:22 I describe it as an emotional tsunami. In the presence of rejection, criticism, whether it's real or perceived, uh, being slighted or sidelined, people with ADHD experience an, an overwhelming, intrusive, uh, emotional response, usually characterized by one of, one or more of three main features. The first is shame, top of the list, a sense of shame, of being exposed, of having messed up. The second is anxiety or panic in some situations. Um, 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." Um, but it can also be projected outwards, and often, um, takes the shape of rage, uncontrolled rage. Now, when you get into this, this, it's, it feels like you've been hit by lightning, and it's incapacitating. Um, if someone tries to talk to you when you're in this 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 sort of stuck in a loo- in a, in a, stuck in a, um, an endless cycle of thinking through the event, trying to make sense of it. It can last for hours-

Alex Partridge 3:13 Mm

Dr. James Kustow 3:13 ... and sometimes even days, and it's really impairing.

Alex Partridge 3:17 It, it's painfully relatable what you just said. It shows up in my life almost every day.

Dr. James Kustow 3:23 Mm.

Alex Partridge 3:23 The extremity of the experience can vary. Um, but even on the minor end of the scale, the lesser end of the scale, it's still a, a, a visceral response that completely derails me, uh, in that moment.

Dr. James Kustow 3:39 Mm.

Alex Partridge 3:39 And it, it's not the big things that, that set me off, that derail me. It, 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-

Dr. James Kustow 4:00 Mm

Alex Partridge 4:01 ... um, 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 internalized rage, and I'm, I try and keep it internalized when it does happen.

Alex Partridge 4:18 Do you have any visual analogies that might represent this horrible thing for someone who doesn't recognize what it feels like?

Dr. James Kustow 4:29 Well, yeah, I've got a few that I'm thinking about, but the experience of it is like a, a punch in the gut-

Alex Partridge 4:36 Mm

Dr. James Kustow 4:36 ... or a slap around the face. A good analogy would be if you were sunburnt, everyone's had the experience of being sunburnt 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, on your fingertip. Every time you touch anything, it's like extreme-

Alex Partridge 5:02 Mm

Dr. James Kustow 5:02 ... sensitivity. I think that sort of captures what it's like, so something that would otherwise be regular sensation or a regular experience is amplified.

Alex Partridge 5:13 Mm.

Dr. James Kustow 5:14 And, uh, uh, I think people can relate to that height. I mean, people with ADHD, um, are, as a group, more sensitive often than others, heightened sensitivity. There's, uh, higher rates of sensory processing issues, and although it can be various things, o- o- 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-

Alex Partridge 5:48 Mm

Dr. James Kustow 5:49 ... 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. D- why didn't they respond with a positive smile, or why didn't, what's their tone of voice? Were they angry with me?

Alex Partridge 6:04 Mm.

Dr. James Kustow 6:04 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 braking 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, and suddenly becomes much bigger.

Alex Partridge 6:37 Mm.

Dr. James Kustow 6:37 And it's, it, it goes completely in line with my, my model of understanding ADHD, which is as a, an issue of regulation. And those 10 domains of dysregulation, domain four is emotion, and, uh, by far, the characteristic, um, emotional dysregulation in ADHD is linked to this rejection sensitivity

Alex Partridge 7:05 Mm. And in your patients, how do you see RSD presenting itself, both physiologically and mentally?

Dr. James Kustow 7:12 Well, they describe those features that I mentioned before, so they'll talk about these strong emotions, and they'll, they'll talk about, um, 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 z- who talks about zoning out or going elsewhere or getting stuck somewhere else.

Alex Partridge 7:46 Mm.

Dr. James Kustow 7:47 Um, so that's a sort of a mental side of things. Um, a lot, and 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. It's all gonna 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. Um, on a physiological level, where those emotions that I mentioned, particularly the panic and anxiety and the anger, they all fit into, um, the arm of the autonomic nervous system, um, 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, uh, um, and it can feel extremely physical, and that's the links with the body really.

Alex Partridge 9:05 Mm.

Dr. James Kustow 9:05 The autonomic nervous system and the sympathetic nervous system and its balance of the parasympathetic, they innovate all the major organs of the body, and you can see if there's an imbalance there, you're gonna get symptoms of a stress response. Yeah, and a crash afterwards.

Alex Partridge 9:22 Mm.

Dr. James Kustow 9:23 An exhaustion afterwards.

Alex Partridge 9:24 Going back to the, the point where it might not be a negative criti- a negative comment. It might just be a neutral one or not the positive one that you were hoping for, i.e. the, the res- the crit- the comment didn't meet the expectation that you had in that s- particular scenario. Had a, 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-

Dr. James Kustow 9:51 [clears throat]

Alex Partridge 9:52 ... 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?

Dr. James Kustow 10:13 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 knockbacks 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, like, biologically primed from the ADHD in the first place, which I, I do think it is, as does William Dodson, who described it. He says he believes it's much more a, a biological, physiological, neurological glitch, and that makes sense completely, doesn't it? 'Cause the system is dysregulated. Everything about the system's dysregulated, not just the mental health components, not just the attention and, 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-

Alex Partridge 11:37 Mm

Dr. James Kustow 11:38 ... this is going back to survival, isn't it?

Alex Partridge 11:40 Mm.

Dr. James Kustow 11:40 How we deal with attacks is gonna be dysregulated.

Alex Partridge 11:43 I've spoken a lot on the podcast. I've told this 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, 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-

Dr. James Kustow 12:15 Seen through [laughs]

Alex Partridge 12:16 ... seen straight through it.

Dr. James Kustow 12:17 Yeah.

Alex Partridge 12:17 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. Do 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?

Dr. James Kustow 12:54 Absolutely. It's like one of the drivers of this is exposure in some way. Um, 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 facade, 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, um, you don't encounter that feeling as often.

Alex Partridge 13:49 It's interesting you said about the, the autism connection at the beginning, 'cause I'm considering, uh, going for assessment for ASD. Um, I, I feel like there's this, this, like, internalized version of me, this, 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-

Dr. James Kustow 14:11 What age, by the way?

Alex Partridge 14:12 ... get dressed in the morning.

Dr. James Kustow 14:12 What age did you get stuck at?

Alex Partridge 14:14 Gosh, you know. [laughs] Someone who doesn't know how to get, leave the house without, you know, on their own, without being very scared.

Dr. James Kustow 14:24 Mm-hmm.

Alex Partridge 14:24 Um, so when, when someone holds me up on something that I've done wrong, it, it's in those moments that I get triggered, um, 'cause it's like it's bringing the child to the surface, and all of that effort to camouflage the child is being tossed to one side and, 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, uh, and is a contra- contrast to the external version of themselves-

Dr. James Kustow 15:06 Mm

Alex Partridge 15:06 ... that they're putting on?

Dr. James Kustow 15:08 Yes. I think that when we experience traumas, whether they're big T or small T traumas, so big events or even comments in the playground, and we, a- and, and that charge remains w- 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 o- a part of ourselves doesn't move forward and mature. I see ourself as m- 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, you know, the different approaches to processing trauma, um, I think is big piece of the work in ADHD, because then these, ADHD and trauma strongly overlap, and I think to, 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, you caused me too many problems and we're gonna keep you away. The way I like to see it is seeing that part, that child part of yourself, um, 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. Um, and I think those aspects of development that get a bit stuck, um, are what m- make you feel like your younger self.

Alex Partridge 17:12 Mm.

Dr. James Kustow 17:13 I, I, um, I often think, how old 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, the viewers will as well.

Alex Partridge 17:23 Yeah. No, it's fascinating. I'm trying to close that gap between my internal age or persona and the sort of external version that I need to-

Dr. James Kustow 17:33 I, I think that, um, when we start to become more vulnerable and we open up about our difficulties, I've v- very much been through this myself over the last couple of years because I, uh, as we talked about last time, I recently published a book in w- on, 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, uh, process-

Alex Partridge 18:10 Mm

Dr. James Kustow 18:10 ... for me, because it's a lot of work to carry around the facade-

Alex Partridge 18:15 [laughs]

Dr. James Kustow 18:15 ... and 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, uh, it becomes part of a real healing process.

Alex Partridge 18:34 Mm.

Dr. James Kustow 18:34 Um, but I think the vulnerability is countered by the rejection sensitivity. Can I be vulnerable enough, like, or is it gonna 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-

Alex Partridge 18:50 Mm

Dr. James Kustow 18:50 ... in the right setting.

Alex Partridge 18:51 No,

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Alex Partridge 21:44 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, what would, what could you say to Uncle Barry in that moment?

Dr. James Kustow 22:13 So I think the thinking needs to take place in advance. Family's a really complicated thing.

Alex Partridge 22:18 [laughs]

Dr. James Kustow 22:18 So there's often a, there's often history wrapped up in all of this, uh, charges being activated all the time. So it might be that there's a story behind some of these intrusions. But the way I would think I'd approach that is if, um, if this was a pattern that was going on and 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. I'd like to visualize myself being calm and cool and not responding with a shocked, angry, upset, anxious face, but responding with a, a little smile, with a little humor, and perhaps bouncing it back to Uncle Barry and saying, "Okay, Uncle Barry, so, uh, are you, are you an expert in long-term relationships, and how's it going for you?" Like, de- deflect.

Alex Partridge 23:22 Mm.

Dr. James Kustow 23:23 Humor. Um, 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's-- It upsets me when you talk like that, so can we talk about something else?" And just put a really clear boundary in place.

Alex Partridge 23:48 Mm.

Dr. James Kustow 23:48 And the other thing I would say is once you are triggered, it's about how to, how to ground, how to bring yourself down. Now, sometimes you can ground before it's too late, nip it in the bud. Yeah, sometimes that's possible. Um, first signs of stress coming into your system, you might go, "Okay, I need to just take a moment, go and get some fresh air," state change. And then, um, y- 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-

Alex Partridge 24:30 Mm

Dr. James Kustow 24:31 ... excellent way of regulating quickly. Take a few deep breaths, and then go back in confidently. And, um, it might be in those situations that a mask is necessary just to get through the bump.

Alex Partridge 24:45 Mm.

Dr. James Kustow 24:45 Um, but the idea is not to get fully triggered, to avert it, to preempt it, and, and then if necessary, to manage it.

Alex Partridge 24:54 Mm. 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 defense to have a mask, in the short term, as a, as a tool. W- what if you do push back to Barry, [laughs] Uncle Barry, a little bit, and then Un- and Uncle Barry says, "All right. I was only joking. Don't be so sensitive."

Dr. James Kustow 25:15 Mm.

Alex Partridge 25:16 What would you say to some- a, an ADHD naive person like that who doesn't understand the complexities and nuances of RSD?

Dr. James Kustow 25:25 I'd probably... I, I probably wouldn't have that conversation there in the moment because the likelihood is I would be just on the edge.

Alex Partridge 25:33 [laughs]

Dr. James Kustow 25:34 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. And 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, is often the way forward. And listen, if some people will just laugh back at you and say, "Oh, whatever. Here he goes again," and then I would detach, and I would say, "Fine. Well, I'm not [laughs] gonna talk to you then until you start respecting me more."

Alex Partridge 26:27 And maybe Uncle Barry is, [laughs] is self-medicating his own ADHD unknowingly, and that's, this is this journey of, to his own assessment.

Dr. James Kustow 26:35 You're right.

Alex Partridge 26:35 [laughs]

Dr. James Kustow 26:35 Listen, I've always been taught that, um, when someone goes on the offensive or the tackle, starts teasing or criticizing, it's very, very often about them-

Alex Partridge 26:45 How-

Dr. James Kustow 26:45 ... about jealousy, about something that they're struggling with, projected into you.

Alex Partridge 26:49 Mm.

Alex Partridge 26:51 How does alcohol interfere with a person's emotional regulation and have a knock-on effect onto their RSD?

Dr. James Kustow 26:58 I think given the fact that we're, we're in the Christmas or just after the Christmas period, it's probably a very appropriate question. Listen, alcohol, um, disinhibits. It reduces inhibition. We know that. We say things we shouldn't say. We're more impulsive. Um, we make decisions and poor judgment calls around things. And it's important there to, to, uh, recognize that ADHD is an issue with regulation and in- inhibition. Um, 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, to, um, just because they are chasing sensations because they're sensory seeking, or maybe they're sensory underresponsive. And when you're sensory underresponsive, you might try and seek out and grab sensation because it's nice to feel something.

Alex Partridge 28:10 Mm.

Dr. James Kustow 28:11 So the combination of alcohol, alcohol, um, which obviously is 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 'cause 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.

Alex Partridge 28:41 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?

Dr. James Kustow 29:03 I think the first part of the question, absolutely yes. Um, unconsciously, we seek out, uh, we s- we, we seek out dopamine or noradrenaline to bring a sense of, um, 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, through 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.

Alex Partridge 29:44 Mm.

Dr. James Kustow 29:44 Um, if you enter into that conflict, there's a reasonably high chance that the stuff that comes back at you is gonna trigger you.

Alex Partridge 29:52 Christmas has just happened.

Alex Partridge 29:54 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 at... 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. Someone's-- But 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?

Dr. James Kustow 30:27 I think normally A day or two, it 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-

Alex Partridge 30:40 Mm

Dr. James Kustow 30:41 ... 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 RSD a lot and, you know, when I'm in that, "Oh my God, I feel so angry, I just wanna, I just wanna sort of vent," and then I decide, I catch someone's eye, and there's an opportunity to both smile at each other. And, you know, the message is, "Are we really gonna 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, at an easy out, and the easiest out is to, 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-

Alex Partridge 31:44 Mm

Dr. James Kustow 31:44 ... a real mess." Um, I don't tend to see the sort of rejection sensitivity in the moment stuff dragging on for, for, um, a long time in most cases.

Alex Partridge 31:56 Mm.

Dr. James Kustow 31:56 You know? I think when it does, you enter the realms of trauma, a trauma reaction, which I think RSD is a mini trauma reaction-

Alex Partridge 32:03 Mm

Dr. James Kustow 32:03 ... but I think this is something's happened that sort of left that charge in place. We wanna try and get rid of these charges before they set in.

Alex Partridge 32:13 From my experience in 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-

Dr. James Kustow 32:35 Mm

Alex Partridge 32:36 ... sometimes mean.

Dr. James Kustow 32:37 Yeah.

Alex Partridge 32:37 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, how do you go about explaining that to the family member who might not understand the, the complexities of RSD?

Dr. James Kustow 32:56 Mm. Well, first thing is that you need to be out of... You need to be completely okay in your own right. Like, you, you have to go into that discussion without any heightened emotion, and that means you gotta go and do a bit of work on your own. And I think going through the, um... I think whenever you're gonna have a heavy discussion, I think it's important to create the setting, the right setting, and frame it and explain, "I'm gonna be telling you some stuff that might be difficult to hear. I, I want you to listen rather than sort of come back at me. A- 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 just give some honest feedback. Depends whether the individual knows you have ADHD, but assuming they do, it's explaining that, "I have ADHD, and it, the features of ADHD include dysregulation and emotional dysregulation, and this, uh, 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. Uh, I do- I don't want to excuse it. I just want to explain it." And, um, 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 reasons, and you did it honestly. So I'm a real believer in owning my mistakes and, if necessary, apologizing and then moving on.

Alex Partridge 34:49 Mm.

Dr. James Kustow 34:52 And it's now their job to decide-

Alex Partridge 34:53 Mm

Dr. James Kustow 34:53 ... how they, how they do that.

Alex Partridge 34:55 We're in January. All of the parties are finished. It's very dark.

Alex Partridge 35:02 Can loneliness be a trigger for RSD?

Dr. James Kustow 35:05 Absolutely. Um, 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, and we have, we, 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 it... You know, loneliness is perceived as rejection, and, um, particularly a- around the sort of festive period, if people don't have good, loving friends and family to go to-

Alex Partridge 35:50 Mm

Dr. James Kustow 35:50 ... uh, it's a time of heightened social comparison. So-and-so's going to their family, and you're going to your friend's, and I'm here on my own, and I'm really bor-... 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 on a creative project. A massive mural on the wall, a painting, a, you know, a video, a video diary of something. Something to occupy you because it's in the space where some of these unhelpful- ... thoughts and ruminations and sensitivity. "Oh, well, no one likes me, and my life's falling apart." It's in the space that this happens, so you wanna sort of limit the amount of unstructured time.

Alex Partridge 36:41 Mm.

Dr. James Kustow 36:41 And connect with the people. The worst thing to do when you're feeling lonely is to go, "I'm gonna retreat to my bedroom, and stay in bed, and cut off from everyone even more." Actually, it's the time you wanna reach out, but reach out to people who care about you and maybe show that vulnerability. You gotta balance it. You don't wanna be the one who's completely moaning and drawing every- sucking, you know, sucking the energy out of other people the whole time. But when you need to, you need to reach out and ask for help, and a good friend will help you.

Alex Partridge 37:10 Mm.

Dr. James Kustow 37:10 Will arrange to meet with you, will pop round.

Alex Partridge 37:13 RSD isn't, isn't well-studied or studied at all. It's definitely not an official, uh, medical diagnosis.

Alex Partridge 37:21 Why do you think it's not a- an official medical diagnosis, and do you think it ever will be?

Dr. James Kustow 37:27 Don't think it will be a diagnosis, but I think it will, uh, w- it will get studied. I d- I think it's not just not been studied because it's a relatively new concept, and it's probably quite challenging to study. When you're studying a drug, medication, you know, 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, it will become a thing in time. I've no doubt about it. It's too, it's got, it's face validity, as we call it.

Alex Partridge 38:01 Mm.

Dr. James Kustow 38:01 It's too, it's, it's strong. I mean, it, people resonate. You resonate. I resonate. We're talking about it. It's real. Um, 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 will sit as it does now under the emotional dysregulation of ADHD, which extends beyond RSD, but RSD is without a doubt a central part of it.

Alex Partridge 38:30 Mm. My mind's whirling trying to think of ways you could study it, which is ridiculous. It's, like you said, it's almost impossible. You'd have to g- give, like, 1,000 people a notebook and say, "Journal your emotions when you're p- when you are triggered," and, and then put data points together. Very difficult.

Dr. James Kustow 38:48 One of my colleagues, Professor Philip Asherson, uh, he, he and his team, he's retired now, but in h- he did, he's done quite a lot of studying on, uh, emotional dysregulation and, um, one of the studies involved giving participants, so there were two groups, one group had ADHD, another group didn't, and they had this little buzzer thing in their pocket. Every time they became, um, dysregulated in any way, they'd press the buzzer, and it, it allows a comparison between the groups. You could do a similar thing-

Alex Partridge 39:21 Mm

Dr. James Kustow 39:21 ... 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, um, quantitative, uh, and qualitative research. So quantitative is like how many buzzes in a day, and qualitative is what was the experience, and I think it needs to be looked at from both of those angles. Um, we, uh, when we look at things like medication, we look at symptom scores, it's numbers. It's like how many numbers does it go down?

Alex Partridge 39:58 Mm.

Dr. James Kustow 39:59 But we mustn't forget that quite a lot of research, useful, helpful research, is descriptive, clustering into things and, and I think this needs both.

Alex Partridge 40:10 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? [laughs] That seems to be, like, the almost impossible thing to measure.

Dr. James Kustow 40:30 Well, that's why you'd capture the scenario at the time, and then you'd have to cluster those into-

Alex Partridge 40:38 Mm

Dr. James Kustow 40:38 ... was it appropriate or not appropriate? You know, um, again, s- subtleties of study design. Uh, but there will be ways of capturing those, answering those sorts of questions.

Alex Partridge 40:53 Mm.

Dr. James Kustow 40:53 But it needs, you know, it needs a good study.

Alex Partridge 40:54 Yeah. Well, if there ev- ever is one, sign me up. [laughs]

Dr. James Kustow 40:57 [laughs]

Alex Partridge 40:59 What social interactions do you think might trigger RSD within someone that a neurotypical person might just be able to brush off, ignore?

Dr. James Kustow 41:10 So the, the thing that comes to my mind is the, you know, when you used to get selected for teams for sports-

Alex Partridge 41:17 Oh

Dr. James Kustow 41:17 ... at school, and they'd ch- each, each captain would choose someone for their team, and then slowly the numbers would w- dwindle down-

Alex Partridge 41:25 [laughs]

Dr. James Kustow 41:26 ... until you were left there.

Alex Partridge 41:27 Mm.

Dr. James Kustow 41:28 Um, 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, maybe, maybe that's a, 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 w- 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'll interpret it in a different way. And there's many different situations. I'm trying to think of ones in my own life. I, I will often through-- And hyperfocus is actually part of this because individuals with ADHD who hyperfocus 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, if you are checking a document, the ADHD individual with hyperfocus won't miss a single dot.

Alex Partridge 43:17 Hmm.

Dr. James Kustow 43:18 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.

Alex Partridge 43:31 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 gonna break up with you, or if your boss asks for a quick chat but doesn't give you any context-

Dr. James Kustow 43:53 Mm

Alex Partridge 43:53 ... you catastrophize and think you're gonna get fired.

Dr. James Kustow 43:55 Mm.

Alex Partridge 43:56 There's nothing there.

Dr. James Kustow 43:56 In fact, I, I felt my gut going just then when you said that. I mean, I agree with you. That sort of open-ended thing, leave it to you, [laughs] you, you to work out what it's about is not good in ADHD. It's-- 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."

Alex Partridge 44:16 Mm.

Dr. James Kustow 44:17 Um, and the inhibition would kick in. But you remove those breaks, and that thought goes here, there, and before you know it-

Alex Partridge 44:25 Mm

Dr. James Kustow 44:25 ... you know, you're resigning yourself.

Alex Partridge 44:26 Yeah. You know, you think your world's gonna end.

Dr. James Kustow 44:28 It's, [laughs] it's amazing-

Alex Partridge 44:29 I mean, some-

Dr. James Kustow 44:29 ... the shifts, the shifts-

Alex Partridge 44:30 Yeah

Dr. James Kustow 44:30 ... that can take place in how extreme you feel from one minute to the next always puzzles me.

Alex Partridge 44:36 Mm.

Dr. James Kustow 44:37 It's amazing.

Alex Partridge 44:39 Do you think RSD and people pleasing are connected?

Dr. James Kustow 44:42 100%. Talked 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, aren't there? So people pleasing is one of them. Um, overextending yourself to compensate, to make it less likely that someone's gonna criticize you, which essentially translates to people pleasing, taking on too much, volunteering where you don't really wanna do it, um, agreeing with people when you don't agree with them. And there are other things that, patterns that form-

Alex Partridge 45:29 Mm

Dr. James Kustow 45:29 ... such as avoidance and perfectionism, and all of them are there to mitigate, protect in some way. And again, it's like, it's part, it's the mask.

Alex Partridge 45:43 Hmm.

Alex Partridge 45:45 Can RSD manifest itself in more subtle ways, sort of less physiological ways that we haven't mentioned before?

Dr. James Kustow 45:55 Mm. 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, takes a step back, is sitting at the end, the, on the outside circle-

Alex Partridge 46:22 Mm

Dr. James Kustow 46:23 ... doesn't make eye contact. Those sorts of things are clues, are slightly more subtle clues. People who will never, yeah, who will never-- Agreeers. I call them agreeers-

Alex Partridge 46:37 Mm

Dr. James Kustow 46:38 ... who will just go along with whatever you say.

Alex Partridge 46:41 In all of these things, it's like creating a, a shield between that person and the possibility of them encountering a criticism?

Dr. James Kustow 46:50 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, we develop and grow older, our challenge is to, is to try and shed these layers, these protective layers, so that we can connect more, we have be- more nourishing relationships, not just with other people, but with ourself because when you, when you mask a lot and when you people please and when, you know, you work really hard to perfection, you get burnt out and you suffer long term. It's, it is never enough. If 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.

Alex Partridge 47:58 How does someone-

Dr. James Kustow 47:58 It's a life's mission. It's, it's, 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, you know, 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 much sleep you've got, how you've, how much sleep you've had, whether your nutrition's good, whether you do any form of mindfulness and grounding, whether you have good tools of, 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's always better. That's why I put so much weight on, you know, self-care and movement and breathwork and mindfulness. But it has to, it has to be the thing that you have to, it has to work for you.

Alex Partridge 48:58 Mm.

Dr. James Kustow 48:59 Not all approaches work for everyone.

Alex Partridge 49:02 So if someone has a shield that is ultra thick, i.e., they have a mask that's ultra thick, they, they, they struggle to put boundaries in place, they say yes to everything, they overcommit, 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 thin or too thick?

Dr. James Kustow 49:30 Well, if your mask is too thin, you're gonna get hurt easily, and then you're probably gonna 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 a joint, it's like putting a protective layer, cotton wool layer around you in some ways, protecting you a bit. Um, so I think too thick mask means that you don't know yourself. You don't connect with people. You, yeah, you, you don't, you can't relate to people if you can't, if you can't, if you, if it's too, too much of a barrier. And if it's too thin, then you're sort of being thrown around like a, you know, in a fairground ride without a seatbelt on, you're being thrown around continually, and it's not nice. And at some point you'll do something to stop that happening.

Alex Partridge 50:28 Mm.

Dr. James Kustow 50:28 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 on nights out with friends, but not too much. You need to, um, you know, you need to be able to vary your diet and mess up a bit and, you know, break some rules, but not too much.

Alex Partridge 50:52 Mm.

Dr. James Kustow 50:53 Everything's about balance. I don't know any answer to any question that involves personal development or growth when it doesn't involve someone having to get the balance, reestablish a better balance.

Alex Partridge 51:08 I want to talk about how RSD can show up at work and in people's relationships,

Alex Partridge 51:14 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?

Dr. James Kustow 51:24 So it's a, 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 sen- the, the thinness of it, it 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, and just the shame of people watching you scrambling around and-

Alex Partridge 52:12 Mm

Dr. James Kustow 52:13 ... on the floor trying to sort of recover things, uh, made me think of, uh, of RSD, the impact that, how dramatic the impact is, um, and how vulnerable one's, um, sensitivity is, is really captured by this thin glass.

Alex Partridge 52:31 Mm.

Dr. James Kustow 52:33 And it can all feel like it's fallen apart.

Alex Partridge 52:35 Yeah. No, it's amazing analogy. I mean, it's so stunning and amazing to look at, but, um, to prove how fragile it was, I actually did sha- uh, crack it earlier. [laughs]

Dr. James Kustow 52:46 Did you?

Alex Partridge 52:46 When, when trying to place it here, it fell. It was about two inches.

Dr. James Kustow 52:49 We'll see what happens. No, we want to keep it on the shelves though. [laughs]

Alex Partridge 52:52 Such an amazing object, but a two-inch fall and it's completely cracked. [laughs] So yeah, no, it's brilliant.

Dr. James Kustow 52:56 Exactly. That's sensitivity, vulnerability, yeah.

Alex Partridge 52:59 James, I want to do the ADHD agony aunt section-

Dr. James Kustow 53:02 Yeah

Alex Partridge 53:02 ... which is called The Washing Machine of Woes because I always leave my laundry in the machine. That's my ADHD item. Although I am using the Tiimo app, so I'm getting a little bit better at remembering the washing. This week in The Washing Machine of W- 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 patronizing. How can I stop myself from feeling such intense hurt and rage?"

Dr. James Kustow 53:41 Not uncommon that people project, family members project into people what they think is what they should do. Um, 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've 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, that you're passionate about, and once you've found it, don't let go of it-

Alex Partridge 54:20 Mm

Dr. James Kustow 54:21 ... regardless of what other people, how other people judge it. Um, 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 boundaried about what you'll accept and not accept as an adult. It might be different as a child. You know, 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, it's very easy to slip back into old roles, to regress back into that childhood part of yourself, and the parents perhaps assuming the, the role of a, um, you know, a guide or a judge. But actually, things have changed, and, and clearly, assertively say, making it quite clear that this is your decision, it's not for anyone else. Uh, and maybe once and for all 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, um, removing yourself, judging whether or not you wanna go in the first place. And if something's really, really uncomfortable, you have a right to say, "I don't wanna go." Um, but I think feeding back your views and feelings clearly without getting angry is, is important.

Alex Partridge 55:59 Mm.

Dr. James Kustow 56:00 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've found my path, and encouraging me."

Alex Partridge 56:16 Mm. No, it's brilliant. Thank you so much.

Dr. James Kustow 56:18 Mm.

Alex Partridge 56:18 And then you mentioned there when someone with ADHD, it- it's important to find or to put the energy towards something that you're passionate about.

Dr. James Kustow 56:28 Mm.

Alex Partridge 56:29 How does someone figure out what they are passionate about?

Dr. James Kustow 56:35 It's that inner feeling that, uh, it's that, uh, that excitement inside when, when you encounter that thing. I'll never forget, so my journey into psychiatry wasn't pre-planned. I, I trained as a doctor. I worked two or three years as a, a doctor in, in emergency departments and various different wards of the hospital. And then when I was, uh, I decided I was, at that stage, gonna train to be a GP, and as a GP, you do, 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 a 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, and you know. In fact, I had actually ruled it out.

Alex Partridge 57:50 Mm.

Dr. James Kustow 57:51 But my instinct led me that way, and I learnt at that stage to follow my instinct a little bit more. Not always, 'cause it can lead you down-

Alex Partridge 58:00 Mm

Dr. James Kustow 58:00 ... dangerous paths, but to listen to what my gut is telling me.

Alex Partridge 58:05 And if someone listens to what their gut is telling them, and they make their passion their work,

Alex Partridge 58:10 how does RSD show up, or how can it show up in someone's work?

Dr. James Kustow 58:15 In so many ways. I find lots more people with ADHD choose not to work as part of a larger system, like a, the big organization, um, where there's lots of rules and regulations and protocols and security this and swiping in this. You know, it's a nightmare. You know, the, the punctuality, the remembering logins, the, um, you know, the sense that you're constantly being monitored in some way doesn't go well for ADHD.

Alex Partridge 58:45 Mm.

Dr. James Kustow 58:45 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 RSD. "Am I gonna lose my job? Am I gonna be shamed in front of everyone?" It's that whole feeling of going and standing outside the headmaster's or headmistress' office.

Alex Partridge 59:01 Mm.

Dr. James Kustow 59:02 And other ways it can show up, I think, are in, um, not, not, you know, not wanting to volunteer or take on projects, feeling like you wanna s- 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, uh, you know, when I actually get something done and, and deliver it, be judged on it, so that sort of level of exposure. I think the comments by colleagues in the office, um, that perhaps were just fleeting can be misinterpreted. Um, and, uh, and certain looks. When people are stressed at work for all sorts of different reasons, one can, uh, register it as a personalized thing-

Alex Partridge 59:51 Mm

Dr. James Kustow 59:51 ... and get quite paranoid about it.

Alex Partridge 59:53 Mm.

Dr. James Kustow 59:54 Um, 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, this cul-de-sac.

Alex Partridge 1:00:11 Mm. And in romantic relationships, how can RSD show up in that arena?

Dr. James Kustow 1:00:17 Most commonly, by the individual with ADHD misjudging or perceiving something that was neutral, or maybe was slightly irritated or slightly this that wasn't a big deal. It happens with my wife and I all the time.

Alex Partridge 1:00:36 [laughs]

Dr. James Kustow 1:00:36 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, but ... And, and, and then that dynamic of, "You did this," "No, I didn't," and then suddenly you're in this spiral. Um, you know, we need our, we need our partners to be able to feed back and give us-

Alex Partridge 1:00:59 Mm

Dr. James Kustow 1:00:59 ... guidance and advice. Um, in fact, it's an amazingly effective tool to have- Have a, a, 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 s- help regulate you from the outside

Alex Partridge 1:01:21 Mm

Dr. James Kustow 1:01:21 So again, that fine balance between welcoming that. Again, if you ask for some- if you ask for that sort of input, sometimes it takes away the intensity of it. Sometimes when it comes and it's unpredicted or, like, unpredictable or-

Alex Partridge 1:01:35 Mm

Dr. James Kustow 1:01:36 ... unanticipated, you, you, it, it hits you hard, whereas actually you s- 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, um-

Alex Partridge 1:01:51 Mm

Dr. James Kustow 1:01:51 ... whatever it is, the sign.

Alex Partridge 1:01:53 [laughs]

Dr. James Kustow 1:01:54 So I think that, I think, I think bringing the partner on board and them, 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 [laughs] and I know you haven't done anything wrong, but I've been triggered, and so let's talk about this afterwards." Um, I think there's, uh, lots of... Listen, every time you mess up, you turn up late, you book the wrong holiday, you drop the vase at 2:00 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-

Alex Partridge 1:02:40 Mm

Dr. James Kustow 1:02:40 ... in a brief moment. But you might be left there going, "It wasn't my fault. I didn't mean to drop the vase," and you're having a go at me, and then suddenly it gets into this out of, out of control thing.

Alex Partridge 1:02:51 W- when your wife triggered you and you said, "You've triggered me. Let's talk about this later-"

Dr. James Kustow 1:02:57 Mm

Alex Partridge 1:02:57 ... what do you do in that interim?

Dr. James Kustow 1:02:59 I'll go and state change, and go and get, go, I'll go and play with 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, uh, more increasingly now, like I said before, I will try and make a joke out of it.

Alex Partridge 1:03:19 Mm.

Dr. James Kustow 1:03:19 So, um, some light-hearted, flippant comment that doesn't self-denigrate, but it just captures the silliness of the whole thing. A- 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?

Alex Partridge 1:03:43 Yeah, yeah. No, definitely

Dr. James Kustow 1:03:44 That massively switch.

Alex Partridge 1:03:45 Yeah, no, definitely.

Alex Partridge 1:03:47 Is- one 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?

Dr. James Kustow 1:03:59 Mm. So I can only answer the question, like, anecdotally because, again, we have- don't even know what 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, you know, 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.

Alex Partridge 1:04:49 Mm. We had a guest on here, James, who, who explained the heartbreaking scenario where they were triggered so badly that in that moment they actually considered taking their own life. And I appreciate that there's no evidence to, to back this up, but

Alex Partridge 1:05:07 do you think RSD really gets that bad that someone might want to, in that moment, take their life?

Dr. James Kustow 1:05:15 Unfortunately, yes, I do. The intensity is off the scale. You know what it, you know what it's like. That, it's, 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 and 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, is, 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 in one of these episodes.

Alex Partridge 1:06:20 Mm.

Dr. James Kustow 1:06:20 So I don't know the answer to it. My gut feeling is it's a higher risk period, yeah.

Alex Partridge 1:06:26 Mm. Do you think RSD can dip into the realm of paranoia?

Dr. James Kustow 1:06:32 Yeah, I mean, paranoia is on a spectrum really, from a, a sort of vague paranoia, over-worrying, over-interpreting, um, uh, and then going into the realms of illness in terms of psychosis and persecutory delusions and so on. So I'm, I'd say in the terms of the former, over-interpreting 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, that, 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 gonna break down. If this breaks down, I have to move out, and if I m- move out, then I, I, you know, will be on my own. There's no mo- Like, it spirals.

Alex Partridge 1:07:19 Mm.

Dr. James Kustow 1:07:19 That's the lack of inhibition. You're taking the brakes off. Normally, that look, as I said, would get closed down quite quickly-

Alex Partridge 1:07:26 Mm

Dr. James Kustow 1:07:26 ... because there's no real evidence. So yeah, in terms of, um, a paranoid flavor or themes, I think that's-

Alex Partridge 1:07:34 Mm

Dr. James Kustow 1:07:34 ... really common. Um, I wouldn't go as far as to say it triggers full-blown paranoid psychosis.

Alex Partridge 1:07:39 Mm. And on the f- flip side of

Alex Partridge 1:07:43 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?

Dr. James Kustow 1:07:52 Well, there's no official diagnosis, and it's so common, rejection sensitivity. I'd say it's, you know, it, it's, uh, would be, definitely be the majority of people. But 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, uh, 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, um, but it's certainly really common.

Alex Partridge 1:08:40 People with the community, James, I speak to who have ADHD, they report this sense of heightened intuition.

Alex Partridge 1:08:49 Do you think people with ADHD have heightened intuition? And if so, should we believe everything our super sharp intuition tells us?

Dr. James Kustow 1:09:00 So the answer to the first part of 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 brakes of the brain. So without that frontal part working fully, the brain can go too far. It can, it can, you know, those, those thought l- cycles and they can go on, but the frontal lobe will regulate, will dull down, will pull in, will, um, organize. Now, the frontal lobe in ADHD isn't working in the same way, so there's less inhibition. And so when you take those brakes 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'll be responding too impulsively and where, you know, there's no limits, there's no balance. So I do think intuition is 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. Um, so, uh, I think that's a very real thing, and, um, I think that, uh, 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, I'm not sure you can trust on your intuition as much. When the, um, emotion is, is, uh, rises, um, particularly if there's stress in the system, stress has the effect of shutting down the frontal lobe, literally switching it offline, which is taking the ADHD problem and exacerbating it. It's why we, in a, in a crisis, we, we don't think through things. We just act, like an animalistic way.

Alex Partridge 1:11:17 Mm.

Dr. James Kustow 1:11:17 We just go for it. And so I think when the emotions and, and upset is involved, it certainly influences our ability to accurately perceive.

Alex Partridge 1:11:28 Hmm. Gosh, I'm listening to you, James, and I'm just, so much relatability. The calm in a crisis thing is, is overwhelmingly relatable, and I'm excited by how many people this episode's gonna help.

Dr. James Kustow 1:11:40 Mm.

Alex Partridge 1:11:40 And ultimately, James, um,

Alex Partridge 1:11:43 have you got three tips on how we can manage RSD?

Dr. James Kustow 1:11:48 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 a certain way and actually realize, "Oh my God, that was RSD." And what you'll find is that there's a scattering of these RSD moments that, um, uh, it can explain many of the crises or breakdowns or problems you've had in your life, and it can do, be, uh, go a long way to, um, changing the way you relate to yourself, and that awareness allows you to intervene earlier and to pr- pr- prep your system, um, 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.

Alex Partridge 1:12:46 Mm.

Dr. James Kustow 1:12:47 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, uh, 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.

Alex Partridge 1:13:40 [laughs]

Dr. James Kustow 1:13:40 It actually is finished now-

Alex Partridge 1:13:42 Mm

Dr. James Kustow 1:13:42 ... 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.

Alex Partridge 1:14:03 Mm.

Dr. James Kustow 1:14:03 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. And 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, timeout, um, deflection, um, or, or other things, and, 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.

Alex Partridge 1:15:04 Mm. 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.

Dr. James Kustow 1:15:12 Adult ADHD.

Alex Partridge 1:15:13 Adult ADHD. [laughs]

Dr. James Kustow 1:15:14 It's all good. No, thank you very much. That's

Dr. James Kustow 1:15:17 great.

Alex Partridge 1:15:18 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?

Dr. James Kustow 1:15:35 I mean, specifically RSD as 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 f- from a personal p- point of view. Um, 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, I, I would never realize would have such an enormous impact. And then subsequently, I struggled with mold toxicity probably 'cause my immune system-

Alex Partridge 1:16:13 Mm

Dr. James Kustow 1:16:13 ... 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, um, 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, that intuition, that connectedness, that, um, the positives of sensitivity, the ability to feel where to go and actually trust in it more-

Alex Partridge 1:16:57 Mm

Dr. James Kustow 1:16:57 ... has gone up. And so, um, I think this, although maybe not to that extreme, although I, I think this, this sort of immune dysfunction is much more common in ADHD, and that's a whole separate discussion to have.

Alex Partridge 1:17:12 Mm.

Dr. James Kustow 1:17:12 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 may be a exposure-linked sens- heightened sensitivity like multiple chemical sensitivity-

Alex Partridge 1:17:29 Mm

Dr. James Kustow 1:17:29 ... or other names for that thing. And, um, sensitivity is neither a good thing or a bad thing, but it needs to be managed.

Alex Partridge 1:17:37 Yeah. Gosh, I mean, we're gonna have to have you back for a third time by the sounds of it-

Dr. James Kustow 1:17:41 [laughs]

Alex Partridge 1:17:42 ... to dive into that topic. It sounds truly fascinating. Today, truly, I mean, overwhelmingly helpful for me personally. As I said at the top, RSD has, 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-

Dr. James Kustow 1:18:02 Mm

Alex Partridge 1:18:02 ... so much for sharing so much wisdom

Alex Partridge 1:18:04 today. We have a closing tradition, James, on the podcast where I deliver to you a letter written by the previous guest.

Dr. James Kustow 1:18:12 Yep.

Alex Partridge 1:18:12 They wrote three rules to live by.

Dr. James Kustow 1:18:16 I've got an impulse to smash the orb, by the way. I don't-

Alex Partridge 1:18:18 [laughs]

Dr. James Kustow 1:18:18 [laughs] I don't think I should, though, 'cause it won't find its place on your shelves, will it?

Alex Partridge 1:18:23 [laughs]

Dr. James Kustow 1:18:23 I think I'll leave it.

Alex Partridge 1:18:24 So I'm gonna deliver the letter to you, James.

Dr. James Kustow 1:18:26 Yep.

Alex Partridge 1:18:26 And if you could kindly read out-

Dr. James Kustow 1:18:27 Thank you

Alex Partridge 1:18:27 ... the last guest's three rules to live by.

Dr. James Kustow 1:18:30 Okay. Listen to your knee-jerk reactions. They're your best indication of your true beliefs. That's what we've been discussing really, our intuition. Number two, don't beat yourself up about things you said when you were triggered. Okay? 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 wins, 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 and negativity, because what, ultimately, what we fill our airwaves is what we become.

Alex Partridge 1:19:24 Mm. [laughs] I was laughing when you, when you were reading those 'cause I, I recognized them and I, I remember they're, they're mine. [laughs]

Dr. James Kustow 1:19:29 Are they really?

Alex Partridge 1:19:30 Yeah. [laughs]

Dr. James Kustow 1:19:31 Okay. Oh, 'cause you were sitting in this seat.

Alex Partridge 1:19:33 I was, yeah, before you. Yes. Yeah, yeah.

Dr. James Kustow 1:19:34 Great. Well, excellent. [laughs]

Alex Partridge 1:19:36 Yeah. Brilliant. James, again, thank you so much.

Dr. James Kustow 1:19:39 Thank you very much indeed. Great. [outro music]