The Truth About Female ADHD, The Invisible Struggle (Leading Psychiatrist Explains)

1. 0:00 – 1:39

   Intro

   1. SPSpeaker0:00

      We've let women down in both the diagnostic stage of ADHD, but also in the support that we offer them. We're looking in childhood for very clear symptoms of an impairment with hyperactivity or inattention. Girls are more likely to develop emotional maturity and make efforts to conform to social norms during their childhood. That invites itself for masking to start taking place. Dr Yath Ramesh is an ADHD specialist psychiatrist with a unique twist. He's treated people with ADHD from ages eighteen all the way to one hundred. So with regards to ADHD, he's seen it all. With ADHD, people often gravitate to fast reward, fast feedback mechanisms in order to help cope and regulate your emotions. It could be alcohol, cannabis, shopping, various things that ultimately could lead to an addiction.

   2. APAlex Partridge0:48

      Do you think if left unchecked and that propensity to seek the low hanging fruit, the quick dopamine, can that lead to a dangerous path of crime perhaps for somebody like that?

   3. SPSpeaker0:57

      I think that-

   4. APAlex Partridge0:59

      Can I have just a second of your time? If this podcast has helped you understand your brain or made you feel less alone, can you do me one favor? Can you hit the subscribe button? And I'll repay the favor by continuing to book the best and most exclusive conversations on this topic. Please enjoy the episode and always remember, you're not broken, just different, and you have always been enough. [upbeat music] Dr Yath, welcome to the ADHD Chatter podcast.

   5. SPSpeaker1:26

      Thank you for having me.

   6. APAlex Partridge1:28

      It's such a pleasure to have you here. The patients that you've treated for ADHD, they range from eighteen years old to one hundred years

2. 1:39 – 3:02

   What still shocks Dr Yath

   1. APAlex Partridge1:39

      old. Is there anything that still shocks you about ADHD?

   2. SPSpeaker1:43

      So there are so many things, uh, that shock me about ADHD. Um, but I should start off by saying that I guess the reason why I treat people within the, within that range is I'm a dual trained general adult and old age psychiatrist. And as I went through my training, I essentially, um, developed skills with, uh, treating neurodivergence in both the adult population, but I also took those skills into the work that I was doing in the old- older adult population. I think what shocks me about ADHD at the most is the fact that the symptoms consis- can still persist over the different age groups. And in particular, um, I think what I've learned from working with people across those different age groups is that although the symptoms themselves can, um, can sometimes go away for some people, actually as life gets more complicated, things can get more complicated for older adults. So, yes. Yeah.

   3. APAlex Partridge2:44

      So the symptoms of ADHD can stay consistent throughout someone's life, all the way from eighteen to one hundred. But the way they manifest and show up and cause challenges, does that change as you go through life and get a bit older?

   4. SPSpeaker3:00

      Absolutely. So

3. 3:02 – 11:01

   The life stages of ADHD

   1. SPSpeaker3:02

      let me talk you through the different life stages. Okay, so we're gonna start with, um, children. Now, I'm gonna call this the dependent stage because at this stage, what we're looking at is the amount of dependence that you have on your parents or your teachers or whoever it is that provides support around you. Now, with children, when it's obvious that you're requiring more dependence on those people compared to others, then, uh, we start to notice problems with ADHD. Um, but therein lies the challenge because if you're very good at masking your symptoms, if your symptoms were there, but you had a sibling who had, let's say, hyperactive symptoms that were more obvious, if there were symptoms that were, um, happening, but there was something else going on like parent or divorce or conflict, and they could be rationalized or justified in another way. For all those different reasons, it's very possible to get through childhood where you have symptoms, but they haven't manifested into something that we might consider ADHD. So then we go on to your early adulthood, and in this stage, I'd call this the independent stage, because in the independent stage, you're trying to become self-sufficient, but you might find manifestations of ADHD there where you can't. So I'm talking about the people who do really well academically at school, but then they go into their, uh, university years and everything falls apart. Their grades fall, they struggle with making, making friends, or they struggle with being able to prioritize the differences between s- uh, prioritizing school, pri- prioritizing work, prioritizing friendships, relationships, and the old self that used to jump from thing to thing, um, excitement, one excitement to the other, struggles with handling this sort of ch- stage of life. And then we go on to the next stage, which is the integration stage. So let's say that you managed to get through life and you learnt skills of independence, but when you get to actually trying to bring those skills together, um, so let's say you're a parent, you have, uh, you're juggling responsibilities with childcare, with aging parents, or you're taking on a leadership role at your work. At this stage, you can struggle with trying to bring all of those different skills together. Why? Because you don't have the opportunity to mask in the same way that you did before. All those times that you used to give yourself that downtime, gone. All those times where you used to be able to prepare for conversations, prepare for those situations that you knew were going to be anxiety-provoking for you, gone. And at this stage, ADHD can manifest rather than with symptoms, but with a difficulty with managing the complexity of life.And there is a whole separate thing I can t-tell you about with w- the retirement stage, and perhaps we can talk about that later

   2. APAlex Partridge6:14

      Mm. I've never, ever heard it explained in such a fluent way before, how it kind of can show up at various stages of one's life. So I suppose, uh, at different stages of your life, you have different support systems around you, your environment changes, and in, in response to the, the, the sort of ever-changing landscape of what you are in as a human being-

   3. SPSpeaker6:35

      Yeah

   4. APAlex Partridge6:35

      ... how much your ADHD shows up changes depending on that, too. Do, do you think as you grow up and you m- transition through these different stages, can ADHD get easier to manage as you as an individual become aware of your traits, your challenges, and you, you're able to self-reflect on them?

   5. SPSpeaker6:55

      Yeah. So there are two arguments for why you might think that ADHD can become easier to manage, and I'd say for some people, it absolutely is the case. So first, pattern recognition. You start to be able to recognize those triggers before you let them get to the stage where it becomes a problem for you. You know those people that if you spend time with are going to be triggering for you. You know those situations, those opportunities that if you say yes to, they're gonna completely override you, and you know how to avoid those situations. So yes, for some people, pattern recognition helps. The second thing is emotional maturity. So when you were younger, your RSD may be driven by lots of perceived threats, hypothetical scenarios about what could happen in the future. But now, as you get older, you start to actually realize what does happen, and that can help your RSD to have a more mature understanding about the difference between perceived and actual threat. So this can be really helpful, um, with being able to have the capacity to manage some of the ADHD symptoms that you have. But I would caveat that by saying that you've got capacity, and you've also got demand. And as you progress through your life stages, the demands on you can also grow up, g- and expand. And when they grow, if your capacity doesn't match the demand, then you personally might not find that ADHD gets easier as you age.

   6. APAlex Partridge8:32

      So interesting being able to s- recognize your patterns, and therefore it gives you the tools to mitigate and avoid perhaps an RSD trigger. Are there circumstances in someone's life as they get older, new experiences that their ability to see coming because of that pattern recognition isn't so useful because they have never experienced that life event before?

   7. SPSpeaker8:57

      Yes. So when we look at the experiences that you have as you age, so let's look at some of the most common scenarios here. Parenthood. For women, the menopause. For both men and women, the experience of progressing up the leadership ladder within your working environment. For both men and women, again, the experience of complex physical hea-health challenges as you age. And again, um, going through retirement. At all of these life stages, you're experiencing things that you never may have experienced before, and one of the most difficult challenges with this, and I'll give you an example of this, okay? So, uh, one of the things that people in their later stage of life tell me is that they look back at a certain period, it's around middle adulthood, where everyone is caught up in the thick of things, and during that time, what happens is that you don't have as many interactions with your friends and family around you, but those interactions can be detrimental depending on how they play out. And so something that I've heard time and time again is, "I never really had that good a relationship with my brother, but that one Christmas in 1998 just completely ruined our relationship." And they li- they link it back to their experience of RSD that might have happened during that moment, and what it does is it reinforces to their RSD and to their ADHD brain that this is not a safe space, and that you need to be careful with your social interactions. So as you go through the life stages, things can become more complicated, but also your RSD can become more sensitive to those situations from happening.

4. 11:01 – 18:58

   Unpacking RSD

   1. APAlex Partridge11:02

      What is RSD? How would you describe it?

   2. SPSpeaker11:05

      So RSD stands for Rejection Sensitive Dysphoria. Um, it is a concept and a term coined by the American psychiatrist William Dodson, who I know that you know [laughs] very well.

   3. APAlex Partridge11:18

      Yes. [laughs]

   4. SPSpeaker11:18

      You've interviewed him. Yeah. And, uh, essentially what it describes is an intense physical and an emotional, uh, symptom or pain that you experience in the context of actual or perceived threats, and it's disproportionate to what other people may presume to be a normal reaction to a situation. And this is important because in the moment when you're experiencing RSD, it's very possible that your emotions and experience are completely logical and justified for that situation based on what's going on in your brain. You might regret it later, yes, but in the moment, you will, um, it will make complete sense to you. And one of the most painful things about RSD is that there is a self-perpetuating cycle between RSD and trauma. So-As we all know, you know, from, from ADHD, you're more likely to experience trauma in the context of having ADHD. Now, unlike other experiences, so let's take alcohol, the more alcohol you drink, the, the, the more likely you are to actually dampen your responses to alcohol so that you don't become as sensitized to it over time. It's the complete opposite effect with ADHD and RSD. So the more traumas you experience, so if we imagine that RSD is this bubble that you have, and it's a protective shield, it's a heightened flight, fight or flight response that you have in order to protect you from trauma. Now, if you imagine that every time you experience a trauma, that bubble gets bigger, and with that bubble, it gives you a stronger response so that you protect yourself next time from trauma. But as the bubble gets bigger and bigger, the problem is that it becomes easier and easier for things to actually hit the bubble. So now you get this very heightened response that's also much easier to be able to hit, and that can cause you to want to curl up into a ball and avoid all trauma, and that's why it can be so painful.

   5. APAlex Partridge13:30

      William Dodson, he theorized, and we speak a lot about it on this podcast, is, is those horrible comments that many of us experience in our early years because of our differences. But what other trauma could a, a child with ADHD be exposed to that perhaps someone who didn't have ADHD might for, for various reasons avoid?

   6. SPSpeaker13:51

      Yeah. [sighs] So as a child with ADHD, you are more likely to go through life being told things, uh, that are a different narrative to why you're experiencing life the way that you are. So let me just get this, um, out from the start as well, because some of these listeners of this podcast will have gone through generations of life where we didn't even have the culture, uh, or language to experience-- express neurodiversity. So what does that actually mean? So what that means is that inattention wasn't even considered a possibility to be something that was wrong with your brain. These children were probably told that you're not listening, you're not paying attention. There must be something that's, you know, wrong with you because other children are not like this. You're messy. You're disorganized. You misbehave. Why can't you just be like your sibling or someone else? So these are ADHD-specific traumas that you can have. But then there's another problem that happens. Children with ADHD who are exposed to the same traumas that someone without ADHD doesn't have, so let's say parent or divorce, for example, they not only experience the worries that they might have caused it because of all the things that they were told about themselves, but for their RSD, suddenly you go from having a perceived threat to confirmation that there is an actual threat here. This event actually happened in your life, and maybe you might have had some contribution to it. And I find this one of the most painful experiences to hear about when people carry that. So yeah, childhood trauma has a very, very strong, uh, role to play in how ADHD develops in children.

   7. APAlex Partridge15:57

      Gosh, it's heartbreaking. If a child experiences those traumas you were just mentioning, and, and they're in their really early stages, their developing years, uh, and, and they are on the receiving end of all of those horrible comments, or they witness this, this event like a divorce and, and they internalize it and think that it's their fault, like, what, what does a child do? How do they react? How do they respond to those messages? Do they change who they are?

   8. SPSpeaker16:21

      A child tries to make sense of this by building a narrative about themselves. So that narrative might be that there's just something that's fundamentally wrong or flawed or different about me, and that narrative then can cause a reaction. So for some, it might make them withdraw. It might make them want to spend more time with themselves and not with other people because they worry that, about what other people are going to say or how other things might play out in future relationships. That withdrawal for some people could look like an anxiety. So you may see a child, you know, diagnosed with social anxiety as a result. Some children withdraw so much that they stop doing things, and they stop gaining pleasure in things, and that again could, could cause issues with their mood, and again, that could play out as a depression. Other children, especially when going through adolescence and learning about how to regulate emotions, can have difficulties with identifying with what's safe and what's not safe, and that can very strongly contribute to emotional dysregulation. All of that, I guess, could lead to a child presenting with different mental health issues. But also, as you get older, you start to learn different coping strategies. Now with ADHD, one of the things that we know that people often gravitate to are fast reward, fast feedback mechanisms in order to help cope and, uh, regulate your emotions. What that could involve is it could be alcohol, it could be, it could be cannabis, and it could progress to other substances like cocaine, or it might not be drugs at all. It could beShopping, gaming, various things that ultimately could lead to an addiction. So these are just d- different ways that trauma can have an impact on, on children.

   9. APAlex Partridge18:38

      I asked Dr. Ned Hallowell what ADHD, if it's not recognized and managed, can turn into, and he summarized what you just said. It can turn into addiction and compulsive spending, and it explains a huge percentage of the prison population. Do you think if left unchecked and that

5. 18:58 – 27:40

   The link between ADHD and crime

   1. APAlex Partridge18:58

      propensity to seek the low-hanging fruit, the, the quick dopamine, can that lead to a dangerous path of, of crime perhaps for somebody like that?

   2. SPSpeaker19:07

      Oh. So I, um, actually simultaneously worked in the NHS in an, uh, specialist ADHD service within, within our local area, and I also worked in a drug and alcohol addiction service at the same time. And essentially, what I was doing was seeing ADHD presenting in two different populations. Within the addiction service, we actually had a specific sub-team called the criminal justice team because of the propensity of crimes that were committed by people within, within that service. But what you could actually see was that the exposure to traumatic life experiences, the combination of not having the resources to be able to support those people through the education system, through s- the social care system, and inevitably what happened for some of those people is that they experienced an addiction, but without the financial resources to be able to manage the addiction, you end up trying to fund it. So how do you do that when you don't have the skills or resources to have a job that's going to help you? You need to find other ways, so you end up in the criminal justice system. Then what happens there doesn't fix the problem. And so when you're out of the criminal justice system, you start looking for a way to cope again. And then there's a cycle that happens between, uh, being in trouble with, with the ch- criminal justice system, the addictions, and it's very difficult to break that cycle, and that's fundamentally what we try to do within, within our service. So yes, criminality and ADHD definitely have, have a commonality, and it's sometimes just your life experiences early on that can shape which direction you go.

   3. APAlex Partridge21:13

      It's such a big motivator for me. Like, as someone myself who's an addict and an alcoholic, like I've, I've been in the hospital wards with tubes hanging out of me. I've been in the back of police cars. I've been down an alleyway with someone calling an ambulance 'cause I just can't stop drinking, and then I got my diagnosis of ADHD.

   4. SPSpeaker21:29

      Mm-hmm.

   5. APAlex Partridge21:29

      I got sober, and suddenly I realized that so much of what was holding me back was my not being aware of my addiction and how much ADHD played into that. And with awareness, I was able to manage that challenge, which was my addiction, get that under control, and then afterwards you can really lean into the many strengths that come with, with being different. And that led onto the podcast and, and, and sat here today interviewing incredible people like you, and it's such a passion project of mine. And to hear similar stories of, of people having that moment where they get a diagnosis and, and so much makes sense, and they're able to turn their challenges and confusions into strengths. Out of the patients that you've seen, Yath, do you have any stories of somebody getting a diagnosis and it being totally transformative to their life?

   6. SPSpeaker22:25

      I have many stories, uh- [laughs]

   7. APAlex Partridge22:27

      [laughs]

   8. SPSpeaker22:28

      ... about that, yes. Um, so, uh, what I'm actually going to tell you about is, uh... And I guess this comes from, uh, my experience of working with people across the lifespan, is I had the pleasure of actually treating three, uh, different generations of one family and seeing how ADHD changed things for them. So I'm gonna start off with my original patient. So she was a 19-year-old young woman who was struggling with a transition to university. Uh, again, she did well academically, but really struggled with, uh, how to navigate everything in her first year. And what became apparent when we actually started to unpick her symptoms, and she had a lot of inattentive symptoms that she was masking, was that at a certain age, around 15 or 16, she stopped pursuing the things that she was actually good at and pursued the things that she felt she needed to be good at. So there was a lot of masking that was happening around that time. She picked subjects not based on her strengths, but again, based on a narrative that she was playing. Um, perhaps there's a bit of people-pleasing in there. Um, and it progressed into university. So for her, when we made an ADHD diagnosis, what she actually benefited from was understanding herself, understanding where she was masking, and through coaching she realized that perhaps actually the choice that she made in terms of the degree wasn't the right one for her, and she actually changed her course and thrived in what she did. What was interesting was that during the diagnostic assessment process, so her mum completed an informant questionnaire, and, and we see this a lot, where parent completes the questionnaire and the parent identifies with a lot of the symptoms.

   9. APAlex Partridge24:28

      Yes. Yes. [laughs]

   10. SPSpeaker24:29

       And the chi- child herself said, "My mum has undiagnosed ADHD" when, when I asked about the family history. So-Mum herself was going through a difficult time. So Mum was in her 50s, and she was experiencing a rec- experiencing a recurrence of problems that she used to have in her 20s. Um, again, inattention-based, but more recently she was also having sort of short-term memory problems as well. And when we unpick things for Mum, it wasn't just a case of diagnosing ADHD, it was also recognizing that she was going through the menopause and the impact that ADHD and the menopause can have on each other in terms of symptoms. So with Mum, what she actually benefited from, I mean, she had a choice of what to do, but, uh, she'd lived life up until that point without ADHD medication, so she decided to try hormone replacement therapy, and it worked wonders for her. But the insight into her diagnosis also helped her too. Usually, that's where the story ends. But in this case, during Mum's assessment process, so my original patient's grandma com- helped Mum with the diagnostic assessment, and Grandma identified with a lot of the symptoms, not just of inattention, but also of hyperactivity as well. A lot of people in a later stage of life don't necessarily pursue an ADHD assessment, even if they know that information. But interestingly, Grandma was actually already under mental health services. She had a diagnosis of generalized anxiety disorder, and she was seeking treatment. She was trying medication after medication. Nothing was working for her, and she also had a small stroke a couple of years ago and was riddled with health anxiety since then. So we went through the assessment process with Grandma. We had to get lots of background information in order to confirm the diagnosis. But once I made a diagnosis of ADHD in her case, actually, we did talk about starting medication and, um, we started her on ADHD medication, but we also thought about the fact that her health anxiety was very understandable in the context of what she was going through. We actually found out that she almost died when she was a small child, and that really had an impact on her when she was going into her later life, and it brought back those memories and thoughts about death again. So with a combination of ADHD medication and also anxiety-focused therapy, she did really well, and so, I mean, this is just an example of how even within one family, you can approach ADHD in completely different ways, and that's actually how to deliver individually tailored support for someone.

   11. APAlex Partridge27:21

       What a story. What a story. What a, what a fantastic argument as well for some of the naysayers who might say that it's not genetic. [laughs]

   12. SPSpeaker27:28

       Yes. [laughs] Absolutely.

   13. APAlex Partridge27:29

       Do you mind me asking how old the grandmother was?

   14. SPSpeaker27:32

       Yeah. So the grandmother was in her, uh, late 70s.

   15. APAlex Partridge27:36

       Do you think there is... I wanna get to the age in a bit,

6. 27:40 – 33:42

   The post diagnosis grieving process

   1. APAlex Partridge27:40

      but just rewinding a tad. Do you think there is a general grieving process that someone goes through when they get an ADHD diagnosis?

   2. SPSpeaker27:47

      Oh, yes. So I have met people who have accessed so much content that's out there for ADHD. I've had conversations with people at the assessment who can tell me so much of the information that you put out through this podcast because they identify with so much of it. They identify with having ADHD. But when they hear the words from my mouth confirming that they have the diagnosis, usually the first reaction is still shock. Because despite all of the times that they thought that they must have ADHD, there was also always that little voice, the RSD, that was saying, "It, you might not. Yeah, it might not be you. It might, you know, it might be everyone else, but just not you." So there is a big shock when people can s- can get the diagnosis. But then what happens is, when you let that ride out, there's another emotion that comes in, and it's relief. Because once you start realizing that actually all along, that narrative that you held, that you were flawed, that there was something fundamentally wrong with you, wasn't actually as true as you thought it to be because there is an explanation. You were reacting in a predictable way based on the way that your brain was hardwired. You can start to understand yourself in the past, but it also gives you a clarity to be able to understand yourself in the present and to look to the future. So there is a grieving process, but fundamentally, at the end of it, when it works, you come out with more clarity than you had before.

   3. APAlex Partridge29:45

      So interesting. And just circling back to the age, you said she was in her late 70s.

   4. SPSpeaker29:50

      That's right.

   5. APAlex Partridge29:51

      Do you think the older someone is when they get that ADHD diagnosis, is, is the grieving, is that a, a bigger process, the older you are?

   6. SPSpeaker30:00

      So the older you are, the more likely you are to have lived life by writing your own narrative and your own autobiography. So I guess let's start off with, we are all, all the time writing our own autobiography in our heads, and when you're much older, uh, you've already written many of the chapters. So when you get this diagnosis, often one of the first questions you ask yourself is, "How am I going to fit this into my book? How am I going to make sense of everything that I've written before, all the conversations that I've had with people in the past about myself? How is it all going to fit together?"And with that comes another question, which is, would this book have looked different if I was diagnosed earlier? And that contributes certainly to the grieving process as well. Um, what I would say is that I always ask people this, and it doesn't matter what age you are, but I always ask people to think of three priorities that they have that they would like to improve as a result of having the diagnosis, because it helps people to narrow it down. I don't think it's helpful to have the ADHD diagnosis and then feel like you've got nowhere to go and reflect back and think, "I wish my life was better." You need to have a clear direction of what you want out of this, and that's where we can help. So that often usually helps people to get through.

   7. APAlex Partridge31:37

      Mm-hmm. I suppose it's the ultimate twist in the tale, isn't it, if you get a diagnosis in your late 70s-

   8. SPSpeaker31:43

      Yeah

   9. APAlex Partridge31:43

      ... that perhaps nobody saw coming in, in their story. If you're in your late 70s, is, is there a chance that that particular woman, that particular grandmother, was masking her entire life without knowing about it?

   10. SPSpeaker31:57

       Absolutely possible for that to happen, and if we think about what that actually looks like, so first of all, ADHD symptoms, if you don't have another explanation for them, become embedded into what you think is your personality. So when you think about the fact that I'm not able to, you know, spend time with other people without having energy for myself, if you don't have ADHD as an explanation, what might you label that as? Being an introvert. I need that downtime for myself before spending time with other people, is what you think you need. What is actually happening is you're rehearsing conversations before you meet them. You're trying to remember all those things that they told you last time so that you don't come across as being inconsiderate when you see them. So many people with old age, uh, are masking, and they have no idea because they think it's their personality. But then there's a second bit, and I think this is almost sort of the ultimate, um, mask, is aging. So you go through many stages in life, and you try and find different ways to rationalize your symptoms. But then, all of a sudden, as you get to a certain age, you can actually justify what, y- your executive dysfunction problems by talking about, uh, the fact that you're getting older, and society accepts that as well. So I meet a lot of old people who, what they tell me is that they're going through aging, and they tell me that this is all something that's new. But when you actually hear the story, the problems have been there all along. It's just got a new name for it now.

7. 33:42 – 42:37

   Tiimo advert

   1. APAlex Partridge33:42

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   2. SPSpeaker35:06

      If you're seeing a psychiatrist at that age, it's probably because you've got to a stage where you're experiencing some level of distress about something, and I'm gonna give you an example here just to, just to help with painting this picture. So I had a gentleman in his early 80s who was due to see me for an assessment, and, uh, he actually wrote into the clinic to ask if the appointment could be moved forward, um, and the reason for that is that he said that, "I'm not sure if I have time to... You know, I'm going to be alive and around for the assessment." And he'd just been given a diagnosis of a life-limiting cancer, and he'd always considered the possibility of neurodivergence. But once he had the cancer diagnosis, he was worried that he might not ever find out whether this could explain things for him. And actually, what's, what's interesting as, as this goes on is that he'd actually been doing really successfully, but there was one bit of his life that he didn't understand, and this is what happens in later life. You start to reflect, and you start to want to understand that every bit of your life. So we... I saw him earlier, and we, we did his assessment, and he came with his daughter, who gave us lots of useful information. But what transpired was that this was a man who struggled through much of his childhood with inattentive symptoms and also hyperactivity symptoms, called a naughty boy, um-Punishments looked a bit different back then, uh, to what they are now, so he was punished a lot at school. He then went into a corporate role and really struggled with, um, managing the administrative parts of that role. There was a lot of masking going on in his job that he didn't realize, and he then got to a stage where he couldn't cope with the demands of family life and his role. So he was married, he had a daughter, and he came back every day with n- no energy for the, for the rest of the day. Eventually, he started to use alcohol as a way to cope, and at one point when his daughter was aged eight, his wife cited his lack of interest in the relationship, his lack of interest in parenting, and his alcohol use as the reasons why she was separating from him. That was the first chapter in his life. In the second chapter of his life, he started to turn things around. He became sober, he moved out of the corporate world, and he became a decorator. He ran his own business. He did something he loved, and he had a team, and he continued, uh, with that career for decades and decades, and he only retired in his late 70s. Why did this man come and see me? Because the narrative he told himself was that, "I went through a difficult time, I made mistakes, and I turned things around by starting my own business and getting more freedom and developing life in a different way." That's what he told himself, but it didn't explain everything for him. What he struggled with was the fact that he was now isolated, couldn't understand why things got so bad, and he'd lost-- he'd become estranged from a lot of his friends and family. When we unpicked it and he realized how much of his first part of his life he had masked and how he had built his second half of his life around his ADHD symptoms inadvertently, it all started to make sense for him. But then what came was, I guess, what do you do next in that scenario? And for him, what was really important is, first of all, he needed to forgive himself. So he felt really guilty about the fact that his daughter had, um, parents who'd separated when she was younger because he'd been through the same thing, and he'd repeated the cycle for his daughter. He needed to forgive himself about that. The next thing is that he needed to make contact with the people, the friends and family that were still living, that he'd lost contact with in order to explain to them and apologize to them for how he had been. And what his daughter said to us, uh, after all of this is, before his passing, this was one of the most impactful things that he did in his life before he died. So yes, there are some people who actually are happy to go through life where they can, they can, uh, mask and, you know, continue into old age, but there can be that niggling feeling that I'm not content with life, and that can cause people to come and pursue an assessment at such a late stage like this.

   3. APAlex Partridge40:33

      Such a powerful story. Yath, thank you so much for sharing that. So he, he struggled in his early years. He, he made changes. He took a path that was better suited to him. If you suspect, like he did, that you have some kind of neurodivergence in your life, at that age to get that confirmation, had he already done some processing and accepted it, and therefore, at that age, is it more a case of it being some kind of closure?

   4. SPSpeaker41:03

      It's difficult to come to that understanding yourself, I think, when you have multiple competing factors that are there as well. So during the time when he was abusing alcohol, he was also experiencing depression. And I think this is the particularly, you know, big challenge with, with ADHD and the comorbidity, is you start to question, "Was it that I was depressed, and is that why everything was happening at the time, or was it the ADHD?" And actually, um, on its own, on your own narrative, sometimes it is difficult for you to be able to make that distinction. So one of the things that actually helped is, yes, he did identify with neurodivergence from things that he'd read, but he couldn't on his own join up all the dots because of all the different things that were going on in his life. The assessment process itself allowed us to bring together different people that knew him at different stage of his-- stages of his life and collate and combine all that information in order to build this narrative about him. Once we'd done that, yes, absolutely, it started to make sense to him even before I'd confirmed the diagnosis. But sometimes you do need to go through that process of getting all that information, a bit of detective work, to help people with this.

   5. APAlex Partridge42:28

      Yath, whenever I meet someone who's dedicated so much of their career towards a particular topic, in this case, neurodiversity, I always wonder where their passion comes from. So

8. 42:37 – 46:21

   Yath’s ADHD mission

   1. APAlex Partridge42:37

      what is your mission?

   2. SPSpeaker42:39

      Right. So, um, I'm gonna go a bit deep with this, Alex, if that's okay. I grew up with a parent who had a severe-- or has a severe mental illness and has had so for all of my life.And that person, my mother, is also who made me who I am today. So from seeing her, what I learnt was that it's possible to both suffer and thrive at the same time. But to be able to lean into your thrive state, you need to be able to be seen for you, the whole you, beyond any diagnoses, beyond any, any labels, beyond all of that. And this links into, I guess, how I, um, entered the ADHD space really, because when I was working within mental health and seeing people with the full range of mental health conditions, it was only after I started to work in specialist ADHD services that I realized that there was a complete dimension and foundation that we were missing with some of the people that were struggling to respond to treatments. I realized that we were trying to create all these different software updates when we didn't even know what operating system we were dealing with. And this links in to my mission now. So first of all, I want to reduce the anxiety that people can have around seeking an ADHD assessment. There are going to be people listening to this podcast today who are terrified about having an assessment, and the reason that they're terrified is because they're worried that what happens if I get a diagnosis, but it doesn't actually help explain me, it doesn't join the dots up for me, or I get a diagnosis and I get pigeonholed into starting medication that may not work for me. What do I do then? And for all those people, I want you to know that there are clinicians who, who will see you for you, who will see you beyond all of that, see both your strengths and your challenges, and can help you through that. And tied in with this is my second mission, which is to challenge the notion that there is a one size fits all approach to treating ADHD. There are going to be people who have, have questions like, "Am I too old to have medication for ADHD? If I treat my ADHD, will the anxiety go away?" And I want those people to be, one, better informed at having conversations about what's going to work for them, but also to appreciate how individual those decisions are. In the era of information, it's really easy to be both heard and feel so lonely and isolated at the same time. It's really easy to hear s- a story and think, "That's me," and question whether any of the advice linked to it should be applied in your own life, and I want those people to know that there is support and there are ways to, to help you.

   3. APAlex Partridge46:15

      Yeah. Just circling back to the grandmother you mentioned earlier, uh, 'cause I know eighty-five percent of the people who listen and watch this podcast

9. 46:21 – 1:00:54

   Why women were missed

   1. APAlex Partridge46:21

      are women. Do you think generally women get diagnosed later in life, and if so, why?

   2. SPSpeaker46:26

      There is really good data on this. So historically, it has always been the case that boys are more likely to get diagnosed than girls during childhood, and it's only at a later stage in life that, wh- where the gender gap narrows. So, uh, if we look back 10 years ago, so 10 years ago, five times as many boys were diagnosed with ADHD compared to girls, and that gap would narrow over time. Now, what's happened is, and the most recent data, so this is publicly available data, um, for the 2024 to 2025 year, is that at every age group, we're getting better at being able to diagnose ADHD in girls and women, which is great, but the gender gap still exists with age. So for, uh, the zero to 18 age group, for every two boys, there is one girl that gets diagnosed with ADHD. That gap sort of narrows, you know, as you get older, um, up until around 34 to 44, where it's around one and a half boys to one girl. 45 plus, it's almost even. And really interestingly, at 65 plus, if you look at the total number of ADHD diagnoses, more women are being diagnosed than men of that age group in that last year. So why is this the case? So overall, I'd say it's probably because we have actually... I mean, I've gotta be direct about this. We've let women down in both the diagnostic stage of ADHD, but also in the support that we offer them. So let's look at the diagnostic stage here. So at the diagnostic stage, we're looking in childhood for very clear symptoms of an impairment, uh, in school and the home environment or other environments with hyperactivity or inattention. Who's most likely to, to get picked up at that stage? It's more likely to be hyperactive boys. And why is that the case? Well, first of all, let's look at inattention in girls. So girls are more likely to develop, uh, emotional maturity and make efforts to conform to social norms during their childhood. So that invites itself for masking to start taking place. So here I'm talking about the girls who may struggle with being able to complete their...Complete their work, um, with making mistakes all the time, but then going through it three or four times before they ever submit it, so no one ever finds them out. The girls who sit through lessons and have no idea about what the teacher has actually gone through in terms of material, but then over-prepare for subsequent lessons by studying at home. In these situations, it's really difficult for these girls to get a diagnosis of ADHD because they've masked so well. But then if we progress things, there's an opportunity not only for us to miss the diagnosis, but there's an opportunity to misdiagnose ADHD. Now, there is a significant overlap between ADHD symptoms, particularly emotional dysregulation and RSD, with other conditions which include borderline personality disorder and bipolar disorder. There's sort of a spectrum between the three where there, there is an overlap with all three. And the problem that women have is that, yes, they might get labeled with another diagnosis, um, when it could be ADHD, but when the treatments don't work, what do we do then? We don't necessarily circumvent back to thinking about ADHD. They might pick up another label, treatment resistance, and at this stage, they trial more and more treatments, and it feeds back to the original thought, which is, "There must be something seriously wrong with me." So we have this, this problem come up, and then the third step in this is that they go through-- they get the diagnosis missed. They can get misdiagnosed. And after all of, all of that as well, the support that we offer them isn't personalized to take into account the complexity of ADHD in their circumstances. So what I'm talking about here is... I mean, I think this is probably a good time to talk about menopause. So in the perimenopausal state, you obviously have fluctuations in your estrogen levels, and then you have a depletion of estrogen in the menopausal state. Now, it's very easy to oversimplify the experiences of a woman to a single diagnosis. So we recognize the influence of trauma. We recognize the influence of hormones, of menopause, but if we don't recognize that all of these things can interact with each other, then again, we can pigeonhole women into a, a single diagnosis and not appreciate the complexity. And for all these reasons, I think it's very easy to miss ADHD until a much later stage in their life.

   3. APAlex Partridge52:06

      Gosh, there's a lot there, Yath. So a, a, a young girl with ADHD has to put so much more effort into masking-

   4. SPSpeaker52:12

      Yeah

   5. APAlex Partridge52:13

      ... to, to trying to fit in, to feel less misunderstood. Then perhaps she gets misdiagnosed. Then perhaps she gets told wrong information about how the hormones and the menopause are gonna impact her. By the time they get to you, do you see women that genuinely feel like they're losing their mind, like they've gone mad?

   6. SPSpeaker52:31

      So if we think about the situation that you're, you're in by the time that they come to me. So first of all, if, if we look at treatment resistance, so women may have been given a diagnosis that they feel fully doesn't explain their symptoms. They may have tried multiple medications. They have-- may have tried multiple therapies, or they may have been declined for certain types of psychological therapies because they don't fit into the box that that therapy was designed for. And so they can often feel like there is no clear solution or way forward to help them to understand their experiences. That in itself, if we think about the fact that the underlying issue here might be ADHD, reinforces this feeling that there is something fundamentally wrong with you, and often they can feel, feel like they're going mad from that perspective. But there's a second element as well, which is that as you go through life and as things become more complicated, again, the pressures and responsibilities on women are-- can be different for men, as we, we all know. Um, but rather than recognizing that complexity and recognizing those burdens and responsibilities for them, there seems to be more of a focus on the fact that they're struggling and not able to cope and not able to manage in those situations. So then what happens? Again, a woman might understand herself as being-- her experiences as being the product of everything going on around her, but society might tell her that to internalize it, to think that there is something wrong, we need to treat it. Um, and it might be depression. It might be anxiety. It might be your failure to be able to cope with those circumstances. So there, there's another sort of stressor there. But then if we go back to menopause again, so what menopause can do in the context of ADHD is, yes, it can exacerbate some of those ADHD symptoms, but you m- also might find particular cognitive symptoms come out even more. So short-term memory deficits, um, difficulties with processing multiple inputs. These might have been things that you hadn't seen before, but when you start to experience new cognitive difficulties, again, it can lead to women feeling like-I'm going mad. There's something... You know, something crazy is happening in my brain, and I can't explain it. And if you don't have the language, the understanding, and the ability to comprehend the complexity of that, then it's really difficult for you to be able to connect the dots for, for that woman. And look, I hold myself up and my hands up and say that it's a learning journey for me as well, and h- listening to... It's through listening to other women explain these things that I even understand, um, where I get my understanding from. But yeah, so there's a, there's a lot of more work that needs to be done here.

   7. APAlex Partridge55:54

      I think you hit the nail on the head when you said women have been let down generally in, in the medical community. In many, in many areas, particularly in the conversation around neurodiversity and ADHD. Do you think zooming out and looking at it from a broad lens, do you think women deserve an apology from the medical community in, around neu- the conversation of neurodiversity?

   8. SPSpeaker56:15

      I think that an apology itself probably does... Uh, I'm th- I'm thinking back actually, you know, as you ask me this question, to, um, when the healthcare service received a clap during the, uh, COVID pandemic, and I'm thinking that it might be an insult, uh, to women actually to, to simply receive an apology, uh, about this. I think what they actually want to see is action. They actually want to see services potentially being redesigned to recognize the complexity, to be able to handle a formulation where there are multiple things going on without being streamlined into one box, to be able to access therapy where you aren't told that you need to change yourself in order to be, to be able to access it. So I think once women see that, then you won't need to give an apology.

   9. APAlex Partridge57:17

      As I said earlier, Yath, 85% of people who, who watch and listen to this podcast are women, many of whom are, are, uh, fall within this category that we're talking about, like they feel very let down. What would you hope a audience member might take away from this episode that is a new and refreshing perspective on ADHD?

   10. SPSpeaker57:39

       So I want the listeners of this podcast to know that the assessment and treatment process for ADHD is, and should always be, a unique and individual experience for you. I want you to know that the process and path of understanding ADHD is there to help you with joining up the dots of your life, and you need to be seen for both your strengths and your challenges. I also want you to know that there is no algorithm that's going to tell us what we do next. It's going to be based on your experiences and based around how to bring out the, the strengths in you and help you to get through those next few years as well. I want the listeners of this podcast to know that the assessment and treatment process of ADHD is, and should always be, a unique and individual one. And most importantly, and I guess, you know, I'll go a bit deep here, um, but this sort of ties into my own personal mission. So I grew up with a parent who had a severe, uh, mental illness and has a severe mental illness, um, and it's my mother, and she's had it through all of my life. But she's also the person who made me who I am today. What I learned from seeing her life is that it's possible to both suffer and thrive at the same time. But to be able to lean into your thrive state, you need to be able to seen, to be seen as you, the whole you, with all your quirks, your strengths, and your challenges. I want the listeners of this podcast to be able to walk away from this knowing that there are clinicians who can help you with being seen for the whole you, so that you can get an individualized plan that best fits your life and helps you to move forward.

   11. APAlex Partridge59:58

       Incredible advice for the listeners. Thank you so much, Yath. And speaking of the listeners, we do have three very interesting questions from the listeners-

   12. SPSpeaker1:00:07

       Oh, yes

   13. APAlex Partridge1:00:07

       ... uh, for you, which I'm going to ask you, and they're inside the washing machine of woes. And it's called the washing machine of woes because they're woes from the audience and they're in the washing machine because for me it represents memory loss because I always forget my clothes in the machine. So I do ask all my guests.

   14. SPSpeaker1:00:22

       Yes.

   15. APAlex Partridge1:00:22

       Do you relate to that memory loss? Do you leave your clothes in the machine after the cycle's finished?

   16. SPSpeaker1:00:27

       Oh, Alex, so first of all, I have to have a timer on my phone, and if I forget to put the timer, then those clothes could stay there for days.

   17. APAlex Partridge1:00:35

       [laughs]

   18. SPSpeaker1:00:36

       Yes. So yeah. I, [laughs] I totally relate to that.

   19. APAlex Partridge1:00:38

       That's good. Well, you've made me feel like I'm not the only one now, which is very, very good. I do rely on the Tiimo app-

   20. SPSpeaker1:00:43

       [laughs]

   21. APAlex Partridge1:00:43

       ... uh, which does help me actually, but, uh, so the, the smell of mold, the smell of damp is getting less frequent, but we're still there a little bit. [laughs] The first question, Yath, somebody has asked,

10. 1:00:54 – 1:02:31

    How ADHD causes distress

    1. APAlex Partridge1:00:54

       does ADHD cause a lot of distress in the people that you treat, and why is this?

    2. SPSpeaker1:01:00

       So with ADHD, you have the double whammy of the fact that life can be more difficult for you from a young age because of the fact that you are dealing with ADHD symptoms. But at the same time, you have all the criticisms that you have throughout your life because of the fact that you have ADHD symptoms. And I'd say there's a third seg- segment to this now as well, which is that you're constantly trying toaddress this and trying to learn strategies, while society might be challenging the diagnosis and challenging you. And so for all those reasons, it can be very distressing.

    3. APAlex Partridge1:01:40

       Do you see an increase in distress amongst your female patients over your male patients?

    4. SPSpeaker1:01:48

       So with female patients, what I see is the combination and the complication of how all of the things that I just mentioned can affect emotional dysregulation, how they can in- interact with the menstrual cycles and menopause, as we talked about as well. But also, um, the fact that it's difficult for some of our female patients to get the right type of individualized support that they need to be able to handle all of that complexity, and all of that absolutely causes more distress for them. Yeah.

    5. APAlex Partridge1:02:27

       Very useful. Thank you very much, Yath. And secondly, on to the next question.

11. 1:02:31 – 1:05:05

    The ADHD assessment explained

    1. APAlex Partridge1:02:31

       What exactly do you try to figure out during an ADHD assessment, and what is the threshold to be diagnosed?

    2. SPSpeaker1:02:39

       Okay. So ultimately, what we're trying to do with an ADHD assessment is to identify a pattern of symptoms that have existed from your childhood, persisted into your adult life, which are to do with how you regulate yourself. It could to do... could be to do with inattention, to do with your activity levels, or I guess in the case of autism as well, um, to do with structure and routine and how that influences regulation. What we're looking at is to see how that affects you across multiple settings, and we're looking for impairment. And this is where there is a s- subjective element here, because on a superficial level, impairment can be quite obvious for some people, but not for others. If you're very good at masking, you can go through a lot of domains without actually showing an impairment, and a typical one would be, "Oh, I was academically really good at school." Yes, it's possible to do really well at school academically, but be masking at the same time. So we look for that as well. And I think that this is where the subjectivity element probably gets questioned a little bit, um, when we... I get asked, uh, you know, probably more frequently than, than I expect by people about, "Isn't it just that we all have a bit of ADHD in us and, uh, you know, aren't we all a bit on the spectrum?" Well, first of all, if you go through the process of an ADHD assessment, um, you find out that actually not all of us are all on the spectrum. Um, some of these challenges completely don't make sense to someone who's neurotypical. Yes, you might identify with an individual symptom, but not with the whole constellation of issues. But the second thing is about predictability. So if we try to conceptualize ADHD for most of the population, it doesn't help us to predict or understand them. It doesn't at all, and that's why it's really important to go through the assessment process and to identify these things.

    3. APAlex Partridge1:04:53

       You mentioned something earlier. You said that sometimes ADHD can look similar or perhaps sometimes get misdiagnosed as BPD, Borderline Personality Disorder. So I suppose when, when someone comes into your clinic,

12. 1:05:05 – 1:08:34

    ADHD vs BPD

    1. APAlex Partridge1:05:05

       how can you s- tell the difference between ADHD and BPD?

    2. SPSpeaker1:05:11

       The overlap is very significant, and I, I've gotta say that this is probably, um, the conversation of the debate between these two diagnoses as well. Um, there are many psychiatrists who would argue that we should be screening for ADHD and anyone diagnosed with borderline personality disorder. Um, often what we can look at is with ADHD, the microtraumas that we experienced in our childhood can contribute to emotional dysregulation and to RSD, um, and they can sort of feed into that. With borderline personality disorder, you might find that there are specific individual traumas that can be a very significant driving force behind a lot of the symptoms within borderline personality disorder. So, um, some of them may experience symptoms like flashbacks, nightmares, re-experiencing of a select few childhood, childhood traumas, and what that means is that ultimately some people with BPD will require a trauma-focused approach in order to help them with dealing with those individual traumas. But this is where it gets particularly complicated, because there can be people who have ADHD but are also exposed to all of these individual traumas that are so painful that they have a trauma response to them as well, and that complexity might mean that you're handling both ADHD and borderline personality disorder, and you need two approaches for both. So yeah, that's it in a nutshell.

    3. APAlex Partridge1:07:00

       So interesting. This, this section of the show is slowly becoming the most, uh, unpredictable part of the show. I never know what I'm gonna pull out of the washing machine. [laughs]

    4. SPSpeaker1:07:08

       [laughs]

    5. APAlex Partridge1:07:08

       But this is such nice bite-sized bits of information.

    6. SPSpeaker1:07:11

       Yeah.

    7. APAlex Partridge1:07:11

       Uh, so thanks so much, Yath. And finally, the last question from the washing machine, which ties in nicely to what we've been speaking about.Someone has asked, "I'm 73. Do you think it's too late for me to get a diagnosis of ADHD?"

    8. SPSpeaker1:07:25

       It's absolutely not too late for you to have a diagnosis, and let me talk to you about some practical things to help you with that pathway. So first of all, if you are having an ADHD diagnosis, it's helpful for us to get as much information as possible about your background. So I know that might not be easy, but if there are people that knew you across different life stages, it's useful that you do involve them in the process because they can help with building up a picture about you. But don't worry if you don't have that information. Uh, the next thing is, if you are going through a particularly difficult time at the moment, let's say fatigue is really getting to you, you're exhausted, then it can be helpful to make sure that some of those basic things with your health are checked out. Make sure that you've, you've seen your GP recently, you had blood tests, because it's useful to rule out some reversible things that are very quick to change, um, before you go through the ADHD diagnostic process. But I hope from listening to me, you know that you definitely can and will be seen for this at this age.

    9. APAlex Partridge1:08:29

       Dr Yath, thank you so much on behalf of all of the people that have written in questions for this week's

13. 1:08:34 – 1:09:28

    A letter to my younger self

    1. APAlex Partridge1:08:34

       episode. I just want to, before we finish, deliver to you a letter that was written by the previous guest where they wrote a letter to their younger self. There we go.

    2. SPSpeaker1:08:42

       Cool. All right. Better handwriting than mine.

    3. APAlex Partridge1:08:44

       [laughs]

    4. SPSpeaker1:08:45

       So, to my younger self, you don't have to be quiet and well-behaved all the time. You are allowed to share different ideas and be silly. If you start different clubs and interests, you get excited, and you give up. You are not irresponsible and immature. Your brain is just working in that way. Feel good about yourself and keep going.

    5. APAlex Partridge1:09:14

       Incredible.

    6. SPSpeaker1:09:14

       Beautiful.

    7. APAlex Partridge1:09:14

       What a lovely tone to finish on, too. Dr Yath, on behalf of everyone listening, trying to grapple and understand their brains and the many complexities that come with it, thank you so much.

    8. SPSpeaker1:09:25

       Thank you for having me. [outro music]

Episode duration: 1:09:29