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The Truth About Women's ADHD (Explained by a psychiatrist)

Dr Shyamal Mashru is an award winning psychiatrist and ADHD expert having assessed and treated thousands of people with ADHD Working in both the public and private sector, he has a deep understanding of ADHD and the consequences it can have on your mental health. 00:00 Trailer 01:28 The most common ADHD trait 05:34 Dr Shy’s mission 11:12 ADHD and sleep 15:20 How ADHD affects self esteem 22:44 Tiimo advert 23:51 Rejection Sensitive Dysphoria 30:44 Why ADHD people feel shame 35:14 Top female ADHD challenges (how to overcome them) 36:47 Common co-morbid conditions 46:42 The link between ADHD and dementia 54:25 Dr Shy’s ADHD item 57:54 Audience questions (the washing machine of woes) 01:01:13 A letter to my younger self The ADHD Health Clinic is an official CQC registered clinic. Our staff are all highly experienced Consultant Psychiatrists with years of medical leadership experience in the NHS and private sector.  They have also published books in this field. For Adults (over 18s) Book an online Combined Adult ADHD and Autism Assessment 👉 https://adhdhealthclinic.co.uk/autism/book-a-combined-autism-adhd-assessment/ 💰 Saving of £345 compared to booking separate appointments for Autism and ADHD Book an online Adult ADHD Assessment 👉 https://adhdhealthclinic.co.uk/adhd-treatment-options/book-an-adhd-assessment/ Book an online Adult Autism assessment 👉 https://adhdhealthclinic.co.uk/autism/book-an-autism-assessment/ For Children (6-17 years old) Book an online Combined Child ADHD and Autism Assessment 👉 https://adhdhealthclinic.co.uk/adhd-treatment-options/book-an-online-combined-child-autism-adhd-assessment/ 💰 Saving of £450 compared to booking separate appointments for Autism and ADHD Book an online Child ADHD Assessment 👉 https://adhdhealthclinic.co.uk/adhd-treatment-options/book-an-online-child-adhd-assessment/ Book an online Child Autism Assessment 👉 https://adhdhealthclinic.co.uk/adhd-treatment-options/book-an-online-child-adhd-assessment/ Meet Our Experienced Clinicians 👉 https://adhdhealthclinic.co.uk/clinicians/ Get 30% off an annual Tiimo subscription 👉 https://www.tiimoapp.com/offers/adhdchatter Buy Alex's book entitled 'Now It All Makes Sense' 👉 https://www.amazon.co.uk/Now-All-Makes-Sense-Diagnosis/dp/1399817817 Producer: Timon Woodward  Recorded by: Hamlin Studios Trailer Editor: Ryan Faber DISCLAIMER: The content in the podcast and on this webpage is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your doctor or qualified healthcare provider. Never disregard professional medical advice or delay in seeking it because of something you have heard on the podcast or on my website.

Dr. Shyamal MashruguestAlex Partridgehost
Nov 11, 20251h 2mWatch on YouTube ↗

EVERY SPOKEN WORD

  1. 0:00 – 1:28

    Trailer

    1. SM

      70 to 80% of people with ADHD have cycles of anxiety and depression. The classic story that I hear is, "I've been feeling like this for as long as I can remember. I've been treated with antidepressants." When you hear this as a healthcare professional, you need to have some understanding of the nuances, otherwise you're gonna diagnose that person with generalized anxiety disorder. Dr Shyamal Mashru is an award-winning psychiatrist and ADHD expert. Working in both the public and private sector- He has a deep understanding of ADHD- And the consequences it has on your mental health People with ADHD release melatonin. So melatonin is a chemical that tells your brain, "It's time to switch off now, and go to sleep." They're releasing melatonin about three hours later than non-ADHD people, so their sleep cycles are shifted. Coupled with patients essentially procrastinating their sleep and doom scrolling social media until it's 2:00, 3:00 in the morning, they're absolutely knackered. They're falling asleep with their phone by the side of the pillow. Naturally, you're gonna struggle to wake up.

    2. AP

      What are the long-term consequences to someone's self-esteem after they repeat this pattern time and time again?

    3. SM

      I think the impact on self-esteem comes from a core...

    4. AP

      Dr Shyamal, thank you so much for joining us.

    5. SM

      Thanks for having me.

    6. AP

      I know how hard it is for many people to get in front of a good psychiatrist, so on behalf of all of the listeners and the viewers, um, a huge thank you for being here.

    7. SM

      Yeah, no, I'm really looking forward to this. Thanks, Alex.

    8. AP

      You've treated a ton of people for ADHD, and I wondered, i-

  2. 1:28 – 5:34

    The most common ADHD trait

    1. AP

      is there a common trait that you see binds them all together?

    2. SM

      Yes. Um, one thing that I hear about from all different spectrums of people with neurodivergence is feeling misunderstood, not quite fitting in their whole lives. It's often quite a revelation for people once they are diagnosed, actually, and then they reflect back on their life. So they felt misunderstood by teachers, by their parents, by partners, people at work. Struggling to fit in socially, academically, in work and education, et cetera. I think that's one common trait that I see amongst all different types of people with neurodiversity, whether they're very successful or they're really struggling. That's something I see in everyone.

    3. AP

      Would you say it's an innate human desire to be understood?

    4. SM

      Definitely. I think so, to, to some extent. So socially... It depends on your personality type. Socially, if you struggle to fit in, you're gonna go one of two directions. Either you're gonna move inwards and avoid social contact, but those people will often say that they felt actually incredibly lonely. That wasn't something that they loved doing. Or number two, you're gonna do everything possible to fit in. So how do you then fit in? You start people pleasing. You might come across overly enthusiastic. You know, people often say with ADHD, or when I was young, "I thought people thought I was a bit intense," you know? Kind of in their face. But what's going on there? Why are you intense and in their face? Because you're trying to best... You know, try your best to fit in. You're like, "Oh, yeah, no, no, me too. That happened to me as well. You know, I agree with you," blah, blah, blah. So you're naturally trying to do that. You then move into your work environment. You have... You know, say you're new to a job. You have work parties, work, work gatherings. Then you get all wound up about, right... I've had patients say to me, "Dr Shy, I've actually had to rehearse conversations before going to an event."

    5. AP

      Mm.

    6. SM

      And they thought everyone does that, and they find it, you know, a bit jaw-dropping when I say, "Well, not, not everyone does that, actually," you know? Or when you're going on a second date, 'cause the first date went well, right? So you don't wanna mess up that second date. So then you're in the conversation with this person opposite you, and all you're thinking about is, "Pay attention. Pay attention to what they're saying. Don't look weird, don't... You know, make sure you look like you're paying attention. Do the nodding, and all those things," right?

    7. AP

      [laughs] I'm laughing because I, I can see myself so much in what you're saying.

    8. SM

      Yeah, yeah. So, and then actually, in all of that, signals to yourself of pay attention, you're actually not paying attention, right? And then you're like, "Oh, God, they're gonna find me out." So then what are you gonna do? You're now getting anxious. "I'll have a drink. I'll have a few more drinks. Now I've told them everything about myself. I've revealed too much of myself." You wake up the next day not just with a hangover, but with that dreaded feeling of, "Oh my God, what did I say?" Right? So that we all have this natural desire to wanna fit in, whether you have ADHD, you don't have ADHD. I just think that is a human desire. But w- how we respond to that is, can be different in different people.

    9. AP

      So relatable. Um, masking is exhausting, right?

    10. SM

      Mm.

    11. AP

      You... It took me so long to realize m- eye contact was masking. You can either have my attention or my perfect eye contact, but you can't have both. And I... Even looking at you now, and generally in social situations, if I'm making eye contact with you, what you're saying [laughs] probably isn't gonna go in. And when it's my turn to speak, I'm gonna look silly because I haven't been paying attention. I, I... When I look at someone like yourself who's put so much of their energy into raising awareness on a particular topic, I always wonder where their motivation comes from.

  3. 5:34 – 11:12

    Dr Shy’s mission

    1. AP

      What is your mission within the world of ADHD?

    2. SM

      So I have two things, two missions, which are kinda linked to each other. There are gonna be loads of people who are doom scrolling and watching this episode at 2:00 or 3:00 in the morning on their phone, right? 'Cause they can't get to sleep. And they're in a desperate situation, right? They're in a desperate situation because they're not managing their relationships very well.They're being performance managed maybe at work, or they're just in a job that they hate and they can't get things done, or they're a student and they're really struggling with education. One of my missions is to raise awareness that this is very treatable. Now, I don't want the neurodivergent community to be up in arms here. I'm not saying... There are lots of strengths with people with neurodiversity, but I see the struggle. Right? You, you come to see me or my colleagues at my clinic because you're struggling. This is highly treatable, not just with medication, with things like coaching and therapy as well. So don't just sit there in despair, right? M- Don't procrastinate by watching only the videos. Watch the videos, it's great, but do something about this. My second point that I wanna make on this is find a suitable healthcare professional. This has become a very commercialized industry in healthcare, right? And find a suitable healthcare professional, for example, a consultant psychiatrist, doesn't have to be, but someone that doesn't just have knowledge about ADHD or ASD, but other mental health conditions as well, because what you don't want is to be misdiagnosed for something else, which happens to so many people, and then get the wrong treatment. So shift from watching the videos, go and get help, 'cause this, you can get help, and find the right person to help you.

    3. AP

      The people that come to you who previously hadn't been lucky enough to find the right person yet, what are some of the biggest struggles they open up to you about?

    4. SM

      Yeah. So the... Okay, so one of the biggest ones is that they were misdiagnosed with other comorbidities, okay? And therefore treated with the wrong thing. The most common being depression and anxiety. If we look at the chemical pathway that's going sort of awry in ADHD, this is the current thinking, this might change in the future, right? Lack of dopamine and lack of noradrenaline, two chemicals in the brain and nervous system. Okay? So ADHD medication typically corrects your dopaminergic and norad- noradrenergic pathways in the brain and nervous system. 70 to 80% of people with untreated ADHD go through their life developing cycles of anxiety and depression, and they get misdiagnosed with things like generalized anxiety disorder or clinical depression. So what do they get given? An antidepressant. Most antidepressants work on a different chemical pathway, serotonin. Those patients will come back essentially saying that they just felt horrible with side effects and they felt emotionally numb. They didn't feel anything at all. And then when they're treated with ADHD meds, because their depression and anxiety was coming from their ADHD, one of the biggest benefits that they find is an improvement in emotional wellbeing. Even more sometimes than attention and concentration. That's almost secondary. That becomes secondary, a benefit to them. Be treated for the right thing. Similarly, I've had the opposite. So someone's gone to see a healthcare professional for an ADHD assessment. They've been diagnosed with ADHD. They've been given stimulant medication. That healthcare professional didn't see that actually this was bipolar disorder. Those mood swings were not coming from ADHD. They were actually different in their nature and quality, which we can talk about, but they were given a stimulant. You give a stimulant to someone who has got undiagnosed and untreated bipolar disorder, you will highly likely make them manic, and I have seen people being admitted to psychiatric hospitals because they develop mania secondary to stimulants. So you need to find a person, a- and a, and a psychiatrist is a good example, who has experience in other conditions as well as ADHD.

    5. AP

      Mm-hmm.

    6. SM

      I think that's really important.

    7. AP

      If we just rewind a bit, because firstly, I was misdiagnosed with an anxiety disorder when I was 16. I remember very well being put, put on antidepressants-

    8. SM

      Mm.

    9. AP

      ... and it quietened my mind in a really horrible way.

    10. SM

      Mm.

    11. AP

      Um, I came off them, and then my mind, which I've always described as having loads of highly caffeinated squirrels up there barreling around, and they've been a great positive to me in some environments. They've turned into creativity and pattern recognition. But in other environments, like a classroom, they've turned into anxiety.

    12. SM

      Yeah.

    13. AP

      The, the patients that come to you, how do they describe ADHD showing up on their day-to-day basis?

    14. SM

      Okay. So let's take the day of a ADHD patient, right? So

  4. 11:12 – 15:20

    ADHD and sleep

    1. SM

      number one, sleep cycle irregularities, right? So there is now research that shows that people with ADHD release melatonin. So melatonin is a chemical that tells your brain, "It's time to switch off now and go to sleep." They're releasing melatonin about three hours later than non-ADHD people. So their sleep cycles are shifted. Coupled with patients essentially procrastinating their sleep, and doom scrolling social media doesn't help, right?

    2. AP

      And ruminating over that thing-

    3. SM

      Yeah

    4. AP

      ... instead of that party, right?

    5. SM

      Yeah, yeah, yeah. Right. Or things like that.

    6. AP

      Mm.

    7. SM

      But especially social media, I have to say. They're just scrolling on their phones until it's 2:00, 3:00 in the morning. They're absolutely knackered. They've fallen asleep with the phone by the side of the pillow, right?So naturally, you're gonna struggle to wake up in the morning. So you've got to wake up for work or take the kids to school, whatever it is, you're gonna struggle to wake up. Then you now want to get ready for work. Time blindness can become a problem. So you either overestimate or underestimate things, how long it takes to do things. So it's not just about running late, it's about not regulating your time, right? I've had patients who come to see me, they've got an afternoon appointment with me. They've come in the morning because they're like, "I can't do anything else for the rest of my day." Right? For fear of being late. They'll be sitting in the cafe opposite for hours, or they may run late, you know, with work, et cetera. The next step is forgetfulness, right? Forgetfulness for your belongings. You go out the house, "I forgot my work lanyard or my laptop."

    8. AP

      Hmm.

    9. SM

      Run back in again. Or you're making your cup of tea, you boil the kettle 10 times before you make the actual cup of tea, right? For some people, that forgetfulness extends into even their own personal hygiene, and it's a cross between forgetfulness and procrastination. So they put off brushing their teeth, and they've forgotten to brush their teeth. For some people, it's even more severe. It's eating or drinking, it's showering, depending on the severity. Then it's your weekly shop, right? So you've either got too much milk or too little milk.

    10. AP

      [laughs] You've been, you've been, uh, spying on my fridge.

    11. SM

      Yeah. So, so items have gone off in your fridge maybe, or you needed to get milk. You went to the shops, you got everything but the milk, or you had enough milk, but you ordered the milk again, things like that, right?

    12. AP

      Going to the supermarket without a shopping list is never a good financial decision for me.

    13. SM

      Yeah. No, but even with the shopping list, patients will still get like distracted and just forget the thing that they needed to get, right? And then spending. Some people, it's really severe. They get into sort of major debt. For a lot of people, it's not that severe, but they lose track of budgeting and their finances, right? That happens as well. And then obviously then the impact on education and employment, um, that plays a big role. So these are all the different sort of factors that we see, uh, that I see.

    14. AP

      Hugely relatable. Um, you can... Your anecdote about having an appointment at 4:00 PM and not being able to do anything-

    15. SM

      Mm-hmm

    16. AP

      ... before that, waiting mode is a s- real place to be trapped in.

    17. SM

      Yeah.

    18. AP

      And getting ready. I think when I reframed five minutes as 300 seconds, that helped because in my mind I say, "I'll be ready in five minutes," and that seems like a lifetime.

    19. SM

      Yeah.

    20. AP

      You change it to 300 seconds, and suddenly you realize you don't have time for a shower, dry your hair, get ready. It frames it in a lot more realistic sense. I mean, there is relatability to these points, but if you do these things time and time again, you're late, you miss an appointment, you're stuck in a coffee shop in waiting mode because you're so anxious about the appointment you've got at 4:00,

  5. 15:20 – 22:44

    How ADHD affects self esteem

    1. AP

      what are the long-term consequences to someone's self-esteem after they repeat this pattern time and time again?

    2. SM

      I think [clears throat] the impact on self-esteem comes from a core belief about yourself, which develops over time, which is, "I am not good enough," or, "I am not enough." Right? "I'm not a good enough parent. I'm not a good enough student. I'm not a good enough partner because my partner is having to do all the household admin and carrying me in this relationship or marriage," for example. "I'm not a good enough employee." That's what batters your self-esteem over time, right? If you feel that you're not good enough, you get to a place in society, your worldview of yourself is, "Well, maybe people are actually just better off without me," in its worst form. That's what batters your self-esteem.

    3. AP

      How severe can that get? Can that lead to depression?

    4. SM

      Well, more, I, I see people with suicidal thoughts, right? Really serious suicidal thoughts. Guilt is a big factor. Where you see this happen a lot is in, in relationships, particularly parents. Actually, more moms, actually, mothers. I see this happen a lot, where they feel guilty that they're not a good enough parent. They themselves might be dealing... You might have an undiagnosed mom who's dealing with an undiagnosed ADHD child, right? So they describe certain things which they get very guilty about. So they get noise sensitivity. So the toddler that's screaming, they just can't bear it. Toddlers are gonna scream. So they scream back. That's not containing for the toddler. So what does the toddler do? Starts crying and screaming more. Afterwards, mom feels terrible. Mom feels, "I'm not a good parent." Right? Guilt is the big one, and, and that's when, when you start having those thoughts, and this is where you really should get help, I think. When you start having those thoughts that, "The world is a better place without me," that's a dangerous area to be in.

    5. AP

      It seems tragically unfair, though, because in a world where there's so many people, it seems that the neurodivergent people are the ones struggling. So in the world where there are so many people, how come the neurotypicals have won?

    6. SM

      This could go to a question around why does neurodivergence even exist? Okay, so let's start with that first.You may have heard of the hunter farmer hypothesis

    7. AP

      Yes

    8. SM

      Right. So maybe for people who haven't heard, who are watching this and never heard of this before, if you're a, if back to early human, uh, ages, you're a hunter, it would have been an evolutionary advantage for you to have what we now call ADHD traits, right? So being constantly on the move, which is what we call hyperactivity symptoms.

    9. AP

      You would have been up all night stoking the fire-

    10. SM

      Yeah

    11. AP

      ... watching for prey.

    12. SM

      Yeah, and, and also be ready to run.

    13. AP

      Mm.

    14. SM

      Right? And constantly scanning the environment for stimuli, which what we now call being distracted by environmental stimuli as a symptom, right? That would have been an ev-evolutionary advantage at that time. So if it's an evolutionary advantage, that's gonna get passed on to your offspring by the laws of evolution, right? So all the hunters would have had a higher proportion of what we call ADHD traits, compared to the farmers who maybe had a more passive lifestyle, more routine. There might have been less ADHD traits over time with the farmers. But we're not living in that society anymore. So there's an evolutionary mismatch now. We are living, perhaps a lot of people are living in a more sedentary lifestyle where those traits are now seen as maladaptive in today's current society and environment. And that's where the neurotypicals might win because the environment is not catered correctly. And I wanna go a step further into this, into looking at the education system, okay? This is not a dig to any teachers or schools out there, but the education system in my view, is still very archaic even today. It's so theory based. It doesn't encourage entrepreneurialism or entrepreneurial spirit, right? You do well in your GCSEs, then you do well in your A levels. You go to university, you do well in your degree. It's all based on books and learning, which is fine, but where's the practicality? That type of learning does not necessarily suit people with ADHD.

    15. AP

      I think school is a trauma factory for people with ADHD.

    16. SM

      Right? So you might have someone who's really bright, their natural IQ might be really high, but in that environment they don't do well, okay? Then you go on to employment, and if you look in certain employment sort of mainstream professionals, what do they look at? Academic merit. What was on your CV, especially graduate jobs. So they, now you're stuffed. If you didn't do well academically, you're now not going into a job environment at, you know, the highest job environment. So what do you feel about that job as a graduate? You're like, "This is rubbish," right? "I can't get anywhere." Now, modern day jobs, what do they involve? Especially at junior level, most jobs, admin work. At junior level, you don't have other people to delegate your admin work to. You are the admin work, right? I mean, AI is gonna probably take over all of that, but that's a different conversation. So you are the admin work. People with ADHD don't necessarily do well with admin work. What else do you have in jobs? You're taking the notes as the junior in the meetings. Struggle to focus-

    17. AP

      Mm

    18. SM

      ... in those meetings. You zone out. "Oh God, I forgot. What did they say?" So it's almost like it, the, the world as it is, is kind of geared against you, whereas a long time ago it was advantageous to be you, right? So it's not a biological error. It's just that we're living in a different world now.

    19. AP

      If people with ADHD used to be the hunters, but now you can go to a supermarket to buy your food-

    20. SM

      Mm

    21. AP

      ... that strength has now been made redundant.

    22. SM

      Yeah.

    23. AP

      And if someone with ADHD had this heightened intuition and sensitivity to danger to keep the camp safe, now you're gonna be picking up on people who maybe are criticizing you more than an average person-

    24. SM

      Yeah

    25. AP

      ... and feels more threatened by a perceived rejection.

    26. SM

      Yes. So this is where the concept of rejection sensitive dysphoria comes in.

  6. 22:44 – 23:51

    Tiimo advert

    1. AP

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  7. 23:51 – 30:44

    Rejection Sensitive Dysphoria

    1. AP

      the show. RSD for me, Rejection Sensitive Dysphoria, is the hardest part of the whole ADHD experience.

    2. SM

      Yeah.

    3. AP

      And I think that heightened sensitivity now can, if someone replies with a text message with a thumbs up emoji or ends an email with a full stopInstead of an exclamation mark

    4. SM

      [laughs]

    5. AP

      I mean, these things sound totally bizarre to, to many people, but for someone with ADHD, I think many people do believe this to be true. How would you describe the feeling of RSD or how have your patients described it to you?

    6. SM

      So one thing I wanna say about RSD, let's talk about a bit about research into this, right? 'Cause there was a chap who's still around actually, called Dr. William Dodson-

    7. AP

      Yes, I know him well

    8. SM

      ... right, who, who's done a lot of work in this field. What he's found, and I've, I... Look, I've probably seen circa 15,000 patients, so I'm, I'm going on my own experience. I'm not a researcher, but I'm just also going on my own experience. It's currently not part of the diagnostic criterion for ADHD, right? But it's seen in almost every patient to some degree. What Dr. Dodson found was that in up to a third of patients, it was by far their most crippling symptom. I think that's, in my own experience, I think it's higher. More common in women than in men, but I've seen it in tons of men as well. It's des- So the reason why it's been hard to research this is because it's actually very hard for patients to describe, and it's hard to quantify, and when something's hard to quantify, it's very hard to do research on it, right? The closest that I have got to describing this from patients is for some patient, it feels like a physical pain, right? Like chest pain or they feel tight in their chest or quite physical. It comes on all of a sudden, and there's normally an obvious trigger. Those are the qualities of it, and it can last for varying amounts of time, actually. For some people, it can go on for a long time, actually. When I bring this up in an assessment with someone, 'cause it's obvious when they... When people are giving me examples of it and they don't know what it is, they break down. This happens so many times where people just break down into tears 'cause they finally feel seen, right? And there, there's a lot of shame that comes with RSD, where you try and hide this feeling from everyone.

    9. AP

      Mm.

    10. SM

      Right? You hide it, and when it's finally seen, it's like, "Oh, that's what this is." And just knowing it in itself, that's what this is, is a massive part of the therapy afterwards. Because if you know now what, what this is, you start to start picking up the warning signs or the triggers, okay? And then you can prepare yourself a bit more mentally 'cause you know this is what this is, and eventually, right, it doesn't feel great, I don't like it, but it will pass. And then you start rationalizing things a bit better. You know, maybe that full stop isn't... It's actually all right. You know? It doesn't have to be the enthusiastic exclamation mark all the time.

    11. AP

      It's your boss asking you for a quick chat on a Monday morning.

    12. SM

      So, so triggers. Triggers. Um-

    13. AP

      I, I mean-

    14. SM

      The worst one. That's the worst one.

    15. AP

      I mean, that's-

    16. SM

      [laughs]

    17. AP

      ... that's a, a clear one. You know, or showing someone your favorite film and they get up to use the bathroom and say, "Don't worry about pausing the film."

    18. SM

      [laughs]

    19. AP

      Or you could find out there's a social event and you ask the person if you're invited, and they say, "Come if you'd like."

    20. SM

      No. Worse still, you, you're gonna go to the social event. You are invited. Then you start thinking about, "I don't wanna put my foot in it. I'm gonna be meeting people." This is, say, a work event, so it's... Work events are not, you know, they're not really a party, right? It's still a work event. You can't just go mad, right? You're not mo- amongst your closest buddies. It's still a work event. You've got your boss and other people there. So you absolutely start stressing out about that event.

    21. AP

      It's an overwhelming, intense incident, and I wanna talk about this because we say sadness, internalized or externalized, but I feel like there's sometimes a lot of rage that can come after a trigger, immediately after a trigger, and I'll... Often that's internalized, and I feel like if you know someone well, you can see it. I feel like the partners of people with ADHD can often see the moment they're triggered, and they can see that they're hiding it. But this rage that, if not understood and you do externalize it, it can be the cause of so many blowups, arguments, rage quits of jobs. Where does that rage come from? Is that coming from a different place to the sadness?

    22. SM

      I think it's all... There's a mixture of emotions that go on, but I think the rage is coming from frustration, right? 'Cause a lot of it's frustration. So it's if you go through life being misunderstood, and you don't even know how to put words to this, so you don't know how to make other people understand you, that's very frustrating, right? So I've had patients tell me when I ask them a question in a history saying, "Have you self-harmed?" They said, "Well, I've not cut myself, but I've bashed myself, like, in the head. I've hit myself out of frustration." It's frustration.

    23. AP

      Mm.

    24. SM

      And, and frustration has to either go external or it goes internal, and you just get angry. It... Because you, you, you're feeling misunderstood and you don't know how to explain yourself.

    25. AP

      It makes so much sense. I think you could be on social media and you see a, a picture of a group of friends and you haven't been invited, and it can pl- completely derail your day to the point where you-Fill up with shame because you don't understand how 30 seconds ago you were in a great mood, uh, almost euphoric sometimes, depending on what was going on, and then suddenly you've seen something and you've completely changed, whether it's internally or, or externally. And the optics of that can expose you to comments like, "Why are you so Dr. Jekyll and Mr. Hyde?" It was instant, the change, and the shame.

  8. 30:44 – 35:14

    Why ADHD people feel shame

    1. AP

      Do you think as a consequence of RSD, people with ADHD are more destined to feel shame? Is it part of our wiring?

    2. SM

      No, I don't think it's part of your wiring or destiny. I think it's a learned emotional response, right? If you've had experiences throughout your life... So I've, as part of assessment, some people bring their school reports, whoever has them, but they, some people bring their school reports, right? Especially with, with kids, when we have kids in the clinic, um, they've got their school reports. There are certain themes that go through their school reports. One of them is that they're not meeting their potential. It might not be written like that, but that's basically what it means. Parents, I think there's a cultural bias with this as well, but parents sometimes are just looking at the kid as lazy, especially if the sibling is not maybe like that, for example, right? So you go through life basically feeling shame, not good enough, et cetera. When you feel not good enough, essentially you feel guilty as well that you're, m- in other aspects of life, that you're becoming a burden to other people. So you try and hide away your feelings. It's an acquired response according to the responses that were given to you throughout your life.

    3. AP

      Do you think the journey you just explained, does that show up differently within men to women?

    4. SM

      I think in, so in women, although I do see this in both, but in women, there's a couple of themes that I hear a lot. Emotional overwhelm and burnout. Okay? So there's a lot of masking that goes on, probably more with women than in men. It does happen in men too, though, actually. I'm not gonna say it's only happening in women, but there's a lot of masking that's going on. So there's a lot of compensatory mechanisms. What is masking? Masking is you're not being you, you're not being your true you, right? So from a social perspective, it's actually bloody exhausting if you are that person that's rehearsing their conversation before they go to the, the date or-

    5. AP

      Mm

    6. SM

      ... the work party or whatever it is. That's, that is exhausting, right? That's gonna drain your social battery. And then when you're in that social situation, you're worried about not putting your foot in it and paying attention, et cetera. Then in terms of masking at work, you might be... I've had loads of patients tell me, "I'm working after hours at home to get the same things done that my colleagues are not having to do, for sure. I know that they're not doing that." And then where that changes over time in women is the link with the sex hormones. That's a big thing. So where you have hormonal fluctuations, teenage years, perimenopause, menopause. With those hormonal fluctuations, you, the classic description that I hear sort of female patients say is, "Look, I was struggling before and managing, but now I'm just not managing. Like, this is now too much for me, and I'm totally overwhelmed, and I'm totally burnt out. I'm done." And that is where also rage I've seen happen there, because they're masking so much at work, they're bottling everything in. Where is it gonna come out? 'Cause it has to come out. It's gonna come out at home.

    7. AP

      And I guess-

    8. SM

      So now they, they've just lost their cool with their partner and their kids, et cetera.

    9. AP

      Mm. And I guess many people around that particular person who is working through the night, putting in all that extra time to achieve the same or maybe even more, the optics of that could look like high achieving. They could be getting-

    10. SM

      Mm

    11. AP

      ... the good marks, they could be getting the promotion, but I guess it's the extra work that's happening behind the scenes that other people don't see. It's the arguments with the partner. It's the being so burnt out after work that the, the door closes and they just fall to the floor and, and they've got nothing left because they've exerted so much more invisible energy in the workplace.

  9. 35:14 – 36:47

    Top female ADHD challenges (how to overcome them)

    1. AP

      Are there any other areas, do you think, that women ask for help that might be different to, to men?

    2. SM

      I think another area, um, the big one is relationships, right? So yes, relationship with a partner, but the other big one is mums that are parents, and this is where a lot of guilt comes in. The mum that's the parent that's struggling to cope with parenthood, right? So, you know, you, nowadays schools are, you know, you're on these WhatsApp groups. I'm saying this as a parent myself, right? So my wife's on these WhatsApp groups which are constantly have, "Well, today's this day and you've got to wear this particular outfit, and then tomorrow is the, another thing with a different outfit." How embarrassing is it? You've got ADHD, you misread that message, your kid's the only one that's come in in school uniform. Everyone else is dressed as a teddy bear or whatever [laughs] , right? That's embarrassing on you. I'm talking about young kids. The young kid pro- just, well, they might think something's happened, but they don't quite get it. That's really embarrassing to you as the mum, right?Or, you know, you're just struggling to keep up. And then when you feel you're letting people down, that's where I get moms come to me because they're just feeling so bad. They might even tolerate, you know, the partner, "Fine, we have arguments." But if it's affecting the kids, that's something that they

  10. 36:47 – 46:42

    Common co-morbid conditions

    1. SM

      can't tolerate.

    2. AP

      I want to talk about comorbid conditions that might appear alongside ADHD. But I suppose firstly, how common is it to have a comorbid condition with ADHD?

    3. SM

      So that's a very poignant question. So yesterday on my LinkedIn popped up a very recent... It must be a very recent article 'cause it popped up yesterday from Attitude Magazine. You know Attitude Magazine?

    4. AP

      Oh, yes.

    5. SM

      Um, and it said, "Up to 80% of people with ADHD have comorbid mental health symptoms." And I would agree with that in my experience as well. So highly comorbid-

    6. AP

      Mm

    7. SM

      ... is the answer.

    8. AP

      And what would be the main ones, the more common ones?

    9. SM

      Most common ones are what we call mood disorders. So 70 to 80% of people with ADHD have cycles of anxiety and depression. Right? Those-- The classic story that I hear is, "I've been feeling like this for as long as I can remember. This is, this is how I've always had this experience. I've been treated with antidepressants. They made me feel rubbish. I felt emotionally numb and just had loads of side effects." When you hear this as a healthcare professional, you need to have some understanding of the nuances, otherwise you're gonna diagnose that person with generalized anxiety disorder. The anxiety in ADHD, in my experience, is different in its quality. It's typically task related or there's an element of social anxiety. We've spoken about RSD. So task related is, "I've got that big project. I've got that big presentation. I've got my dissertation to get done, and I just dunno where to start, and it's due." That's different to generalized anxiety, 'cause in generalized anxiety, someone is naturally a worrier about everything. So they might develop health anxieties, they might develop phobias, all sorts of other things. Why is it important to know the difference? 'Cause you're treating different things with different chemicals. Most antidepressants contain a chemical or enhance a chemical called serotonin. That's not what's deficient in ADHD. What's deficient in ADHD primarily is dopamine and noradrenaline. So you're just now gonna get the side effects of se- high serotonin levels, basically. Other mood disorders, bipolar disorder, very, very careful to tease out if someone's got bipolar disorder because if you give someone who's got undiagnosed bipolar disorder stimulant medication, which is the first line of treatment in ADHD, they are 10 times more likely to become manic than, than if they didn't have that medication. So what are the, the, the characteristic differences in bipolar disorder? You get mood dysregulation, but you typically get weeks of hypomania or mania and then months of depression. You can almost see them, those changes. They're, they're that prolonged. Whereas the mood swings you see in ADHD are going on within a day, typically. Number two, the mood changes that you see in bipolar disorder are what's called not non-congruent with the situation. So what that means is if someone's manic, there might be a terrible circumstance that's going on and they're laughing away bizarrely. It looks strange. That's not what you see typically in ADHD. What you see in ADHD is people experience appropriate emotions but more intensely. They experience the high highs and the low lows more intensely, but it's appropriate to the situation, right? Other conditions, which I know you've discussed in this podcast before, but autism of course, you know, um, and I think it's very important, again, to find the right healthcare professional 'cause if you have autism or autistic traits, you wanna see someone that knows about that. Because again, when it comes to ADHD treatment, when you treat someone's ADHD symptoms, their autistic traits become more prominent and they need to be counseled about that, right? That person will describe saying, "I feel like I'm losing my personality here, becoming more inwards." It's because I've taken out the other thing that made you more extroverted and now you're left with the autism.

    10. AP

      As a healthcare professional like yourself, 'cause it sounds like there's a lot of potential comorbid conditions, how difficult is it a job to tease apart and identify them individually?

    11. SM

      I think this is where seeing someone with the appropriate expertise is really important, right? I'm not having a knock at any other healthcare professionals here. I'm really not. But for example, a consultant psychiatrist, we've had to do training and had clinical experience in lots of other conditions. Another one actually is addictions, which maybe we can talk about, but that's another one.There's that phrase, 'The man with a hammer sees every problem as a nail.' Right? If you only know... If you've been on your few day training course about ADHD, and you really don't have other experience of other mental health conditions, you don't know what someone with-- what, what does a patient with bipolar disorder look like? What do they say, right, for example? Or you don't have experience about addictions, for example. You're not gonna even know to ask the right questions. So you're gonna have your list of ADHD symptoms, and you've either got that or you haven't got that. That's, to me, not the way to do things. You need to do a comprehensive overview of a person, right? If I was a patient, don't just tell me yes or no if I got ADHD. That's not what you wanna know. I think you wanna know, "Well, give me an overview of everything that's going wrong with me, and what can I do to help myself? What can you do to help me?" Treat the person as a whole.

    12. AP

      And as a healthcare professional, you must have to have an awareness of masking, right? Because is it possible for the different co-morbid conditions to perhaps mask each other?

    13. SM

      Yeah, and look like each other, right? There's a lot of talk in this field around, is this a condition that's being over-diagnosed? And I think we're coming to more and more understand that actually it's probably been misdiagnosed and looking like other conditions all along. But actually, I think it's even more dangerous to diagnose someone with ADHD when actually it's not ADHD, and then you start giving them treatment for something that it's not, and you might be making those other things worse. If you give stimulants to someone who really does have generalized anxiety disorder, who doesn't have any management with, say, an antidepressant, you're gonna make that person really anxious. You're gonna aggravate the generalized anxiety disorder.

    14. AP

      How do we make sure that there isn't a misdiagnosis and therefore a misprescription causing someone with generalized anxiety disorder or maybe another BPD who might therefore go into a mania? How do we limit those misdiagnoses from happening?

    15. SM

      So, well, maybe at this point I'll talk about how me and my colleagues, for example, at our clinic, try and untangle these different conditions, right? The first step, if you came to see us at our clinic, you're gonna get given some pre-assessment forms, which is probably the bane of, of your life as an ADHD person, but those forms are important. One of those forms is asking about ADHD symptom frequency. The other form is asking about autistic traits, even though it's not an potentially... I mean, so we have a certain type of assessment where we do a combined ADHD and autism assessment, but even with our generic ADHD assessments, because it's highly co-morbid, we ask about autistic traits. Number three, there's another form asking about depression and anxiety symptoms. We then ask you to give us informant reports from collateral, other people close to you, about your childhood and your adulthood to get a longitudinal picture of you, right? What, what has Alex been like his whole life, if at all possible. During the assessment itself, we will ask about ADHD symptoms, obviously, 'cause that's what you came for, but we'll also ask about past psychiatric history. We will get information from your GP, with your consent, from your medical records. Have you seen other mental health professionals? Can I see those letters? Because of knowledge of medication, if you tell me your medication history, I'll tell you what you were diagnosed with, whether that, that was correct or not, right? And then we'll do a mental state exam. A mental state exam is a description of how is Alex presenting to me right now. And again, this comes with pattern recognition and experience. If I have seen enough people with all these other conditions, I'll spot it. But if you haven't, you don't know what you're spotting, right? So then it's just ADHD, not ADHD.

  11. 46:42 – 54:25

    The link between ADHD and dementia

    1. AP

      What about dementia?

    2. SM

      Mm.

    3. AP

      Because I've heard some scary headlines that are linking ADHD-

    4. SM

      Mm

    5. AP

      ... to a heightened risk of developing dementia.

    6. SM

      Mm.

    7. AP

      Is there any truth to that? Is there any new research that backs that up?

    8. SM

      So there's, there's some very interesting research around this, and it's current. Um, in the last year, um, there've been studies done across Europe, big scale studies, that show, where they've looked at populations of people with ADHD and without ADHD and matched for other confounding factors, right? If you are left untreated across your lifespan with ADHD, you are at two and a half to three times more risk of developing dementia compared to someone who doesn't have ADHD. But then follow-up studies have showed, specifically with stimulant medication, that if you are treated, you are at the same level of baseline risk as someone who doesn't have ADHD.

    9. AP

      So without treatment, what is causing the heightened risk? Lifestyle choices?

    10. SM

      That's very hard to, to answer. I think if we look at the treatment, some theories are around neuroplasticity. Okay? So if you're modulating neurotransmitters, the dopamine and the noradrenaline, you are changing brain chemistry across time. So there's very interesting studies about actually, so in the US, where they quite aggressively medicate even children, right? I think we're a bit more reluctant to do that in the UK. And what they're starting to seeAnd this is not completely conclusive or proven, by the way, 'cause I know I can imagine you're gonna get lots of people in the comments talking about this one. But what they're starting to see is actually if you treat this early, you might actually be able to change brain chemistry to such an extent that the person is no longer presenting with this later on in life, which is actually phenomenal 'cause now you're talking about a cure. We're not there yet. Just wanna really highlight this, okay? So, you know-

    11. AP

      Absolutely

    12. SM

      ... we don't, we don't want the BBC to come down at us, but we're not there yet. So I think there's a thing about neural plasticity. You're changing the brain structure a bit at, at, at a chemical level, not the whole brain, obviously.

    13. AP

      [laughs] How many people did you say you've assessed?

    14. SM

      About 15,000 at least.

    15. AP

      And do you see any... 'Cause I suppose when someone's in that room with you, right, and they have probably spent years and years feeling misunderstood, not understanding where the shame comes from, being called lazy, and not understanding why, when you say ADHD, when you first say that there's a reason, do you see a change in the person when you say that to them?

    16. SM

      Yeah. It's, um, it's a bit like the bereavement process. Okay? So there's four stages in the bereavement process. Number one is shock and disbelief. "So what, Dr. Mashru, uh, do I have ADHD then?" They'll say this two or three times at the end of the assessment after I've told them that they've got it and I've explained through the diagnostic criteria why I think they've got it. So there's that element of imposter syndrome, and that's there because their whole lives they've been told something different about themselves as to why they are the way they are, and it's not ADHD, right? So that's stage one. Stage two is anger. They are angry at parents, teachers, partners. They've been wronged and misunderstood, and they're angry about it, naturally so. Angry at themselves actually as well for not picking up on it sooner. Stage three, sadness. They grieve the life that could have been had they been treated earlier, right, and really met their potential, especially people who are diagnosed much later in life now, yeah? Stage four is acceptance. 'Cause only if you then accept, right, this has happened, can you then start accepting treatment and moving on. So four stages is what I generally see-

    17. AP

      Mm-hmm

    18. SM

      ... post-diagnosis, and it's like the bereavement process.

    19. AP

      And who do you think the diagnosis helps the most? Do you think it helps the person who's been diagnosed, or do you think it helps the people around them?

    20. SM

      If done correctly, it can help everyone, and I say that, if done correctly, right? Naturally, it can help the person if you give them the right tools, whether that's medication, talking therapy, both, whatever it is. But I think the next step is the really important one. So, for example, in our service, we have coaches who will actually have sessions with family members just to explain to them what's going on for their child or for their partner. We even offer sessions to employers if the employer is willing to listen, right? Or if the person wants us to talk to their employer about reasonable adjustments or sessions with the university to explain what kind of reasonable adjustments can be put in place to help that person. So if it's done properly, comprehensively, then yes, I think it could help everyone.

    21. AP

      When I got my diagnosis, I started speaking to as many people as I could in the community, and one of the main words that got repeated time and time again was broken.

    22. SM

      Mm-hmm.

    23. AP

      People felt broken, and it kind of became the slogan of this podcast, really, Not Broken, Just Different, um, because of that motivation to try and change the narrative. Is a feeling of being broken a, a word that gets brought up by the people that come to see your clinic, and why do you think that is?

    24. SM

      I think the word that gets brought up in the people that I see is despair. Right? Despair. There are loads of people who are watching this podcast right now, 2:00 or 3:00 in the morning, you're not going to sleep, and you're watching this. What's driving that, apart from your ADHD, maybe? You're desperate. You're desperately, internally, maybe, stuck. You're stuck, and you don't know what to do, and that goes back to the original question about what my mission was. Don't remain in that desperate, stuck stage, people. Go and seek the appropriate expert help because this can... There are things out there to help you. Right? Neurodivergence has got its strengths. Right? People can be really creative. When they find their passion, they do extremely well. Look at yourself as an example, right? But it also causes a lot of difficulties. Don't remain stuck in a difficult place. Go and get help, and get the right help.

    25. AP

      Really profound and amazing advice to finish on. So, Shy, thank you so much.

    26. SM

      Thank you.

    27. AP

      I wanna move on to my favorite part of

  12. 54:25 – 57:54

    Dr Shy’s ADHD item

    1. AP

      the show-

    2. SM

      Yeah

    3. AP

      ... which is the ADHD item section.

    4. SM

      Yeah.

    5. AP

      Your item has been patiently waiting underneath that cloth-

    6. SM

      Mm-hmm

    7. AP

      ... and I'm gonna reveal it now.

    8. SM

      Okay.

    9. AP

      Da, da, da, da.Right. I'll say what that is first. That is a remote control and a tie, and I think we're gonna cut. Okay, and through the magic of editing, I've now put, on your instruction, your tie as a blindfold, and I've got the TV remote in my hand, and I'm pointing it at an imaginary TV.

    10. SM

      TV. Yes. So Alex, press number one for me.

    11. AP

      I'm scared. Yeah, okay. Number one.

    12. SM

      So what you're actually pressing, I think, is the volume button there.

    13. AP

      [laughs] I can't...

    14. SM

      [laughs]

    15. AP

      That, that was a guess. That was a guess.

    16. SM

      Right. Press number three.

    17. AP

      I don't even know if the remote's facing the right way.

    18. SM

      It's facing the right way-

    19. AP

      Is it? Okay

    20. SM

      ... which is quite incredible.

    21. AP

      Three.

    22. SM

      So that's-

    23. AP

      Are the numbers up here?

    24. SM

      So you've now turned the TV off there.

    25. AP

      Oh, no. Okay, so I press it on again, I think.

    26. SM

      Yeah. Well done.

    27. AP

      I'm gonna guess three is around there somewhere. I don't know.

    28. SM

      So now you've pressed number nine, but you've stumbled across number nine, and there's a really interesting channel on there. A lot of noise in the background. Let's turn the volume up. Yeah, so you turned the volume down.

    29. AP

      [laughs]

    30. SM

      All right, so now you can take off your blindfold, Alex.

  13. 57:54 – 1:01:13

    Audience questions (the washing machine of woes)

    1. AP

      I wanna move on to the ADHD agony aunt, which is called The Washing Machine of Woes.

    2. SM

      Mm-hmm.

    3. AP

      And an audience member writes in with a question, a woe.

    4. SM

      Okay.

    5. AP

      It goes in the washing machine, and it's a washing machine because it represents, for me, memory loss-

    6. SM

      Okay

    7. AP

      ... because I always forget my clothes in the machine after the cycle's finished.

    8. SM

      All right.

    9. AP

      And I do ask all my guests, do you relate to that?

    10. SM

      Do I relate? I, I definitely see that in other patients.

    11. AP

      Yeah. [laughs]

    12. SM

      I'm not sure if I relate to that all the time, but yeah.

    13. AP

      I have been using the Tiimo app, which is the sponsor of the show, and I've been getting a lot better. They give me a little prompt to remind me to empty my washing machine. This week, Shy, someone has written in and asked, "Both of my parents have ADHD, and I'm 16 without a diagnosis. If I want an assessment, what can I expect, and why are waiting lists so long?"

    14. SM

      Okay. So I think we can go through this, actually. So I'll, I'll tell you what we do in our, in our service, um, for children. The first step is there are some forms which you're probably gonna hate, um, especially as a 16-year-old potentially with ADHD. Those forms are for three people to fill out, your teacher or your school, yourself, and your parent. You will then have a detailed assessment that goes through, like I said, not just ADHD, other possible things that might be going on for you. How do your symptoms impact you, and where do you want help with? So we tailor that towards you. If there's also then liaison required with your school, for example, maybe at 16, we would assist with that as well, 'cause I think that's, that's probably a big problem area, but not just school, but there might be other or lots of other things going on too for you. And then essentially treat you appropriately according to your needs. I think the second part of the question is, why are waiting lists so long?

    15. AP

      Mm.

    16. SM

      I think the reason for that is because the current resources are being outstripped by the current demand. Simple supply and demand.

    17. AP

      Mm.

    18. SM

      There's been increased awareness about ADHD and other neurodivergent, neurodivergences, right? So schools, et cetera, have not been given the funding to, to match that demand. So a lot of these people were unrecognized before, especially if they weren't tearing up the classroom, right? The more inattentive people. They were just going through their, their sort of education system, quietly doodling away to themselves, being distracted in their own thoughts, not troubling anybody, right? Those people were missed, but now there's more awareness. So those people are putting their hand up saying, "I need some help," but that, the help hasn't caught up.

    19. AP

      Mm. Fascinating, Shy, and it makes a lot of sense.

    20. SM

      Mm.

    21. AP

      I wanna say thank you so much again, and just finally, we're gonna

  14. 1:01:13 – 1:02:07

    A letter to my younger self

    1. AP

      do a new part of the show, actually. It's, it's the previous guest has written a letter-

    2. SM

      Mm-hmm

    3. AP

      ... to the younger version of themselves.

    4. SM

      Mm.

    5. AP

      And I want to deliver it to you.

    6. SM

      Mm-hmm.

    7. AP

      And if you could kindly read it out to us.

    8. SM

      Yeah.

    9. AP

      If you could kindly read out the letter.

    10. SM

      Okay. "Dear my younger self, the life and version of yourself that you want to be when you grow up is even better than you wish it to be. The hopes, daydreams, ideas, and fear you have is your gift that will make your future amazing. Don't stop dreaming. Believe in yourself. It is all going to be a wild ride. Enjoy it." That's very positive and exciting. That's nice.

    11. AP

      Amazing.

    12. SM

      Thank you.

    13. AP

      Once again, Shy, thank you so much from behalf of everyone watching, listening on their mission, grappling to try to understand how their brain works. Thank you so much.

    14. SM

      Thank you. [upbeat music]

Episode duration: 1:02:08

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