#why it’s difficult for adhd brains | Explore Tumblr Posts and Blogs

ms-demeanor · 1 day

Note

You posted about adhd and I was hoping to follow up to clarify something. I’ve explained to my partner a million times about how the borderline-hoarding mess of his space is very mentally draining to me, and he understands but we’ve both essentially accepted he won’t clean his mess because he can’t because of his adhd. You’re saying he’s actually being a shit head?

This isn't necessarily an issue of him being a shithead, but it also isn't a sustainable situation. It's not good for you and there's a level of clutter that's probably not good for him either.

Large bastard is a lot more clutter-y than I am. The solution we've come to is trying to keep our messes at least isolated from one another; he can have his messes and I can have mine, but he can have those messes in his spaces, not all over the place. Sometimes those messes migrate, and that's when it's important for him to make the effort to rein them in rather than trying and failing to make a daily effort to keep our entire shared space tidy.

I think when you say "we've both essentially accepted he won't clean his mess" what I'm hearing is resignation; you're not happy about this but you don't know what to do so you've thrown up your hands and he feels helpless and unsure of what to do to improve the situation. This is the kind of "it's fine" that isn't really fine.

I think it would be worthwhile for you to each separately think about the mess and talk about it together. Are there areas that YOU *need* to have not-messy? Both for utility and your mental health? Are there areas where you can tolerate more mess than otherwise? Are there areas that are going to be harder for him to keep the mess out of than others? Are there things he doesn't *know* about cleaning up the mess?

I'm obviously a big "communication communication communication" person so I'm going to recommend a lot of talking about stuff, which is probably going to mean a lot of thinking about and interrogating stuff. I'm going to say "talk to him about why the mess bothers you" which means you also have to really articulate to yourself why the mess bothers you (for instance I'm not actually *bothered* by a messy kitchen, but I know it's going to reflect badly on us - and me specifically b/c of presumed gender roles - if someone pops by and the kitchen is a disaster, AND a messy kitchen is going to be harder to use). Genuinely, sometimes knowing *why* something is a problem might make it easier for someone with ADHD to do something. And it's not that he doesn't care that it upsets you, it's just that "Oh if I don't wash my breakfast dishes Anon won't have clear counterspace to make lunch" might be stickier in his brain (and less hard to look at emotionally) than "this thing I forget to do upsets my partner so I should do it."

For the record, I think that people with ADHD should read up on Demand Avoidance and see if it might explain some of the issues that they have in their day-to-day life; I've seen some really unfortunate situations with friends where trying to do things that their partner needed became the subject of demand avoidance. *I* have experienced negative outcomes of demand avoidance. The solution to that, however, isn't to stop making attempts to do the thing OR to simply try harder to do as they're asked/told (which reinforces the demand), it's to work on setting up a situation where the partners' needs are not interpreted as a demand. This is fuck-off difficult and requires a lot of patience and care and many attempts to succeed and will be different for each person and relationship.

(Also for the record demand avoidance isn't *super* strongly linked to ADHD and it's not a definitive symptom; like Rejection Sensitive Dysphoria, it is something that occurs in some number of people with ADHD and can be a useful lens through which to examine various behaviors; you don't need to have DA or RSD to have ADHD, and having DA or RSD also doesn't invalidate your diagnosis; they're symptoms. For me, DA often feels like "if I don't look at it, it can't get me" - If I ignore all the messages I've got they aren't real and don't have real consequences so I'll just ignore my texts. If I don't look at the vendor email about the order, the problem with the order isn't real and it won't get added to my task list. If I don't look at the requests in my inbox I can't let people down when I don't do them. It's a self-protective coping mechanism but it's *maladaptive* and I can't just ignore the vendor email or all my texts. I need to work on a way of doing the stuff that I'm avoiding in a way that makes it less stressful and doesn't hurt the people relying on me. That takes a lot of effort, personal insight, trial and error, and )

But before I dive into specifics I want to be really really clear about one thing: sometimes people are simply incompatible. Sometimes one person has such a low tolerance for "mess" and the other person has such a high threshold for "mess" that it can't be reconciled. It sucks that this can end up being a thing that people break up over, but it is MUCH better to acknowledge incompatibility as early as possible instead of spending years and years building resentment.

There used to be a great forum called MiL's Anonymous that I spent a lot of time on. It had a lot of people in a lot of difficult situations struggling to get by and hold their relationships together. The question that was used as a litmus test to approach each situation was simple: If you knew today that everything about living with this person would be the same in five years, would you stay?

Because you can't control your partner. You can't control the future. You can only control yourself and your proximity to situations that are harmful to you. If you knew, 100%, that things wouldn't get better in five years, would you be okay with staying in this relationship? If the answer is "no," then that's that. Don't worry about questions of whether or not your boyfriend is a shithead, start the process of ending the relationship because there's a good chance the situation is going to be exactly the same in five years.

If the answer is "yes," and you'd stay in the relationship regardless of whether or not things changed, then it's time to take actions to improve your life within the context of the relationship.

(No judgement on that yes or no, btw. If you would hate living like this for another five years, and you would feel like you'd wasted your time and hadn't done the things you wanted to with your life, get out. Bail. Go. It will be better for you and better for your partner if you split instead of spending half a decade building resentments and and problems that you'll have to spend another half a decade healing from.)

Also, a note: you describe your boyfriend's mess as borderline hoarding - is the issue *mess* or is the issue *clutter*? I have friends who are very tidy, but whose homes are very cluttered. They like things, they have many things, they keep many things around, but their houses are always clean and well-dusted and orderly, just with a tremendous amount of *stuff.* I am addressing all of this as though the issue is mess, not clutter. If your boyfriend's situation is clutter (the space is busy and packed with things but it is functional and clean) and your issue isn't with *mess* (things out of place, things not having a place, things that need to be cleaned up gathering in stacks, falling behind on regular chores like laundry and dishes and taking out the trash) then you definitely need to assess whether or not you are compatible.

For instance here's a room that is messy but not cluttered compared to a room that is cluttered but not messy:

That first room is a *mess* but it would be very easy to clean up in under an hour. The second room is fairly tidy, but would take significant effort to pare down and declutter. BOTH of these can be difficult to live with but the second one is not dangerous or threatening to anyone's health. (The second one is QUITE cluttered and if every room in a house looks like this it can be overwhelming to live with; this is actually harder to deal with in a relationship than the first one in a lot of ways. I don't have a lot of advice for what to do if your partner is a high degree of tidy-but-cluttered because I don't actually think it's a problem or wrong to have thousands of books or bins full of lego or a million kitchen appliances as long as you have the space and can keep it safe and well-maintained; this is a really significant compatibility issue)

Okay, all that out of the way, here's the hard work.

Talk about this shit

Talk to your partner and define "mess." Make sure you are on the same page about what you mean when you're talking about what a messy room looks like versus what a tidy room looks like. Gather reference pictures. DRAW reference pictures.

Explain not just that the mess upsets you, but *why* and *how* it upsets you. In this context don't think of it as your boyfriend's mess, think of it as an unpleasant roommate. Discuss this using "I-statements". "When I have to pick up laundry all over the apartment, I feel like a parent more than a partner." "When there are piles of miniatures all over the table, I feel like I don't have anywhere to do things I'm interested in." "When there are dishes in the sink, I feel frustrated because I have to clean before I can feed myself."

Discuss, frankly and openly, whether he knows how to clean. I'm not trying to make excuses for him here but a lot of people with ADHD have a lot of stress and avoidance around cleaning because they spent a lot of time getting yelled at for not knowing how to clean properly.

Discuss your needs, be firm about what you require but willing to compromise. You *need* some spaces to be clean, and some spaces may be harder for him to keep clean than others. It may be MUCH harder for him to keep a bedroom tidy than it is to keep a kitchen tidy; if you need a clean and empty bedroom with everything put away and he simply cannot do that, that is a compatibility issue. But perhaps you need *your* side of the bedroom to be very orderly and can tolerate a moderate level of mess and clutter on his side. Maybe you're really really bothered by a messy kitchen, but it doesn't bug you if the dining table is covered with projects and papers. Figure out something more workable than "his mess goes everywhere and i live with it because he's incapable of cleaning" because he probably is not incapable of cleaning and you deserve to have places in your home that are comfortable for you.

Reduce friction for cleaning

Sometimes the problem isn't cleaning, the problem is the many many steps before cleaning, or not knowing where something should go when you are done cleaning. One of the absolute best things I've done for myself for cleaning my space is getting a broom holder and mounting the broom to the wall. Sweeping is now essentially thoughtless. I don't have to find the broom or pull it out from a pile of fans or go scrounging around for a dustpan it's right there on the wall, frictionless. So here are some ways to reduce the barriers to cleaning:

Make sure you and your partner both know how to use your cleaning supplies and know where those supplies are. When I switched dishwasher soap I had to re-show Large Bastard where I was storing it and how it was used, because to him what happened was the dishwasher tabs just vanished one day and he didn't know what I was putting in the machine or the process I used. He sometimes puts tools away in places that I can't see (he's more than a foot taller than me) so sometimes I can't get started on a maintenance project until he shows me where he put the battery pack for the drill.

Consider making a how-to chart to or having him make a how-to chart to keep someplace accessible so he can reference it while cleaning. Goblin.Tools Magic ToDo is great for this. Basically a lot of the time people with ADHD have trouble knowing what to do from step to step even if they've done something before, so having a step by step guide can make it easier (I have notebooks full of step-by-step guides for everything from paying for my tuition to removing licenses for my customers to weeding my yard)

Remove obstacles; don't keep cleaning chemicals in the garage in a box that's behind a stack of parts, keep them in the room you'll be cleaning. Don't keep the cleaning supplies that you use to clean the bathroom in the kitchen. Sometimes this means buying two bottles of bleach solution and two scrubbers and two sets of cleaning gloves but having fewer steps (fetch the windex, fetch the paper towels, fetch the gloves) is often the key to getting things done (open under-sink cabinet and grab windex, gloves, and paper towels that are there instead of in the kitchen).

This sort of overlaps with the next category, which is:

Create Dump Zones

One thing that I've found that seems very different between people with ADHD cleaning and neurotypical people cleaning is that neurotypical people are good at getting to a point where the cleaning is "done." They have checked off their tasks and they have finished and it is over. There are *SOME* chores that are like this (taking out the trash is a binary state, the trash has been taken out or it has not) and some chores are perpetual (horrid cursed dishes) but I think with people with ADHD, some chores that are binary for neurotypicals are actually perpetual chores. For instance "clean off the counter" is not a one and done for me. "Clean off the counter" may involve a three day reorganization project. "Clean off the counter" does not mean "wipe down the tile and put dishes away" it means assessing whether or not I need to make vegetable stock and bleaching three tea containers and reconsidering whether or not the sharps container should live somewhere else and going through the mail and figuring out what needs to be responded to and taking out the recycling and on and on and on.

We have had company at the house for the last two weeks, so I asked large bastard to clean off the dining room table, which is largely a project zone for him. Cleaning off the dining room table meant putting away his meds (and since he's a transplant patient that involves a 30 gallon rubbermade tote), throwing away some trash, and totally reorganizing his workshop. It also incidentally involved picking up a table from facebook marketplace and moving my plants, which has now involved moving my former plant rack outside (moving buckets, finding and organizing planters and gardening tools) and taking the former table to the thrift store (not done yet) and cleaning the rug that was under the former table. So "either the table is clean, or it isn't" isn't really true for us.

HOWEVER "hang on we can't eat until the table is clear so let's drive to Pico Rivera to get that console table right now" isn't a workable plan, so you create dumpzones as areas of holding between the start and the finish of the chore.

A dump zone can be a laundry basket. It can be a craft bin. It can be a back room or under your bed. It is a place to put things that you are going to deal with later because if you deal with them now it is going to derail the thing you are actually trying to do, which is set the table for dinner.

Dump zones are vital to cleaning with ADHD and I recommend them for day-to-day cleaning as well. The day-to-day dump zones might be more for you than for your boyfriend. For instance, Large Bastard works with bullets and he sheds bullets all over the house. I used to get stressed when I found bullets when I was cleaning because are these work bullets? Are these recreational bullets? Are they in testing? Do they need to be pulled? Do they go in the workshop or the office or the garage or does he need these today so they have to stay on the counter? And the answer now is "that's not my problem naughty bullets go in the jar." Which is perfectly sensible because he gets to say "mystery yarn goes in the bin" and "art supplies go in the bucket."

I feel helpless when cleaning a lot of the time. I'm frustrated and lost and I don't know where stuff goes and everything I pick up spins off into three projects in my head and every step feels like a wall to scale. Dump zones help me with that when there's pressure or a reason for cleaning beyond day to day home maintenance. People are coming over? The bedroom is a dump zone, I'll deal with that later. I'm just cleaning up because I need to? Okay I can find a permanent home for this new dish soap.

AS A VERY IMPORTANT COROLLARY TO THIS:

Active projects do not go in dump zones while you or your partner are cleaning. This may mean designating a project sanctuary area like a corner of the table or one particular chair in your main room where a project can be placed so as not to be disturbed. (if my current crochet project ends up in the yarn bin, that may mean that I don't pick the project up for another three months, it lives on the windowsill behind the couch because that's where it'll get worked on)

Do not put things away for your partner, put them in the dump zone for your partner. Your partner has to be the one to put their own stuff away in a way that works for them. I tend to find that this naturally puts a limit on the time stuff sits in the dump zone, because eventually you'll go "hey where's my thing?" and will put stuff away. If that doesn't happen, it's still generally better to have stuff in a dump zone than all over the home.

Do not decide you know what things go together from your partner's stuff and try to "put like things together." The neurotypical urge to put like things together is the mindkiller(j/k). You do not know which things are "similar" in your partner's organization schema and attempting to organize things on your own is going to end up with all of the things "organized" being functionally lost forever from your partner's perspective. Large Bastard's mom would do this and it was infuriating, she'd say "oh I put all the electronics stuff in one box" and she would mean soldering irons, transistors, ham radios, HDMI cables, and cellphone chargers. We are *still* going through boxes of stuff that she "tidied up" when he was hospitalized in 2020 and 2021.

To prevent the need for quite so many dump zones over time, you can work on setting up landing zones and "homes" for projects and tools.

Landing Zones

Landing zones are places where things go when you come inside from doing various things. Sometimes your landing zone only needs to be a tray for your wallet and keys, sometimes your landing zone needs to be a place to take off muddy boots and put a trowel and gloves down before you shower.

To make an effective landing zone, consider what behaviors you're trying to minimize and whether the people using it are ACTUALLY going to use it. For instance I was tired of the corner of my hearth getting cluttered with random junk so I hung up some hooks and put a shelf and a basket there and it became a really effective landing zone for my bag and keys and the mail, but it was VERY ineffective for Large Bastard because it's by a door that isn't the primary door he uses to enter the house. As a result I always know where my keys and bag are but he has trouble finding his keys and wallet. He tends to enter the house through our bedroom and has an overloaded valet next to the door and that's usually where his wallet ends up. Mounting a shelf to the wall above the valet and putting a basket and a hook on it will be a better place for his stuff to land. It's not that he's not using the first zone because he doesn't know that it's there, or because he doesn't care about lost time when I'm searching for my car keys after he borrows them, he's not using it because it's not by the door he uses. That's all.

I have a landing space for when I come in for gardening that's different than the one when I come in from grocery shopping. I have a landing space for when I walk into the dining room instead of the kitchen when I get home.

Landing spaces prevent stuff from piling up all over the place because they are a limited functional space that should be used frequently. Mail ONLY goes in the landing zone. If you have mystery mail or if you're not sure it's safe to toss, you put it in the landing zone. You can't let the mail get piled up too high or you won't have a space for your keys. You can't let the change in your wallet tray get too deep or your wallet is going to slide off, etc., but you also don't just put change on the coffee table or your nightstand because the landing zone is right there.

Homes for items are just what they sound like. They're the place the item goes. It lives there. My meds live on my nightstand. You would not believe how poorly I did with taking my meds on my vacation because they weren't on my nightstand. A while back large bastard lost one of his sets of sorted meds and we tore the house up looking for them because he couldn't find them in his nightstand, which is where they live. *I* found them in his nightstand because I emptied out the entire top drawer (he had only looked on the top layer) and found them underneath a radio and a hammock. Even though they were *hidden* they were in their home, so they were findable. I recently needed ink for an art class. Art supplies live in a dresser by my desk. Ink lives in the art bin or the top left drawer. The ink was not in either of these places (it was on a cabinet in the dining room behind a teacup) so it took me weeks to find it.

Sometimes the reason that ADHD spaces are so messy is because objects have been assigned homes in places that are visible and if they get moved they get lost. This is a genuinely difficult problem that requires a lot of effort to solve and can involve a lot of trial and error for creating a tidy living space. For some people, open shelving and visible storage might be a good solution. For some people, assigning a VERY clear home and inculcating that location by habit is the only way to clean up a space. For some people one very cluttered corner to at least isolate the chaos does the trick (for me and large bastard open shelving doesn't work because anything in one place for too long becomes invisible; that means that I rely on assigning things homes and large bastard relies on having contained chaos and a general idea of where to search but what that DOES NOT mean is that he is clean or tidy. His spaces look like an explosion. But he can mostly find his stuff and do what he needs to do and as long as that's limited to specific places in shared spaces I can live with it; the dining room table can be a disaster, the kitchen cannot).

People organize things differently. It often takes a while for neurotypical adults to settle into an organizational style that works for them and ADHD adults may need to settle into a new system every few months for it to continue working. The cleanup and declutter is most likely going to be a permanent project that is always going to demand some level of attention from everyone in a shared space, but "my ADHD means I can't do it" is not really going to fly. Maybe his ADHD means that he can't keep his space tidy, but it doesn't mean you can't move stuff from shared spaces into dump zones or that he can't do stuff around the house.

If he's insisting that his ADHD means that he can't clean it is possible that he's not being a shithead, he just feels helpless and doesn't know where to start and has adopted the belief that he's a useless piece of shit who can't even keep a tidy space like a grownup because he's internalized a lot of shitty attitudes (hello, my internal monologue about keeping a clean house). But it's also possible that he's just being a shithead.

It's something that's worthwhile to investigate with him. If he's unwilling to make an attempt, then he's being a shithead.

It is also not your responsibility to rehabilitate another person. If he wants to clean and it's something he feels bad about and needs some help and support with the way that someone might need help or support for learning to use a mobility aid, that is fine but you don't have to be the one who gives him that support if it's detrimental to your health, and you don't have to be the one to teach him that stuff if it's not something you're capable of. And if he is NOT interested in working on making your shared living space more accessible for you, that is not your suitcase to unpack and you just have to ask yourself the question from the start: would I stay with this person if I knew the situation was never going to change?

IDK, I'm sure a lot of this reads like "anon you must take on the emotional labor of training your partner to be an adult" but it's really meant to be more of a way of assessing yourself and your relationship. If you created landing zones do you think he'd use them? Would he get angry if you assigned a laundry basket as a dump zone for his stuff while you tidy the living room? Is living with him long-term going to be comfortable for you if nothing changes? Do you have enough of a shared definition of "mess" that you're at least in the ballpark for what counts as a clean house?

anyway good luck, and a reminder to folks that I'm compiling a bunch of adhd resources and other information on my personal website, ms-demeanor.com. It's coming along slowly but it will eventually include stuff like ADHD cleaning tips and how to tackle a hoard, so maybe keep your eye on that space.

1K notes · View notes

copperbadge · 5 months

Text

youtube

Feeling a little overly perceived by Dr. Dodson right now, not gonna lie.

I'll throw a transcript under the cut, but both reading the transcript and listening to the video can be difficult as it's quite long, so here's some highlights. As always, these are the opinions of a specialist but only one specialist, so take with a grain of salt, and if you have research to add to this, please feel free to comment or reblog with it. I believe this presentation is from sometime in 2022.

ADHD appears to derive from issues in the corpus striatum in the brain. In most people, the corpus striatum filters out all but the most important input AND output; with ADHD, the things normally handled "outside of awareness" must be handled consciously.

People with ADHD don't see their emotions coming. Emotion is immediate, intense, and unfiltered, making therapies like CBT or ACT difficult, because you can learn the technique but you won't have time to employ it. Because people with ADHD have impulse control issues, expressing emotions "inappropriately" is common, leading people with ADHD to believe they can't trust themselves.

One function of ADHD-typical dysregulation is Rejection Sensitive Dysphoria, which nobody understands even a little. People who have it can't even adequately describe it to people who want to study it. It is intense, painful, and apparently impossible to control. Prevention is based in maladaptive behaviors designed to avoid it entirely (perfectionism, people pleasing, generalized withdrawal). The only currently known treatment is alpha agonist medication.

Lastly, by the age of twelve, a child with ADHD has likely received twenty thousand more "negative or corrective" messages than their neurotypical peers. (This isn't relevant to the rest, I just found it sufficiently horrifying to warrant inclusion. Fortunately for me, if I got 20,000 negative or corrective messages, I wasn't paying attention for most of them.)

Anyway, here's the transcript of the first half. I did this by copying and cleaning up the auto-transcript on YouTube, but I stopped at Question Time, so this is only the first half (the presentation). Transcription of the second half is available at YouTube.

There is suddenly a very large interest in the whole subject of emotional dysregulation and ADHD. That has been driven oddly enough by the Food and Drug Administration, which has just opened up several pathways that drug companies can study emotional dysregulation and whether or not their medications can get an FDA indication for emotional dysregulation. So it's sort of follow the money. Up until then, there was not a great deal of interest for ADHD emotional dysregulation.

We have to understand that the ADHD diagnostic criteria were not made for people like you and me, either practitioners or people who have ADHD or their families. They were designed for and made by people who do research and pretty much that's it. People who do research have to have criteria that they can physically see and count. "Little Johnny was up and out of his chair three times in the last hour," and you can write a three on your clipboard. Things which are invisible, not always there, hard to count, or even hidden by the patient, don't lend themselves to research very easily and so tend to be ignored. And so consequently this is one of the main reasons why emotional dysregulation -- until there was some other motive provided -- was pretty much ignored and disregarded.

Consequently ADHD right now, if you look at the 18 diagnostic criteria, are almost entirely behavioral criteria. What is the person doing? Not how is the person thinking, what is the patient feeling, how are they controlling their emotions, how are they sleeping. Things that are all very, very important to the person who has ADHD but which is essentially ignored by the diagnostic criteria.

Why should you care? Who really cares about this? Well, the definition of what ADHD is and isn't defines who and what will be studied. It defines who will actually get into a study and what questions will be asked. It defines who will be diagnosed with ADHD and who will not. One of the most common problems I get is with a secondary referral to me -- somebody clearly has ADHD but they're not pinging off the walls, they can sit and do their work, especially when they get into a hyperfocus, and so they're told they couldn't possibly have ADHD. When really they just have the inattentive subtype and they're not being driven by their behavior, their overt behavior. Therefore it defines who will get treatment, who will get insurance coverage for that treatment, and who will get accommodations in school when they're young and at the workplace when they're older.

Consequently we should also care because the other major components of ADHD get ignored. These are the ones that if you really stand back and look at it cause the greatest amount of impairment, the greatest amount of embarrassment, the greatest amount of just…problems in general. We're talking about cognition and thinking, that people with ADHD fundamentally think in a different way than do neurotypical people. They are able to engage with the tasks of their lives in a totally different way. Their ability to control their emotions and their behavior, control their emotional responses, tremendously affects their self-esteem and their self-definition. Who am I? What am I worth? What am I valued? Why am I valued in a certain way? What do other people think of me?

It affects tremendously the nature and healthiness of relationships. How you respond emotionally to the people in your realm makes a great deal of difference about the healthiness and gratification you get from your relationships. Being highly dysregulated in terms of your energy and emotions also affects deeply how well you sleep, how easy it is to fall asleep and awake refreshed, and of course it affects emotional dysregulation.

And this is probably, when you look at it in the long term and especially with adults, probably the most impairing part of the ADHD syndrome. The vast majority of people with ADHD have found ways around their academic and work performance, but they haven't found their way around their emotional reactions to the people and events of their lives.

At all points in the life cycle -- child, adolescent, adult, and elderly -- people who have ADHD nervous systems lead intense, passionate lives. Their highs are higher, their lows are lower, all of their emotions are much more intense. And that really is what we're talking about: not really the quality of the emotions -- people who have ADHD have the same types of emotions for the same reasons that everybody else does. What we're talking here, in terms of dysregulation, is two things: one, the expression of emotions, being able to choose whether or not you let an emotion out. And then, when you do decide to express it, how intensely that emotion is experienced and expressed by you as a unique individual.

Consequently just about everybody with ADHD, but especially little children, are always at some sort of risk of being overwhelmed by their own emotions from within themselves. This is something that needs to be really emphasized: a lot of people with ADHD grow up not being able to trust themselves.

So why is this happening, especially to people with ADHD? I think that just about everybody now would agree that ADHD is primarily a problem of insufficient inhibition, being able to slow down and keep things from happening. If you look at the mass of the human brain, 85% of all the nerves in your brain and out in your nervous system are inhibitory in function. We happen to be aware of the other 15% because we can see what happens when those nerves are used: they create movement, they create emotions, they create our experience and memory. We have to remember they are a minority of the actual mass of the human brain.

Most of what happens inside the brain occurs outside of awareness. What happens is the brain starts something, it gets it moving, and then uses inhibition to guide that toward the destination it wants. It's like shooting off a rocket -- shooting it off is the easy part, guiding it to where you want it to go is the hard part.

When you look at where stimulant class medications work, they work solely in the deep areas of the brain down in the basal ganglia, and especially in an area called the corpus striatum, which is just Latin for a "striped body". That's how it looks when you look at it -- it's got many very fine stripes in it. This area, the corpus striatum, is almost entirely inhibitory in function. What it does is that it inhibits neurological input and output to just the one piece of information or one action that happens to be most important at that time. Everything else gets handled, but it gets handled out of awareness.

Probably the easiest place to see this in action is when we're driving a car. Driving a car is the most difficult thing that the average human being ever has to learn how to do. It's a very difficult process, if anybody has ever had an adolescent learning to drive. But once we learn how to drive a car we do it largely outside of our own conscious awareness. We can drive along, talk to the person on the seat next to us, think about what we're going to have for dinner, sing along to the radio, and not really pay attention, conscious attention, to what's going on around us. But if suddenly something is out in front of the car, even before our conscious brain can process what that thing is, our corpus striatum has already handled it. Slam on the brakes, swerve to miss it, start to question that person's parentage, in the twinkling of an eye. The corpus striatum has been scanning everything, handling everything.

So basically what ADHD is, is that relative lack of inhibition that should be there. Inattention, which is a cardinal feature of ADHD, is the relative lack of the inhibition of other inputs or distractions. When we look at physiologically what's happening, we don't actually pay attention to one thing. Neurologically, we suppress every other thing we might engage with except the one thing that we want. It is maximally inefficient in that way.

Impulsivity is a relative lack of inhibition, of the expression of actions and emotions before you can think about them and make decisions about that expression. Hyperactivity is the relative lack of inhibition of physical and mental activity. When the physical activity of the hyperactive little boy who's pinging off a wall goes away in adolescence, they're still very much mentally active in their own brains.

So what? The “so what” for most of us is that when this area of the brain is not working as it should, people cannot regulate the experience and expression of their emotions. Emotions are experienced as completely unmodified and unscreened. The word that most people use is that they are raw. They come out without any modification at all, they go in without any modification at all. People can see this in hyperacusis, where somebody chewing or the conversation across the restaurant comes in loud and clear because it can't be screened out.

All this is tremendously overwhelming. We get overwhelmed by entirely too much input, and the impulse to have entirely too much output. It's exhausting, and when it does get inappropriately expressed it's embarrassing, so consequently people with ADHD must always be vigilant of themselves.

Now, when we look at the traditional therapies that have been used, or tried to be used, with ADHD, they have had very very poor track records. They're largely ineffective in helping people control the expression of what they think and feel. The reason for this is that people with ADHD don't see their own emotions, their own actions, coming. They find out about their emotions and actions the same way everybody else does: it's already out there before they even know that it's coming. Consequently they don't have the time and the warning to use the techniques and new skills that they may have learned in behavior modification therapy, or in cognitive therapy. They learned them, learned them perfectly well, but the cat’s out of the bag before they can make use of them.

Right now, as we sit here today, medications are the only thing we have to offer that have a proven track record, because they're there all the time. We have two basic groups: we have the stimulant class medications which are amphetamine, methylphenidate, et cetera, which help directly with inhibition. They help slow things down, they help inhibit both input that would distract us and output. It gives you the same two seconds that everybody else has, to see an emotion or an action coming up, to play it out in your mind. “If this happens then this will happen, then that'll happen. Oh, I don't want that to happen, I'll redirect it.”

The alpha agonist, of which we have two -- guanfacine and clonidine -- inhibit the energy driving the speed and intensity of response. Interesting enough, when we look at just clean effectiveness, when we measure how effective is this treatment, the alpha agonists are significantly more effective than are the stimulants. Usually that's kind of a false choice, because most people end up taking both classes of medication.

A very special type, I think, of emotional dysregulation is -- again a terrible technical term -- what's called Rejection Sensitive Dysphoria. We actually don't know what it is. It's much too early to tell. But it does seem to be a thing with which many people with ADHD identify. There was a brief article from ADDitude that got posted on Reddit, on their subreddit on ADHD; that particular posting got twice as many responses, in less than a month, than any other posting that had ever been put on that subreddit. It really touched a lot of people in a strong way.

In my own checklist, when I'm asking about Rejection Sensitive Dysphoria, the question I have is: “For your entire life, in other words going all the way back into childhood, have you always been much more sensitive than other people you know to rejection, teasing, criticism, or your own perception that you’ve failed or fallen short?” This is directly from a psychiatric textbook, an old one, and it's the definition of a technical term, for psychiatrists called Rejection Sensitive Dysphoria.

It's important to note, this is all a matter of degree. No one likes being rejected or criticized. Everybody hates it when we fail, we fall short, especially in front of other people. Rejection Sensitive Dysphoria is much more intense, and is much more than this universal discomfort.

When they were originally doing the research on this particular idea, 45 years ago, they wanted to get that intensity right up there in the name, and so they chose the word dysphoria -- which unfortunately happens to be Greek -- but it means “unbearable”. Because that was the description they were getting from people over and over and over again. Again, for reasons unknown, people with rejection sensitivity have trouble describing what the intense emotion is all about. They can describe its intensity -- “it's awful, it's terrible, it's catastrophic,” -- but not the quality of the mood. And so, over and over again, these research subjects would finally just tell the researcher, “Look, man, back off. I can't find words to tell you what this awful feeling feels like, but I want you to know I can hardly stand it.” And so that's where the word dysphoria came from. A researcher at Harvard who decided to put it into Greek, but that unbearable quality is very much a part of what's going on, a part of the experience of Rejection Sensitive Dysphoria.

It's extremely common in people with ADHD; my guess is that about 95% of my patients report it as a significant impairment, and about a third of my patients say that it is by far the most impairing part of their ADHD. For the majority of people, and most occurrences, it is not that particularly disruptive, but when it hits, it turns your life upside down.

So how is rejection sensitivity experienced? There's no warning. It hits out of the blue; there's no way to protect yourself from it. It happens all at once, it goes from zero to a hundred percent instantaneously. It is commonly experienced as being physically painful, as if someone just punched you in the chest or punched you in the stomach -- there's an aching in the core of your being.

Once it gets started it seems to be largely uncontrollable until it's run its course, whatever it is. The quality of the mood is indescribable. Most people struggle to find any words at all to describe this feeling, even though it's massively intense. The duration can be a few minutes to several months. It's a very potent experience and can make it very difficult to risk ever being rejected or criticized again.

If this very intense emotional reaction is internalized, it looks for all the world like an instantaneous major depression, complete with suicidal thinking. And so a lot of times people do get a diagnosis of major depression, because the clinician they're working with fails to pick up the triggered, instantaneous nature of the onset of that depressive-looking syndrome. If it's externalized, it presents as a rage that is directed at the person or situation that wounded them so terribly. In fact, being “wounded” is is a very common description. This sort of sudden trigger change, with an intense emotional response, not uncommonly leads to a misdiagnosis of borderline character organization.

So if you can't see it coming, and you can't do anything once it's happened, how do people try and protect themselves from episodes of rejection sensitivity happening in the first place? Some people use perfectionism; they try to be above reproach. They feel driven to be the very best at everything they do. These are the penultimate overachievers. It works, but it's also an absolutely terrible, driven way in which to live.

By far the most common response is that people become people pleasers. They are constantly scanning everybody around them and trying to figure out what that person wants or would approve of, and that's what they give them, so much so that it is the to the exclusion of what they want for their own lives. These are people who take care of others, please others, to the exclusion of any sort of gratification in their own lives.

Another very common way that people try to deal with this is that they give up trying anything new, giving up anything in which they might fail or be embarrassed. I have hundreds of patients who have never been able to apply for a job or ask someone of the opposite sex out for a date. Just the imagination of being told no is so frightening, so devastating, that they just say, “No, I'm not going there. I'll sit this one out.”

One of the most effective ways of dealing with this are the alpha agonist medications, and when they work they can be almost completely effective. Alpha agonist again is a tongue twisting name, but it's not as tongue-twisting as the full name, which is alpha-2 selective adrenergic agonists. So you can see why we shorten it a bit. They were originally blood pressure medications that came on the market in the early 1980s. They worked very poorly -- when they did work, at most they lowered blood pressure about 10%, which was measurable but it still required other things that needed to be done in order to get most people's blood pressure down into a therapeutic range.

We have two of them, guanfacine which was marketed both as immediate release and extended release under the name of Intuniv, and clonidine, which was marketed under the trade name of Kapvay, both as an immediate release product and as a delayed release product. They have been used as a treatment of the hyperactive component of ADHD for more than 30 years, so these are not new medications for the field of ADHD. They're very much the treatment of choice for the “hyperactive, disruptive, and obnoxious little boy” that is what most people have in their minds when they consider the notion of “What does a person with ADHD look like?”

The exact mechanism of action of these medications both in ADHD and especially in rejection sensitivity is highly unclear. We really don't know -- we have a couple of ideas but they are very definitely theoretical. The only thing that we know for sure is that the stimulants don't work by stimulating anything, and that the alpha agonists don't work by being alpha agonists. How they do work is completely unknown.

We have two medications, they seem to work equally well, so there's nothing that would lead you to choose one over the other. The problem is that the robust response that we're looking for that really changes people's lives, is disappointingly low -- at about 30% to either molecule. Luckily that 30% is a different 30% of people, so that 30% of people get a good response to guanfacine but it's largely a different 30% that get a response to clonidine. So if the first medication tried does not work, it makes good clinical sense that that one should be stopped and the other one tried. There was an unfortunately worded sentence in an article I wrote for ADDitude several years ago that gave the impression that you could use the two medications together; they should not be used together. You try one, if that doesn't work you try the other.

The typical dose of either one is in the range of three milligrams of guanfacine per day or about three tenths of a milligram of clonidine per day. If you take all the people who get a good robust response to either one of these medications, about 80% are going to end up at these doses, so it's by far the most common dose.

There are of course side effects. Anything that's going to adjust the adrenaline system of the body is going to have the potential for sedation as a side effect, and this does occur for about 25% of people. It's usually mild and it does go away -- over a period of several months. So a person has to be fairly patient with that. It can cause dry mouth, and it's by a different mechanism then the stimulants can cause dry mouth, so the two of them together can really make your mouth cottony dry. And the third one is an accentuation of a universal experience we've all had, when we stand up quickly and suddenly and we get dizzy, get kind of a head rush, vision goes a bit gray. The technical term for it is orthostasis. And this can happen more frequently when you take the alpha agonist medications.

The benefits of the alpha agonist medications take a while to develop. When you change the dose it takes five days for the benefits to develop, so once again they're not like the stimulants where what you see is what you get at one hour. It takes a while for these medications to work and to see all that they can do.

Now just as a side note, Strattera has been looked at in two studies for emotional dysregulation and the results have been what they call mixed. If they did work it was only to a very minimal degree, almost undetectable, so Strattera does not seem to be a medication one could use and expect to have it help with emotional dysregulation.

So in summary, emotional dysregulation is a basic feature of ADHD, is almost universal in ADHD, and it should be considered as a core symptom of ADHD that ought to be evaluated in every initial evaluation. Rejection sensitivity…it's unclear yet -- this is an old concept that has only been brought up in the last couple of years. Its exact nature is still unclear. It does seem to be a specific form of emotional dysregulation, especially in regard that it does respond very well to medication. But again, how it fits into emotional dysregulation is completely unclear at this point. It does seem to be something that's really important, though. It is a thing that resonates with a large number of people with ADHD.

#adhd #sam has adhd #rejection sensitive dysphoria #RSD #emotional dysregulation #Youtube

926 notes · View notes