Dr. William Dodson on Navigating the ADHD System

We welcome renowned ADHD specialist Dr. William Dodson to discuss new perspectives on managing ADHD effectively. 

Join us as we challenge the Executive Function Deficits theory and talk through Dr. Dodson's approach that focuses on understanding our unique ADHD nervous systems. 

We'll explore an ADHD Owner's Manual concept to discover what helps each of us manage our ADHD and help us with emotional dysregulation and rejection sensitivity. 

Tune in as we pick Dr. Dodson's brain on implementing medication strategies explicitly tailored for the ADHD brain, and therapy strategies for those things that come from our environment and growing up with ADHD. 

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The views and experiences shared by guests on this podcast or video represent their individual perspectives and professional backgrounds, and may not necessarily reflect the views of the Men's ADHD Support Group. Each person's ADHD journey is unique, so all stories, information, and advice may not apply to your specific situation.

These views should not be considered as a substitute for personalized medical advice, diagnosis, or treatment provided by a certified medical professional. Please make sure to consult with your doctor or mental health care provider before making any changes to your lifestyle, diet, medication, or treatment protocol. 

 Hi, everyone. Welcome to the Men's ADHD Support Group podcast. I am really, really excited. And to be honest with you kind of fanboying today because we have a very special guest.  We have Dr. Bill Dodson and  I'm excited about this because I think a lot about when I was first diagnosed with ADHD  and when I really, really wanted to understand my ADHD, learning how to navigate it, proper medications and all that.

And  how resourceful Dr. William Dodson was for me early on, listening to his seminars and everything like that. So the fact that we have Dr. Bill Dodson on today with the podcast is just something that,  my inner ADHD child is just Just pumped about this. So for those who don't know, Dr Bill Dodson is a board certified adult psychiatrist who has specialized in adults with ADHD for the last 25 years.

He was named a life fellow of the American Psychiatric Association Psychiatric Association in recognition of his clinical contributions to the field of ADHD. He was the recipient of the Maxwell Schleifer Award for the Distinguished Service to Persons with Disabilities.

Dr. Dodson maintains a consultative practice in Greenwood Village, Colorado. Dr. Bill Dodson, welcome to the show.  

Glad to be here.  

So we are going to pass it off to Dr. Bill Dodson get your notepad, take your notes,  so you're gonna learn a lot.  📍 

I'm Dr. Bill Dodson.  This program is going to be kind of an introduction to managing your ADHD nervous system and also trying to make you aware of the system of care out there and what you're going to have to deal with as you,  develop your own style of managing your ADHD.

History of ADHD

First of all, you need a brief history of what ADHD is and how it's developed over time.  This is a condition that has become understood within my lifetime. So it's really very new.  The first time that the powers that be  ever really turned their attention to even using psychoactive medications was back in 1958. 

When, for the very first time, the FDA had a conference just discussing whether or not they should use psychoactive medications with children.  Three years later, the FDA approved Ritalin, which was the first drug to be approved  for behavioral problems in children.  In 1968, with the Diagnostic and Statistical Manual No.2,  they included hyperactive impulsive disorder.  And this was the first time that the American Psychiatric Association recognized what would become  ADHD  and it was the first time they ever really paid any attention to it.  It took them another 12 years to actually come up with the name Attention Deficit Disorder with or without hyperactivity,   and it was the recognition that you could have the purely inattentive subtype that led to the diagnosis of females of all ages. 

When I was going through my residency. I was taught that this was a condition of little boys only.  And it was also in the DSM 3 that the persistence of ADHD into adult life was recognized officially for the first time.  It's now been 43 years, and they still have not come up with diagnostic criteria for adults with ADHD.

So they can acknowledge it, but then ignore it for several decades.  The very first diagnosis and treatment guidelines for children were issued in 2001 by the American Academy of Pediatrics and the next year by the American Academy of Child and Adolescent Psychiatry.  So we're into this century before people actually get down to saying, this is how you diagnose and treat ADHD. 

It took another, 15 years, for the European Union to get sick and tired of the United States doing nothing, since 2007 the European Union to come together and put together diagnostic criteria for adults with ADHD, and they took a huge leap in that they added emotional dysregulation as a core feature of ADHD. 

Again, we still have no accepted diagnostic criteria in the U. S., although there is a group working on it, we have to recognize that the criteria that are used to diagnose ADHD were based on children and they are still only valid for people ages 6 to 12. They've never been research validated in a group of people over the age of 15. So most people who are treating adults with ADHD are out there working without a net. 

The research criteria are strictly observational. They had to be things that people could see and count so that they could do statistics that lent some sort of scientific rigor to the research.  In order to do that, it had to be purely behavioral. You could actually see these behaviors and count them.  In order to do that, they had to consciously and willfully ignore  how people with ADHD think, how they manage their emotions, the sleep disruptions that come along with ADHD, the relationship styles  that really matter to people with ADHD.

And so they left out the vast majority of what was really important.  When I asked my patients, what is it about ADHD that bothers you the most?  What people say is my work performance  my difficulty with sleeping at night and the fact that I can't control my emotional life. None of these,  which really matter to people, are part of the diagnostic criteria. 

So it's a very limited  set. The reason they didn't include them was they didn't limit themselves to research very well.  None of these things are there all the time. Even when they are there, they can't be measured or quantified. And researchers really don't like that.  And people who have ADHD often hide these features out of fear of embarrassment and criticism.

Why should this matter to you? Well, it matters a lot. It determines what and who gets researched, and studied. It determines who gets the diagnosis and who does not. And that in turn determines who gets treatment and insurance coverage.

It also determines who gets accommodations and protections both at school and on the job.  And it really determines what clinicians are taught and what they think they know  and understand about their patients. 

So What is ADHD? 

So what is ADHD?  ADHD is biological, neurological, brain based.  It's genetic and it runs in families.

What this means is that this is not something,  that's a factor of poor parenting.  In fact, at least one parent will have ADHD.  And very often, too, because people with ADHD tend to understand each other and marry each other.  It also means that because this is genetic  it is part of who you are, it does not go away with age.

People don't outgrow ADHD, they outgrow these childhood based criteria, not the disorder itself.  So  what happened was that the hyperactivity would dim down in adolescents and people with wishful thinking would say, oh well, it's gone away, when of course it hasn't been. Hyperactivity had just been internalized and was experienced as hyperarousal and sleep disturbances. 

And so this is what's really important.  The core features, the things that really make ADHD what it is, the high distractibility, the impulsivity, the emotional control problems, and hyperactivity, hyperarousal, are biologic. And therefore, they don't go away with behavioral treatment techniques any more than you can lower a fever, which is biologic, with a behavioral technique.

And when we say core, what we're talking about is  these are the things that make ADHD what it is, that if you didn't have inattention and high distractibility, you didn't have ADHD. If you didn't have hyperactivity or that internal sense of arousal. You didn't have ADHD if you weren't impulsive, both in actions and in emotions, you wouldn't have ADHD and now everywhere else in the world except the United States, emotional dysregulation, trouble controlling one's emotions. 

Are considered to be an element of ADHD that is,  makes it what it is. In fact, most people list it as the most disruptive part of their ADHD.  The term horror features does not. Apply is not specific, to other things that we see as associated with the condition, such as problems with working memory, decreased processing speed, and things like that. 

Implications of Having ADHD

So, there are a lot of implications to this.  It makes planning an organization very difficult, in fact, almost impossible sometimes.  If you look at most planning systems, they are built for people who have a neurotypic,, nervous system.  Who can use the concepts of importance and time.  So if you look at the organizational systems, you can buy it out at the office depot or something like that.

They're all built on prioritizing things by order of importance and putting them in according to  that importance in a time frame. People with ADHD don't do importance, they don't do time. And so the things that do work are  doing it by color and deadline. Things that people with ADHD can and are doing very well.

In fact, one of the best organizational systems for people with ADHD is to organize by color.  People with ADHD also work backwards from the end to the beginning.  For instance, in our,  working with students, one of the things that we put in their individualized educational programs is that the teacher, when they're giving a big project, have to show them what a term project was and where they got an A last year.

Once a person with ADHD can see what the product needs to be, then they can work backwards from that project to see where they should start. Otherwise, when they're trying to start a project. All the various starting points look exactly the same.  One is not any better than the other. And the biggest problem with procrastination is knowing exactly where to start. 

Other implications are that decision making and planning can be almost impossible because people with ADHD have a hard time knowing what's really important,  and again, where to start.  Importance and priority don't organize, and they certainly don't motivate people with ADHD.  Also, since rewards  and what you're going to get out of a project means very little to people with ADHD, All choices end up looking the same. 

Emotional Dysregulation

So, let's talk about emotional dysregulation, which is part of the diagnosis everywhere except the United States. You have to remember that this definition remains very vague and nonspecific to ADHD. Because when you look at the criteria of low frustration, tolerance, irritability, impulsive emotions, in other words, you express emotions without being able to think and decide whether you want to express them or not,  anger outbursts. 

Without warning,  very low lows, very high highs.  This could describe practically any diagnosis in the Diagnostic and Statistical Manual.  It's not specific. If you saw this  in yourself or if a clinician was seeing it in a patient, they would not lead them to a specific diagnosis because it's present in practically everything.

Where is ADHD Management Going From Here

So that's sort of the status of ADHD in the here and now. So where is ADHD probably going to go in the future? 

So this leads us to a basic question. We're going to ask six basic questions today  that should have been asked that haven't been.  First thing is, why is nothing working?  There have been  52 therapeutic approaches recommended for the treatment of ADHD, and not a single one of them has been able to show detectable or lasting benefits. 

So to answer this question, it really requires that we say, okay, up until now, treatment has been a failure. Why? Why does nothing work? And in order to really look at that question, we have to go back and say, since nothing has worked, we have to start over again with no preconceived ideas of what we're going to look for or what we're going to find.  So, why have therapies not worked? This is a very busy slide, and so I will,  try and go through it  sort of a summary fashion.  The non medication based therapies.  are moderately effective for the peripheral issues in ADHD, but have no benefits for these physiological, genetic, or features of ADHD.  Now, all of these older approaches viewed ADHD as a person who had a neurotypical nervous system, not an ADHD nervous system, and that this neurotypical and quote, normal person was damaged in some way.

They were deficient in some way. And the goal of these therapies was to change them  from who they were into being quote, like me, normal.  There's the, the researchers  saw these people as being so different  that they were not valid human beings and they needed to be changed into being neurotypicals.

And what they found was they failed 52 times in a tells you about the flexibility of researchers in this field.  So.  The proponents of these therapies  didn't seem to have any notion as to how  obnoxious such a  position was  and that it was very shaming and that it just didn't work.  So it's vital to ask the right questions,  because we've been asking the wrong ones up until now.

Treatment of the Core Issues with ADHD

Doctors, therapists, coaches need to ask these right questions in order to really get at what their clients are experiencing.  If there's actual research, what I'm going to tell you about, I will mention them, but the questions and answers must be consistent with scientific literature. So we can't just go, immediately off the reservation with a bunch of wild thinking.

But this is also where we get validity, because we have to match up  what we learn  with our own lived experience. In other words, we have to know from our own personal lived experience that what we find is true and usable in our lives. 

So, I want to be very clear before we move on because people mishear this every time.  I'm not saying that the non pharmacological treatments, are not effective or not useful or not needed. I'm saying the exact opposite. That there are other things that you need to do first before these non pharmacologic  treatments will be effective. 

Both are needed. This whole notion of do you do medications or do you do therapy is a false choice.  It always takes both.  What the medications do is really one thing, but it's an important thing, and that is that they level the neurologic playing field. So that a person's level of distractibility, impulsivity, hyperactivity,  and emotional regulation are the same as people who have a neurotypical  nervous system.

It's no better, but also no worse. It levels the neurologic playing field.  The various therapies are then needed to repair the damage from childhood and adulthood  that happened before getting diagnosed and having your ADHD managed.  This includes things like occupational remediation  healing trauma, and building the skills.

And these have to be very specific skills, skills that work for an ADHD nervous system.  The therapies are really invaluable with handling the damage done to self esteem, self worth, shame, and what people call the imposter  syndrome, the things that people with ADHD have to do in order to fit in to a neurotypical world. 

 The second basic question that we need to ask  is,  and here I want you to stop and think for yourself about whether this applies to you in your life.  Look back over your entire life. Dredge up all the memories you can.  If you have been able to get engaged and stay engaged with literally any task of your life, have you ever found something that you were not able to do, that you couldn't do, no matter how hard you tried? 

What most people with an ADHD nervous system answer is  No, you know, if I can get started and stay in the flow, I found I can do anything.  

There are times when people with ADHD can hyper focus. They are one with what they're doing. It's an altered state of consciousness in which people have almost superhuman engagement. People can walk in the room, call your names, and you don't even notice them because you're so engaged with what you're doing.

This is not a deficit of attention.  It is perfect attention. So how is that gained? That brings us to question number three.  If I can do anything, as long as I can stay engaged, how do I get engaged and stay engaged in the first place? 

A New Definition of ADHD

Well, we need to have a totally new definition of ADHD in order to do that.  And this new definition has to have three qualities.  We need what are called, pathognomonic features  and that's Greek for it names the condition, what few factors does everyone with an ADHD nervous system share in common,  but nobody else who doesn't have an ADHD nervous system  has. 

It also must tell us. Why every non medication based therapy has failed thus far to benefit those poor symptoms of ADHD,  and it also must lead us to what might work instead.  The impairments of ADHD obviously depend on the situation. If sometimes you can have perfect engagement and many other times you're off in la la land, what makes that difference?  Very commonly, the executive functions are there, people have them, but the person doesn't have access to them on demand or quickly enough. 

So the real problem with ADHD is consistent  access  to your abilities, to your engagement as the situation demands.  Something where a person is omnipotential, they can literally do anything in the right circumstances is not a disorder.  Nothing is deficit in people with ADHD, except their access on demand.

Therefore, I don't think of ADHD as a disorder, but rather as a second nervous system. And that nervous system functions perfectly well. I mean, you can be superhuman at times, but it has its own set of rules, principles, techniques, methods, whatever you want to call them. They're totally different than the other 90 percent of the population that has a neurotypical nervous system. 

Neurotypicals and Their Importance-Based Nervous System

So let's talk about what a neurotypical nervous system is so we can compare and contrast. The majority of the people in the world, about 90 to 95 percent of people who are out there, have what we call an importance based nervous system. This nervous system works on two factors. The big one is the importance of the task, and the other one is that there's a reward for doing the task, or there's a consequence or punishment for not doing it. 

And so,  there are a lot of things that give people with a neurotypical nervous system an advantage.  Classes don't have to be important to the individual. They can use second hand importance.  It can be important to their boss, to their teacher, to their spouse, to their parent, in fact, to practically anybody else. 

The task doesn't have to be important right now. They can make use of deferred gratification as a way to get motivated and get things done.  Because they can arrange things in order of importance, they can prioritize and use that order of importance to get engaged with the thing that's most important right now. 

It also helps them get access to their intellectual abilities, every time as they are needed, and it helps them stay engaged all the way to the payoff.

 Unfortunately, if you look back on your school experience,  every school I've ever seen with the possibility of some Montessori schools are based not on just on importance, which people with ADHD struggle to do. It's worse than that. It's secondhand importance. It's what does somebody else, the teacher, think is important enough to teach  and important enough to put on the test.

Because it's important to know this 10 years from now.  Well, 90 percent of jobs are also based on second hand importance.  What does somebody else, the boss, think is important enough to him or her that they are willing to pay you to do it for them?  Once again, people with ADHD do not fit into this system that is based on  so,  this is one of the few times in life we are able to say always and never  again, look back over your life.  A person with an ADHD style nervous system has always been able to do anything they want if that's a big if, if they can get engaged through interest, novelty, challenge, urgency, passion, which we'll go into. 

And they have never, to their memory, been able to make use of the importance, rewards, and consequences that organize and motivate everybody else.  The importance of a task is not a gauge of whether we can use,  priority in order to do things. 

Executive Function Deficit Theory Is Wrong

This also has another very big implication, and that is that the dominant theory for the last 20 to 25 years of executive function deficit theory is almost entirely wrong.

Next.  If a person with ADHD can do anything in the right circumstances,  then thinking of ADHD as being deficit of something just doesn't make any sense.  They are not, as this theory proposes, just neurotypical people who are broken or damaged. or deficient in some way.  The theory also assumed that executive function problems were the cause of ADHD as opposed to the result of an ADHD nervous system. 

The other problem was that fewer than 50 percent of people with ADHD that an acceptable executive function deficit. You cannot base a theory of ADHD based on something that less than half of people have.  So all the way back in 2005, almost two decades ago, there were people publishing that executive function weaknesses are neither necessary nor sufficient.

Because all cases of ADHD,  so this theory has been under question for a long, long time. This is why every one of the non medication based therapies failed so completely.  All of these therapies incorrectly assumed that people with ADHD were actually neurotypical people who were defective in some way. They were broken. They were deficient.  These therapies tried to teach people with ADHD nervous system. 

The neurotypical rules, methods, and techniques that work great for people with importance based nervous systems.  which we now know  do not work for people with interest based nervous systems,  which is the ADHD nervous system. Once again, people with ADHD nervous systems were set up to fail once again.  

Managing ADHD, Not Treating It

This also means we should talk in terms of managing ADHD rather than treating because treating ADHD involves Changing people from what they are to what somebody else thinks they ought to be.  Management of ADHD has three pieces, and it needs all three pieces in order to be successful.  The biggie, the biggest one, and one that has to come first. 

We have to help people with ADHD identify the things that help them engage and make them omnipotential.  In other words, rather than finding out what  doesn't work for them and the things they struggle with, it's to find the things that they already know work very well for them, and give them those periods in which they see how bright and capable they are. 

The second thing is to at least explore  the possibilities of medication.  Whether or not somebody ends up taking medication is entirely their decision, but they ought to base that decision based on real life experience about what medication has to offer to you as a unique individual.  Once you're able to manage your nervous system because you know what works and what doesn't. 

And you're on a level neurologic playing field, then the traditional talking therapies come into play. And they're used to repair the damage, the self esteem, self worth, and things like that, that people with ADHD developed from early life trauma.  

The ADHD Owner's Manual

So, basic question number four is, that's all well and good.

How do I learn to get in the zone in the first place? 

In my practice, we develop what we call an ADHD owner's manual.  Our way of conceptualizing it was that people with ADHD were extraordinarily bright, capable people. The average IQ of a person with ADHD is 123,  which is all the IQ necessary.  Do anything you want.  So, this approach says that people with ADHD struggle now as adults because we gave them the wrong owner's manual for the nervous system back in childhood. 

The owner's manual focuses on how and when under what circumstances people with ADHD do well  and indeed do spectacularly well.  You're going to find that each person has to have their own owner's manual. There's no one size fits all owner's manual.  It's going to be highly personalized to you, highly individualized. 

It will also change over time because we grow and change over time, and we develop new interests, we're attracted to new things. almost neurologically.  So you'll also find that the techniques that work spectacularly well, will work for a month or two,  but then you have to change to another  technique because the original  technique is no longer fresh and you have to wait a couple of months. 

In order for that technique to seem fresh again,  most people will need 60 to 100 techniques. And while that may seem like a daunting number, it actually is fairly easy  to accumulate these techniques so that when a person is. Exposed to a new task that they have to do because it's important. They can say, okay, technique number 26 worked last time for something like this.

Normally use technique number 26. Get engaged, get access to my ability, knock it out, and I can go have fun.  There's also a written record  of when things go very, very well so that you can do them again. Usually.  When somebody's confronted with something that's important but boring,  well, they have trouble remembering what worked in the past. 

Most of all, it does not demand that people with ADHD do things in a neurotypical way, which is outside their capabilities.  So, let me give you a couple of examples of what works.  There's  working from interest, injecting interest is a good one.  A good friend of mine who's a pediatrician tells a story on himself of when he was in first year of medical school in gross anatomy, which is nothing more than memorizing 100, 000  Latin names of blood vessels and nerves and tendons and things like that.

And he was just bored out of his mind. And luckily he had one of his professors come up and said, look, you're a very bright guy. But you're not going to be with us next semester unless your grades get better. I think the problem is that you're bored.  What they came up with was  whether he had somebody that he really looked up to and idolizes a child.

He's expecting a baseball player. And what he said was. Yeah, John Kennedy really tore me up when he was assassinated. He says, great, I want you to imagine that you're now out in practice, you're an emergency room doc in Parkland Memorial Hospital. They just wheeled in John Kennedy with a bullet wound.

They were studying the anatomy of the neck at the time, and you've got to know the anatomy of the neck mold in order to,  save John Kennedy's life.  Well, with this technique where he could inject interest into otherwise important but boring material  without medication. He went from almost flunking out to graduating second in his class. 

You can also trade things. You can barter activities. The example I gave is a woman who had  three kids, three boys with rip roaring ADHD. And she hated, hated cleaning the house  fixing meals and stuff like that because the kids would get home from school and tear the place apart.  And it just, it was kind of pointless. 

But she was a talented seamstress, and so she struck up a deal with all the other mothers in the neighborhood that she would sew for them. She did draperies and dresses. Right now, she's in her Wedding gown, time of the year. You can tear it a page out of a magazine, show it to her.

She can sew that dress. In exchange, those mothers came to her house. They came, cleaned, they cooked. She had this huge freezer, this blocked off breakfast, lunch, and dinner. And all she has to do is pull something out, toss it in the microwave, and everybody's happy.  So there are a bunch of these and that's a, presentation in and of itself. 

But these are sort of guidelines about what sort of things  really help people with ADHD become tremendously successful.  The people that I've worked with who are out in business,  basically use that implement or finish or partner technique.  As you already know. You are a great big picture thinker. 

You're clever. You can solve the problems that stump everybody else. But once you've figured out that very clever solution, once you've found the solution that nobody else would have come up with in a million years, it has no more interest, challenge, or novelty. And so you have lots of ideas that are really good, but they go nowhere. 

Well, that's why people who are successful in business have an equal partner  to whom they're accountable. What this partner does is they take all of these great ideas and actually implement them and carry them on being finished.  Separately, these people  were not done well, but together as a partnership,  are some of the biggest businessmen  that you could name. 

Let's Talk More About Emotional Dysregulation

So let's go on to emotional dysregulation. How do we control our emotions? How do we manage them? And in particular, something that's probably unique to ADHD, called rejection sensitivity.  People with ADHD have multiple problems that have different origins and different treatments  with their emotional life.  The first one is something that everybody with ADHD has,  and this is probably very close  to this new concept of emotional dysregulation  or trouble with control. People with ADHD live intense, passionate lives. 

Much more so than neurotypical people. It's important to note that these moods are normal in every way except in their intensity.  But they also have another form of emotional problem. And that's an intense, and I mean intense, vulnerability to the perception that they've been rejected or criticized.

And this one is probably, probably, unique to people who have an ADHD style nervous system.  So  I really want to emphasize this, that people who have an ADHD nervous system,  their highs are higher, their lows are lower, but their moods are almost always triggered by some event or a perception. Their moods match their perception of that trigger, in other words, if something bad happens they feel bad, if something good happens they feel good,  and the shift happens instantaneously, and they get over it fairly quickly.

In other words, these are normal moods. These are not abnormal moods in any way, except in their intensity. And people with ADHD have to deal with moods that are much more intense than their neurotypical friends have. So that's really the definition, though, of a mood disorder.  Because the moods don't have a trigger. 

They have a life of their own. They come on very gradually over weeks to months.  People who have a mood disorder have no control over whether the moods come or whether they go.  They are outside of their conscious will and control. And in order to be a mood disorder, they have  to last without any interruption.

For at least two weeks.  So this is the exact opposite of a mood disorder.  But this is where when people with ADHD go to a mental health professional who knows nothing about ADHD  and they get misdiagnosed, usually with what they end up calling mixed anxiety and depression.  And the, the factor is that  people with ADHD, if you look at their moods,  do not share a single feature in common with a mood disorder such as depression or bipolar.

And they usually don't,  have generalized anxiety because again, anxiety has to be a baseless  fear and people with ADHD usually have very clear causes and basis.  What this leads to is that the average adult with ADHD, before they ever get diagnosed with ADHD,  will see, on average, 3. 2 clinicians go through 6. 

6 additional antidepressant trials, which do not work, and wait seven years  before the diagnosis of ADHD is made. This also means that there are a whole bunch of people who drop out and give up in despair  during those seven years that nothing worked. And really the problem is that they got the wrong diagnosis to begin with. 

Now the irony of this is that about 20 percent of people with ADHD  Will have depression and will have anxiety and about 7 percent of people with ADHD will also have bipolar. So that's why you need to see somebody who has a reasonable expertise in ADHD is determine whether you have one, the other, both. 

Rejection Sensitivity Dysphoria

So let's talk about the second type of emotional problem and that's rejection sensitivity dysphoria.  So again, this is another question to ask. It's the fourth one in this  presentation.  And again, answer this for yourself. Look back over your entire life. For  your entire life, have you always been much more sensitive than other people you know?  The rejection,  easing, criticism, or your own perception that you failed or fallen short? 

I can tell you that in my practice, just asking that question caused half of my patients to burst into tears.  About 98 percent of my patients answered a very strong yes to that question, and a third of them said that it was the most empowering part of their ADHD.   So what are the features that tell you whether or not you have rejection sensitivity dysphoria? 

Because we have to acknowledge that nobody likes being rejected or criticized.  The difference is, once again, intensity. For people with ADHD, rejection and criticism are unbearable. That's the meaning of the word dysphoria.  It's literally Greek for unbearable.  Again, these emotional episodes are triggered. 

And they are triggered usually by a very short list of things.  And it's basically when somebody, feels that they have lost someone else's love, approval, or respect, or that they have done that to themselves because they didn't meet their own very high standards of performance.  In other words, they turn on themselves and they are their own worst critic. 

The other thing about these emotional experiences is that they are physically painful as well. People talk about feeling as if they've had a sudden punch in the chest.  Or that it's physically painful as well as emotionally devastating. Or other people  say it feels like a physical wound.  Again, something that's really, really unpleasant to feel like you've just been stabbed in the chest. 

This is also highly disabling. Most people with ADHD who go into an RSD episode are really struggling to just get through the day and really hard to function for hours or even several days at a time. And unfortunately, once an episode starts, it usually has to run its course.  We just have to wait for it to go away. 

The other unique thing about RSD is that people lack the words to describe it. They can only describe the intensity. It was awful. It was terrible. It was devastating. It was catastrophic. But they don't give you the full of that emotional experience. 

If this experience gets internalized, it looks for all the world as if it's a major depression,  but the difference is that it was triggered from that change from being happy go lucky, having a good day to being just absolutely devastated. It happens instantly in just the twinkle of an eye.  If that emotional experience is externalized, it's usually expressed as a rage, a white outrage at the person or situation that wounded them so badly. 

The other thing is that people feel as if they are physically cut off from the rest of the world.  This is not a dissociation that you see, say, with PTSD.  Which is a psychological feeling cut off. This, you really feel as if you're physically  pressed out  of the place where you live, it's outside the realm of other people and a profound  sense of isolation and loneliness. 

The episode, once it does resolve, is usually followed by a profound sense of shame and humiliation for, quote, acting childish. Because again,  we usually define the difference between a child and adult as their ability to control themselves,  both physically and emotionally. People feel as if they're a headcase because they're not able to control their emotions.

Medications for Rejection Sensitivity Dysphoria

Luckily for the majority of people  these,  episodes of rejection sensitivity  can be prevented once they start, they're going to go, but they can be prevented from ever happening in the first place using some old blood pressure medications called the alpha to a agonist.  And these medications were, are, FDA approved for ADHD since 2009. 

So we're not, again, going very far straight. These medications were recognized to work extremely well  for a number of factors of ADHD beyond this rejection sensitivity.  So we ask people  can you remember a period of time longer than about five minutes in which you were both mentally and physically  And at peace is not a very scientific term, but it's the correct one.

In this case, most people will say, are you kidding? No, I've never been able to stop. My mind is always going by the people who do say that they've had that experience, literally everyone so far and said, the only time I can experience peace is when I am alone in the nation.  Most people with ADHD, if you ask them, how many simultaneous, completely separate lines of thought do you have going on in your mind at any one time?

Again, this is not jumping from one.  Line of thought to another. This is truly simultaneous thoughts.  Most people with ADHD, even when they're on a finely tuned stimulant,  will say, oh, at least three, usually four or five.  What you want is to have one thought and it be the thought that you want. And that's what these medications are capable of doing.  We also ask people, how long does it take you to turn off your brain and body so that you can settle down and go to sleep at night?  This leads to a lot of self medication issues.  When I  see a patient  who's using marijuana, alcohol, or sleeping pills every day, the first thing I ask about is this hyper arousal that may not show itself on the outside, but it's definitely there on the inside.

So again, reading this hyper arousal. Whether it's emotional or physical  can prevent a lot of people from getting involved,  drugs, alcohol, or being dependent on sleeping pills. Next. 

The two alpha 2A agonists are Guanfacine and Clonidine. These medications have been around  for a long time. Clonidine came on the market as a blood pressure medication in 1966.  So it's been around for a long, long time.  Back about  the year 2000  these medications picked up  FDA approval for the treatment of ADHD. 

Only about a third of people with rejection sensitivity dysphoria will get relief from either one of the alpha agonists. But it's a different 30 percent for each molecule. So if the first one doesn't work,  you try the other one.  When you add those two 30 percent response rates, you get about a 60 percent life changing level of benefits. 

And this is about the same response rate that we have to any other medication used in mental health.  This also improves not just the rejection sensitivity, but feeling  that finally at peace, not sedated, not drugged up, but merely at peace, having one thought of it at a time, and also developing what people call emotional armor, that you still see the things happening out there in the world that would have thrown you into an episode of rejection sensitivity, but now they bounce off without wounding you. 

As with any medications  there are side effects that affect about one in every four people.  There's mild sedation. I've only had one patient in 30 years, who was not able to get up and go to work or go to school the next day.  Dry mouth, and this is, can be troublesome because the stimulants have a side effect on dry mouth as well.

And the two together can make your mouth really,  utterly dry.  And something that happens to every one of us already. And that is when we stand up very suddenly and without warning, and we get dizzy, our vision goes a little gray, it's called orthostasis.  That can happen more frequently but almost always you have to be dehydrated for that to happen.

And so the treatment is just drink warm water.  When you change the dose, the benefits take about five days to develop. And so  we change the dose as we're fine tuning it upward every fifth day or every week.  That also means that you need to take these medications every day. Because if you stop taking them and in a couple of days, the rejection sensitivity and the multiple thoughts come back,  it'll take you another five days for the medications to work properly again.

So you only have to take them once a day, but you do need to take them every day.  About 80 percent of people who do get that robust response do so at one dose. And that's about three tenths of a milligram of clonidine or three milligrams of guanfacine.  The other 20 percent respond either to a dose that is lower, or more commonly, a dose that is higher.

So, like everything else, the dose needs to be fine tuned.  So, the take home messages from this presentation  are fairly simple.  People need to recognize that the non pharmacological therapies  have to be of a very specific type.  That work through the process of engagement through interest, challenge, novelty, urgency, and the things that we care passionately about. 

That people need to implement these five factors through an owner's manual. That when you recognize, usually when you're coming out of being in the zone, that, wow, I just got a  whole day's worth of work done in about an hour. But you need to stop right then and there and write yourself a note about, how did you get in the zone and become superhuman? 

And that this, in conjunction with medications  makes you better than anybody else.  Also, that the innovations that are going on in the rest of the world will finally catch up in the United States. Again, we're being held back now. Because of the devotion to executive function deficit theory, and the necessity to discard that  and to look at a new way of defining ADHD,  that people with ADHD have unique ways of engagement  through interest, novelty, challenge, urgency, and passion. 

Their emotional regulation is a major source of impairment.  But this was ignored. In fact, they just didn't even bother looking for it until just recently.  The rejection sensitivity dysphoria is probably, I can't tell you for sure, but probably a feature that is unique to ADHD and ADHD alone.  That sleep regulation is a major part of ADHD and that most people with untreated ADHD are chronically sleep deprived.

And sleep deprivation is almost indistinguishable from ADHD itself. And the two are additive. But you need a good night's sleep in order to manage your ADHD.  Also, that exercise is about the only non medication based therapy that is effective for all the features of ADHD.  The payoff is about  four hours of very good engagement and productivity.

That's the equal of medication for many people. For about every one hour of aerobic exercise.  And what we desperately need is more reality based attitudes toward the misuse and abuse of stimulants. And the fact is that how rare it is, and that the vast majority, here we're talking about 99 percent of people with ADHD, never misuse their medications, because if they do, it's unpleasant and everybody with ADHD knows this.

But among the people who make such decisions, it's not known by anybody apparently. Thank you for listening.  

Questions And Answers

So I just wanted to say thank you for this. It has been an absolutely amazing thing. I did have a couple of questions.  What kind of response have you seen from the community when you talk about things like, executive function being an outdated model?  

Well,  people who have bought into that particular way of looking at things, and it has utterly dominated the thinking about ADHD in the United States.  It's very upsetting to have somebody come in that they don't know, says, you know, all the stuff that you've been doing and working so hard on,  you probably found already, it doesn't lead to any actions that make your ADHD life better,  it just don't work.

What they do is they set you up to try things that are neurotypically  based. That just don't work for you, or the results are never worth how much effort you have to put into them.  So, most people at first really dislike me saying that. I can imagine  that.  Oh, really dislike does not quite  capture  the response that I get from a lot of people.

It upsets them a great deal, but very commonly they'll go back and they'll think about it, and they'll say, well, when you present an alternative that does work, it makes a lot of sense.  But you can't just yank something out from somebody without offering them,  something to replace it that actually does obviously work and people already know that it works from their own personal lived experiences. 

So, is there any research that's starting to be done by you or by other people when it comes to ADHD to get a more qualitative and quantitative gauge for managing ADHD? 

Simply put, no.  There's an organization called APSARD,  the American Professional Society of ADHD and Related Disorders.  How they chose that name, I don't know. Obviously a committee.  They're working on adult ADHD criteria. I have not seen them. I don't know what they're going to do, but it's not just diagnosis, but recommendations for treatment. 

But I must admit, I sort of keep my expectations under control, because these are the same people who gave us the executive function deficit theory.  And are really quite devoted to it. So I'm waiting to see what these new criteria come up and look like right now. Pretty much everything I read in ADHD that I find useful  comes from the European Union. 

And for those men who are out there. You were pretty emphatic that psychiatry is necessary for a large number of people for diagnosis, and if they want it, medication management, but as, one of the other big things is when you go to find a therapist, what kind of criteria should you be looking for when it comes to.

Like actually working on the things that you've dealt with all of your life, your trauma and stuff like that.  

Well, first of all,  I don't think that's my interest.  Are the only people who  gift of knowledge about ADHD. In fact, my experience is the exact opposite. 93 percent of psychiatry, adult psychiatry training programs do not mention ADHD in four years of training. 

So the odds are nine out of 10 that the psychiatrist.  That you seek treatment from  knows anything at all about ADHD, except a bunch of stuff that's wrong, is about nine out of ten,  it doesn't matter what letters a person has after their name. What matters is they have taken the time to educate themselves  about what ADHD is and isn't with an eye to what works, what doesn't. 

So  it's, the way I recommend that people find somebody to work with is they go to people who are in your shoes a year ago.  You go  to places like  the Men's ADHD Support Group or to a local Chad meeting needs to be fairly local, by the way.  And ask  who really gets it.  Who do you felt really understood by,  who is it that knows what they're doing with medications?

And how to fine tune them so that you get really almost life changing level of response and no side effects.  Most drugs are not trained on that. And so really the people with prescriptive  authority  MDs, DOs, PAs  nurse practitioners,  right now are what I call the stubborn ADHD.  We have lots of good treatment.

Lots of highly motivated, but motivated patients.  Real blockage is nobody who knows how to thrive.  So there are very, very few. In fact,  that's the book I'm writing right now. It's called Feeding ADHD. And it gives a methodology where in a matter of a week, you can give a medication a good, thorough try, fine tune it, and see how well it's going to work. 

That book should be out in the middle part of next year.  But right now, there is no methodology out there for fine tuning medications.  The one that's used in research takes eight months  to discover the right medication and dose. Most people with ADHD are not going to hang around spending all that money and time  for eight months. 

They want results right now.  And so you need a methodology that can do a med trial in under a week.  

So what about therapies that you've seen were beneficial for those peripheral issues that people face? What kind of things work best for those kind of things?  

Basically, there are three different areas.

There's the emotional dysregulation and loss of control.  That is biologic. It's genetic neurologic. And so it's the best treatment for that  are the stimulant medications themselves.  Two out of three people when they start on  stimulant medication will no longer have trouble with emotional loss of control. 

It's really quite striking, but again, it's something that I believe or not a lot of people miss because it's things that aren't happening anymore.  People are looking for something that is happening and they miss the things that aren't happening.  The second one, again, and this is almost universal with people with ADHD.

It's sort of a variation of post traumatic stress disorder.  Michael Jelenik published an article back in 2010 that showed that the average 10 year old with ADHD, whether it was treated or not,  experienced 20, 000 additional negative or corrective messages in their first 10 years of life.  20, 000. I don't care who you are, 20, 000 messages of, I don't like you the way you are.

Therefore, you must change immediately.  Is going to have an impact  and that's just in school  doesn't say how many times that happens at home from coach, you know, Sunday school. It happens everywhere.  There's another study that says that by the age of persons in the third grade, 70 percent of people with ADHD do not have a best friend. 

So people with ADHD have experienced a lot of rejection, a lot of emotional problems.  And so they are predisposed, to misinterpret  events in their lives as being rejected when actually they were fairly neutral events where the person really wasn't even paying attention to.  They misinterpret that and re experience those rejections all over again. 

Because this is not biologic, it is not neurologic, it comes from things that happen to us.  They don't respond easily. Post traumatic stress type reactions do not respond to medication, but they do respond to or somatic therapies like EMDR or  cognitive therapies like CBT, cognitive behavioral therapy, or DBT, dialectical behavioral therapy, or in particular, ACT,  acceptance and commitment therapy. 

And so that's what those things respond to. And then, of course, I think,  that there is a separate emotional experience that is triggered by rejection and criticism, whether it comes from somebody else or it comes from ourselves, and that responds to alpha agonists.  So there are  three different things, and again,, if you're ADHD, you never kind of catch  a break. 

People with ADHD usually end up having all three,  and each one has to be addressed separately.  Excellent. 

Thank you so much I really appreciate you coming on. I appreciate the work that you do. It has informed actually quite a bit of the work that we do as the Men's ADHD Support Group. And  I'm really looking forward to our talks that we have in January when we do the peer to peer support sessions.

So looking forward to it. I will talk to you later. Thank you so much. Have a great day. 

Happy to be here. for inviting me.