Why Inattentiveness Might Not Be the Most Important Part of ADHD

It’s a relief to see how discussion and visibility of ADHD has grown over time, however after spending a lot of time reading articles, watching videos, and catching general discourse around it, there seems to be something severely understated. In fact, this one aspect of ADHD has had a greater impact on my life than anything else.

ADHD is known primarily for the effect it has on attention, particularly how that interferes with learning and the ability to perform at work. Understandable, as this is how most seem to experience it, but the same forces that make attention work differently have a powerful effect on emotion regulation.

Not only is emotion regulation more difficult with ADHD, the emotions themselves can be far more extreme- even painful. Considering how depression and anxiety are often comorbidities of ADHD, this isn’t a small detail. What makes matters worse is how ADHD symptoms can actually worsen due to stress or emotional difficulty. 

What is emotion dysregulation?

As Joseph Nigg, Phd. explains, in a neurotypical brain, the amygdala will send a message to the cerebral cortex about the flood of emotion coming in. The cerebral cortex then inhibits the emotional response so the person can take a breath and think things through. In an ADHD brain, the link between the amygdala and the cerebral cortex is weak, and the cerebral cortex fails to act as a safety valve to release that pressure. As a result, those with ADHD may seem to flip out at insignificant things, have tremendous difficulty recovering from said emotion, and even have difficulty understanding the emotions of others and appear insensitive.

What is Rejection-Sensitive Dysphoria?

RSD, or Rejection-Sensitive Dysphoria, is extreme emotional sensitivity caused by perceived disapproval or criticism from loved ones and other respected peers and authority figures. This is  tied to ADHD, because of how many thousands more criticisms children with ADHD receive than neurotypical children. RSD essentially looks like what is described above- it’s an emotional vocabulary much more extreme, painful and reactive than is considered normal and often precludes mood disorders. Those with RSD are fearful of situations that would be emotionally challenging or that make them feel vulnerable. They may become people pleasers, to the point that they start to give away part of their identity and individuality, and give up at the sign of possible future rejection. Perhaps most significant is what’s best expressed in this line from the reliable ADDitudeMag.com: When this emotional response is internalized (and it often is for people with RSD), it can imitate a full, major mood disorder complete with suicidal ideation. However, some are able to harness the emotional potency of RSD and adapt it to overachieve, often with a perfectionist approach. I personally have experienced all of these, to the extent that no other factor or ADHD symptom has had a more significant impact on my life. One of the telltale signs of RSD is emotion that can become so overpowering and painful that it becomes impossible to describe, and this sensation is what causes the most damage in my experience. Because someone with RSD may react to something emotionally harrowing as if it’s a literal life or death scenario, because their emotions are treating it as such.

Testimonial

In middle school I started having severe emotional reactions due to stress from academic difficulties. Emotional overreactions caused chronic depression and worsened my grades more, which worsened my emotional state. The cycle would ebb and flow for the next 20 years. Emotional fallout was- is– a regular part of life, and in many years self-harm and thoughts of suicide were too. While I had been diagnosed in 2nd grade and started treatment for it in middle school, none of us were clued in on the many forms ADHD can take. ADHD was only a few years old when I was diagnosed and when ritalin and adderall didn’t seem to work, there were no other options. There would be no nonstimulant option until I was in college, and I wouldn’t try it until 2021. By my early 20’s the assumption was that the ADHD was gone, or a non-issue, but it was because I found a field I loved and had no problem paying attention to. However, I worsened in my late 20’s, and we treated depression and anxiety believing they were the sole causes. The cause was emotion dysregulation and RSD, but it took years to realize my emotions weren’t just sensitive or quirky. They were volatile, incendiary, crushing and debilitating depending on the event. I made important decisions based on how my hair-trigger emotions would torture me if I got it wrong. 

Now that I know the truth, I look back at all the times I hurt others because many emotions were like deeply internal panic attacks. That part of the healing process feels similar to entering AA, because I’m only now seeing the path of destruction behind me. This despite the fact that my emotions were turned inward towards myself, as opposed to outward, which can often be the case. In fact, as much as 50% of those in anger management are believed to have RSD. 

A neurotypical person only has their own, normal emotions as a frame of reference, and you simply can’t make people feel an emotion their brain is designed to protect them from, so it’s very easy for RSD to destroy important relationships and make itself significantly worse. That extreme emotional sensitivity simply does not exist in most people. And a broken relationship is the exact kind of rejection RSD itself is in constant fear of.

Inattentiveness and other ADHD symptoms have certainly had an outsized effect on my life. I have never once felt like I had my life under control unless I was in a degree program. Inattentiveness laid the traps, but RSD and emotion dysregulation set them off. ADHD may have started problems but emotion was the last straw in nearly every situation. It led me to believe that my emotions were more important than they really are, because with RSD your emotions are out to hurt you at the slightest provocation. Suddenly every negative life event is a crisis, and every crisis becomes a downward spiral.

RSD not only covered up the significance of ADHD in my life, it acted as a red herring as I puzzled over why the anxiety and depression treatments weren’t working. A year ago I began to believe that anxiety and depression were symptoms of a larger problem, and the previous fall I found out my ADHD was still significant enough to need treatment. Even with two therapists and a psychiatrist- all of whom are skilled and dedicated- It took until March of 2021 to finally recognize the source of the problem. By then, ADHD and the lack of treatment for it led to the dissolution of the most meaningful relationship of my lifetime. Following that, RSD made the situation far worse than I could have predicted. I lost 3 additional friends, two of which due mostly to emotional instability with the third being a total mystery. This all overlapped with the covid pandemic and the loneliness that comes with it, threatening to continue the downward spiral endlessly. While this is a very specific scenario, it began and worsened due to what I once perceived as a minor affliction in adulthood. I had no idea it could cause symptoms so incredibly life-altering.

I am incredibly lucky despite it all, because there were many times where I may have cost myself the chance to figure out what was wrong. I was also privileged, and had that cushion to fall on every time I fell apart. While this may have prolonged the realization, it also meant the difference between life and death on many occasions. Many thousands don’t get that chance.

Presumably millions have tremendous emotional responses and may not know why, only that it drives people away. Those around them may think they’re mean, inconsiderate, or selfish. And as with other ADHD symptoms, without knowing the source, the person internalizes these issues as personal failings. Potential wasted, happy relationships ruined, good jobs lost, and some of them have no idea it’s because of ADHD. Many may not know they have ADHD at all. When I began searching for the “umbrella cause” of my anxiety and depression, my first thought was Dependent Personality Disorder. This, I believe, is because my rejection fears manifest as emotional dependence, attachment, and frequent need for approval and reassurance. 

RSD affects most with ADHD, as well as many on the Autism spectrum and even some who are neurotypical. It isn’t a disorder and cannot be diagnosed the way ADHD can be, and since nobody can compare the internal power of their emotions with others, it can be difficult to figure out if you have it. As with any health-related issue, one should never attempt to self-diagnose. If you think you may have RSD I would ask a psychiatrist about it, primarily if you’re neurodivergent.

Visibility and the DSM

What has been most alarming to me in all of this has been how easy it would have been to fix this had I known. In fact, since discovering RSD, my emotions have changed completely- or at least my handling of them has. Even without treatment, knowing the full extent of ADHD and its symptoms would have allowed me to avoid the most cataclysmic and painful period of my life. While things did become difficult again due to lack of sleep, they were otherwise much easier to control once their severity was given context. 

Medication is important, as is therapy and mindfulness, but there’s also a very significant impact when realizing several of your bad habits are textbook ADHD symptoms, and that you’ve been diagnosed with it. Your whole perspective changes, whereas if you think it’s just your personality, you push back against criticism. You stay defensive. Because you already have enough “wrong” with you, you don’t need more reasons to dislike yourself. You may end up rationalizing your way into a hole you can’t crawl out of.

All of this underscores just how powerful visibility and public knowledge is. One person saying “maybe your emotions are so painful because you have ADHD” could change the course of someone’s life. However even the emotional aspects of ADHD, much less RSD, aren’t part of the public consciousness. RSD is so new that one of my sources was apparently written three days before I found it, after I began writing this article

That said, the emotional components of ADHD are well known among mental health professionals, and is often factored into their decisions. However, the DSM-5 (the diagnostic manual used in mental health) has no mention of emotion whatsoever in its diagnostic criteria on ADHD. The DSM is not an encyclopedia, it’s a diagnostic manual, and the emotional components were removed deliberately out of fear of misdiagnosis- someone with a more serious mood disorder diagnosed with ADHD and not receiving the medication they need. However there are many calling on the DSM committee to return emotion to the criteria, and as a layman and patient I feel inclined to echo that. In my case, I believe I faced the opposite scenario from the one the DSM board initially feared- instead of treating ADHD, we treated depression and anxiety until those medications were little more than a bandaid on an increasingly terrible wound. Again, I’m a layman, and can only speak based on what I’m feeling, and often it is better (or the only option) to treat the symptoms instead. Stimulant medications also don’t help emotion regulation, they just dumb down the limbic system, blunting emotions at the source in an area of the brain totally separate from ADHD.

Let’s not forget, psychiatry is incredibly difficult. It’s a comparatively young science and there are still countless mysteries contained within the human brain, along with constant variation from person to person. Because of this, the public consciousness really needs to be aware of warning signs and when to reach out to a general practitioner or a mental health professional. There are untold numbers of people with this and other conditions who don’t know it, and in the United States many who can’t afford the treatment or are unwilling to pay for a doctor’s visit if they don’t think it’s serious. Thankfully, we’re in an era where it’s easier than ever to increase visibility and public consciousness about an issue, and where mental health is concerned we’re seeing it happen at a greater rate every day. Current and future kids have a much better shot at avoiding the problems I faced, with a wider array of therapeutic and pharmaceutical options. But in order to receive that treatment they have to first know when to see a doctor, and have some idea of what the real problem inside them is, deep down inside where nobody else can see it.

If you have any experiences you’d like to share about emotion regulation and ADHD, or some helpful information to add, please let us know in the comments.

Dodson, W., Dodson, W., & Saline, S. (2021, March 19). How adhd ignites rejection sensitive dysphoria. Retrieved April 30, 2021, from https://www.additudemag.com/rejection-sensitive-dysphoria-and-adhd/

Dodson, W., & Dodson, W. (2021, March 24). Why add makes you feel. so. much. Retrieved April 30, 2021, from https://www.additudemag.com/slideshows/adhd-emotions-how-they-affect-your-life/

Constance, L. (2020, July 07). New study: Adult adhd diagnosis criteria should include emotional symptoms. Retrieved April 30, 2021, from https://www.additudemag.com/adhd-and-emotions-diagnosis-criteria-study/

The importance of emotion in adhd – dr russell barkley [Video file]. (2015, August 01). Retrieved April 30, 2021, from https://www.youtube.com/watch?v=hzhL-FA2v10

Villines, Z. (2021, April 27). What to know about ADHD and rejection sensitive dysphoria (1347617621 987176764 N. Washington, Ed.). Retrieved April 30, 2021, from https://www.medicalnewstoday.com/articles/adhd-rejection-sensitive-dysphoria#symptoms-of-rsd

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