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In-law etiquette, and seeking an ADHD diagnosis

Neuroscientist & Clinical Neurologist

Dear Dr Ash,

I’m usually a confident sort of person but for some reason my in-laws reduce me to jelly. My wife’s father comes from what I suppose you’d call “landed gentry” and hasn’t really strayed much outside that milieu. He’s disappointed with his daughter for marrying the son of a pharmacist and doesn’t bother to hide it. When we go and stay in their huge, draughty country house I feel I’m constantly under judgement for my leftie views and vulgar ways. My sins include preferring beer to wine, never wearing a suit and sending my children to state schools. My wife and I are both film editors and when we’re together everything is fine. But at her parents’ house she somehow becomes gymkhana girl again and I feel she’s embarrassed by me and my table manners. This may sound trivial, but sometimes it makes me so furious I want to walk out of my marriage.

Can you give me some advice on handling the clash of cultures?

Déclassé,
Dalston

People who are comfortable with their station in life feel no need to humiliate others

Dear Déclassé,

I read your letter over coffee this morning and took the chance to sit briefly in the garden. Last week’s glorious weather has collapsed back into a flat grey and I was bundled into a thick jumper, but it did give me a moment to observe the chaotic behaviour of a parliament of rooks that nest in the trees across the lane. It’s like Coronation Street over there, a constant drama of who’s in and who’s out, a riot of flapping, canoodling and squawking that drowns out any chance of a peaceful morning for the rest of us. You are not alone in feeling vexed by the complications of social hierarchies.

I used to believe that social jostling in the animal kingdom had to do with access to limited resources, things like food, shelter or sex. But this spring has been verdant, it seems like there is always a worm underfoot and certainly no lack of twigs. Given the amount of time these birds waste arguing I can’t imagine they are too busy to build a few more nests. Maybe some corvidian planning authority is dragging its feet on applications for new construction, but more likely this behaviour is an essential part of social life in all animals. Robert Sapolsky, the renowned Stanford neuroscientist who spent decades studying the social behaviours of baboons, pointed out this pattern in his own work. “If you’re a baboon,” he suggested, “you only have to spend about three hours a day getting your calories. You’ve got nine hours of free time every day to devote just to making someone else miserable.” I gather from your letter that your in-laws, too, have a lot of spare time on their hands.

Research into the brain basis of social hierarchy, in both animals and humans, reveals the kind of context-dependence that you have noticed in your own life. Social hierarchy makes us feel stressed when we notice it, but not when we don’t. In the presence of our social superiors we experience a threat response driven by the amygdala and the limbic system. They in turn experience a reward response, a dopaminergic surge in the orbitofrontal and medial frontal cortices, the same sort of response they might have to a slice of chocolate cake. But as real as these aversive or rewarding responses may be in a biological sense, they are nevertheless dependent on the context. When your in-laws aren’t there, you’re fine; as you’ve noticed, your gelatinous transformation only happens in their presence. And therein lies the key to your salvation: you can choose to redefine the context.

Despite their clumsy and misguided methods, your in-laws are likely motivated by a desire to care for their daughter. Your wife, in turn, is probably just trying to please her ageing parents. If you become deeply aware of what motivates them all you will find it has almost nothing to do with you and plenty to do with their own insecurities. After all, people who are genuinely happy and comfortable with their station in life feel no need to humiliate others. That is the quality of grace and it transcends class and culture. If you can find it in your heart to be compassionate, it won’t matter what you do with your salad fork or your wine glass. Feeling compassion for the situation of others is the most direct way I know to escape feeling judged by them.

And, if you can’t manage that all the time, take comfort in the fact you are not alone; time spent in the natural world will remind you that all God’s creatures can make mountains out of molehills.

Best wishes,
Dr Ash

Dear Dr Ash,

In the last couple of years six of my friends have been diagnosed with ADHD. We all work in the creative arts and are in our mid-50s. The odd thing is that I feel I have more classic ADHD symptoms (having done research online) than the lot of them put together. My brain feels like 30 computer tabs have been left open simultaneously. I am always late, my office looks like a bomb went off, I forget important meetings and engagements, suffer from terrible procrastination and am plagued by anxiety that people will uncover the extent of my chaos. And my family suffer because I often can’t do simple things like pay bills on time or remember doctors’ appointments. But I am also capable of extraordinary single-minded focus and drive – hence my career success.

But, here’s the thing. I feel strangely angry with my diagnosed friends. And I can’t work out why. I have a
feeling they are cheating by gunning for a diagnosis and taking mind-calming drugs. Perhaps because my parents drilled “mustn’t complain or make excuses” into me.

What should I do? Every time they talk about their ADHD I want to slap them.

Aggrieved,
St Davids

The only reason to seek out a diagnosis is if you want treatment or support

Dear Aggrieved,

Diagnosis is a tricky business. It’s an act of lumping, of grouping different clinical situations together under an umbrella description which necessarily obscures individual variation. In that sense, diagnosis runs contrary to the overwhelming trend in medicine towards individuation and differentiation, towards patient-centred care that emphasises the personal story over the group average. Having said that, were I to wade into these turbulent waters, I might suggest that the phrase “every time someone talks about their ADHD I want to slap them” could itself be added to the diagnostic criteria for ADHD.

But before we go down that road, it’s important to think about why someone might want a diagnosis in the first place. As a physician, I would say the purpose of a diagnosis is first to guide treatment choices and second to facilitate communication between clinicians. Diagnosis is a tool, not an insight. From that perspective, the only reason to seek out a diagnosis is if you’re interested in a medical treatment or if it gives you access to formal services and support.

Nevertheless, there are plenty of non-medical reasons to look for a diagnosis, and maybe these are the ones that are getting your goat. For some people a diagnosis becomes an identity, and in an era where identity seems to carry a lot more value than understanding, this can serve as a badge of honour. For others, a diagnosis can help them to feel understood and seen – but this can have the unfortunate side effect of encouraging them to think that others ought to spend a lot of time understanding and seeing them. Like a good diet and regular exercise, a diagnosis may very well have a salubrious effect but it’s still an awfully boring subject of conversation.

In the end, though, a doctor makes a diagnosis in the hope that a medical intervention can help to alleviate some of a patient’s suffering. If your friends carry psychiatric diagnoses, it is likely because they were suffering enough to push them past any barriers to accessing mental health care, past any concerns about the stigma that is still associated with mental health conditions, and past any doubts about the effects and side-effects of psychiatric medications that, after all, act directly on the brain. Most people really don’t go down that road lightly.

If your struggles are manageable enough that you don’t want to explore a diagnostic pathway, count your blessings and enjoy your strengths. If, on the other hand, you see your own story reflected in your friends’ and you think a diagnosis might really benefit you, it’s not a bad idea to talk to a doctor. Just try not to go on about it to everyone else.

Best wishes,
Dr Ash

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