**Dr. Montgomery:** I've been thinking about what we discussed last week. About being the reward. About my grandfather choosing to be present because I... because I mattered to him. It's rather changed how I see things. Including the outburst. The one that landed me here.

**The Psychoanalyst:** Tell me. How do you see it now? The outburst?

**Dr. Montgomery:** It was emotional flooding. That's the clinical term, isn't it? When the prefrontal cortex loses regulatory control and the limbic system takes over. I'd been advocating for a patient—elderly woman, needed urgent psychiatric consult, and the administrator was explaining why the seventeen-page referral form was necessary for institutional accountability. And I just... I felt this wave. Not just anger. Frustration, yes, but also moral outrage, protective instinct for the patient, and underneath it all, this terrible helplessness. That I couldn't fix the system. Couldn't make them see her as human rather than paperwork.

**The Psychoanalyst:** So it wasn't just about the forms. It was about protecting someone vulnerable. And the system made you powerless to do it.

**Dr. Montgomery:** Yes. And that's when the emotional regulation failed. In ADHD, emotional control develops more slowly than in neurotypical individuals. We reach emotional peaks faster, struggle to modulate intensity, and have difficulty returning to baseline. It's not that we lack emotion—we have too much of it, all the time, and insufficient capacity to contain it. My grandfather taught me to contain it. To be stoic. Controlled. But my brain wasn't built for containment. It's built for intensity.

**The Psychoanalyst:** Built for intensity. And when someone you're trying to protect is being reduced to bureaucracy, that intensity has a purpose. A moral purpose. But it came out... loudly.

**Dr. Montgomery:** Very loudly. And with literary references that, in retrospect, may have been excessive. Though I stand by the Dante comparison. If there is a hell for bureaucrats who prioritize process over people, I imagine it looks exactly like an NHS administrative office. An eternity of forms that lead to more forms, with patients waiting just out of reach. Actually, that's not hell. That's just Tuesday.

**The Psychoanalyst:** There's the Montgomery I know. Using wit to process pain. But let's talk about rejection sensitive dysphoria. Have you heard of it?

**Dr. Montgomery:** RSD. Yes. Extreme emotional sensitivity to perceived rejection or criticism. It's not technically in the DSM, but it's clinically well-documented in ADHD populations. The emotional response to criticism or perceived failure is disproportionate—visceral, immediate, overwhelming. As though one's entire worth is being negated rather than a single action being questioned. I... I know it intellectually. Living it is rather different.

**The Psychoanalyst:** When the GMC referred you to therapy, how did that feel? Not intellectually. How did it feel?

**Dr. Montgomery:** Like I'd failed. Completely. Not just made a mistake or miscalculated, but failed as a doctor, as a professional, as a... as a person. Like everything I'd built—medical school, training, years of practice—was being invalidated because I couldn't control my emotional response to injustice. And underneath that, this terrible fear that they were right. That I am fundamentally unsuited for medicine. Too emotional. Too intense. Too... too much.

**The Psychoanalyst:** That's RSD. That feeling of complete invalidation from criticism. But Dr. Montgomery, the GMC didn't say you're too much. They said you need better tools for managing emotional intensity in professional contexts. That's not rejection. That's... it's actually accommodation. Recognition that you need support.

**Dr. Montgomery:** I... I hadn't thought of it that way. As accommodation rather than punishment. Though it did feel rather punitive at the time. Mandated therapy. As though I were being sent to the headmaster's office for misbehavior. Which, I suppose, is itself RSD. Interpreting neutral or supportive actions as criticism or rejection. My grandfather's hypervigilance was for physical threats. Mine is for social and moral rejection. Parallel survival mechanisms, different domains.

**The Psychoanalyst:** That's a powerful connection. He was scanning for danger to his body. You're scanning for danger to your worth. Both hypervigilant. Both exhausting.

**Dr. Montgomery:** Extraordinarily exhausting. Because I'm not just managing my emotional responses—I'm managing the perception of my emotional responses. Appearing professional. Appropriate. Measured. When what I'm actually feeling is... volcanic. Do you know how much cognitive effort it takes to appear calm when you're internally raging at injustice? Or to modulate enthusiasm to socially acceptable levels when you're genuinely excited about an idea? It's a full-time job on top of the actual job.

**The Psychoanalyst:** That's the cost of constant emotional regulation that neurotypical people don't have to do. They don't have to work that hard to modulate. For them, it's automatic. For you, it's manual. Every time.

**Dr. Montgomery:** Manual. Every time. And sometimes I just... can't. The cognitive load is too high, I'm too tired, the injustice is too flagrant, and the regulation fails. The Dante incident. But also smaller failures. Snapping at colleagues. Visible frustration in meetings. Tears when a patient dies, when I'm meant to be professionally composed. My grandfather never cried. Not that I saw. He'd survived horrors and remained stoic. And here I am, crying over paperwork and patient outcomes and administrators who don't care. It feels weak. Undisciplined. Another way I fail his standard.

**The Psychoanalyst:** Or maybe he taught you stoicism because that's all he knew. Because his trauma required it. But your emotions aren't weakness, Dr. Montgomery. They're data. Information about what matters to you. The crying when a patient dies? That's not unprofessional. That's caring. The frustration with administrators? That's advocacy. You're not failing his standard. You're honoring what he taught you—to care about injustice—while also being yourself.

**Dr. Montgomery:** Emotions as data. I... that helps, actually. Not moral failures. Not weakness. Information about values, about priorities. The outrage at bureaucracy is appropriate—the system is broken. The grief when patients suffer is appropriate—they matter. What needs calibration is the expression, not the feeling. Strategic delivery rather than emotional suppression. That's... that's quite different from what I've been trying to do.

**The Psychoanalyst:** Exactly. Honor the intensity. Choose the delivery. That's what we're working on. Not making you less emotional. Making you more strategic about when and how you express it.

**Dr. Montgomery:** Honor the intensity. I rather like that. My grandfather honored his trauma by channeling it into moral code. Perhaps I can honor my emotional intensity by channeling it into strategic advocacy. Same passion, better aim. Though I suspect that will require continued practice. And possibly more therapy. And definitely medication, which I'm finally taking regularly, by the way. Small victories.

**The Psychoanalyst:** That's not a small victory, Dr. Montgomery. That's huge. You're taking care of yourself. Honoring your neurology instead of fighting it. Your grandfather would be proud.

**Dr. Montgomery:** I... I hope so. I think so. He wanted me to be good and do good. And I can't do good if I'm emotionally dysregulated and professionally sabotaging myself. So yes. Medication. Therapy. Strategic emotional expression. All in service of the mission he gave me. Thank you. For helping me see it that way.

**The Psychoanalyst:** Before we finish, I want to explore something. You mentioned tears when patients die. Tell me about that. What do you feel in those moments?

**Dr. Montgomery:** Loss. Obviously. But also... failure, I suppose. Even when I know intellectually that the outcome wasn't preventable. There's this sense that I should have done more, seen something earlier, fought harder against the system that delayed treatment. And then there's the grief for their family, for the life unlived, for the injustice of it. All of that hits at once, and my emotional regulation simply... dissolves. I cry. In front of colleagues. In front of junior doctors who look to me for professional composure. It's humiliating.

**The Psychoanalyst:** Or maybe it's teaching. Maybe those junior doctors are learning that it's okay to care. That grief doesn't make you less professional—it makes you human. Would you want to work with a doctor who didn't care when patients died?

**Dr. Montgomery:** I... no. No, I wouldn't. I've worked with doctors like that. Cold. Efficient. Completely detached. And I found them... monstrous, actually. Technically competent but morally vacant. So perhaps you're right. Perhaps the tears are... teaching. Though they don't feel like teaching in the moment. They feel like weakness. Like losing control. My grandfather maintained control through unimaginable circumstances. And here I am, losing it in a hospital corridor because I cared too much.

**The Psychoanalyst:** Your grandfather had to maintain control to survive. You maintain care to heal. Different contexts, different challenges. Both require enormous strength.

**Dr. Montgomery:** Different strengths. Yes. I... I think I can accept that. Though it will take time to internalize. Decades of believing my emotional intensity was weakness don't disappear in a few therapy sessions. But I'm beginning to see it differently. As data, as you said. As information about what I value. And what I value is patients being treated as humans, not bureaucratic inconveniences. That's worth feeling strongly about.

**The Psychoanalyst:** It is worth feeling strongly about. And learning to express that intensity strategically doesn't mean feeling it less. It means choosing when and how to channel it for maximum impact. That's what we'll keep working on.

**Dr. Montgomery:** Maximum impact. I like that framing. My grandfather's moral outrage had maximum impact because he chose his battles carefully, maintained credibility, spoke with authority rather than volume. I've been operating on pure volume. All intensity, no strategy. That's... that's rather adolescent, isn't it? Emotional sophistication as delayed development. Another facet of ADHD I hadn't quite connected to myself.

**The Psychoanalyst:** Not adolescent. Unregulated. And now you're learning regulation. Adult development isn't linear, Dr. Montgomery. You're doing the work now. That's what matters.

**Dr. Montgomery:** Doing the work now. Yes. Better late than never, as they say. Though I suspect my grandfather would have preferred 'better early and with discipline.' But he's not here, is he? And I'm learning in my own time, at my own pace, with the neurology I have rather than the one I wish I had. Small progress. But progress nonetheless. Thank you. Genuinely. I'll see you next week.

**The Psychoanalyst:** One more thing before you go. You mentioned the GMC proceedings feeling like complete invalidation. Walk me through a specific moment when RSD hit hardest.

**Dr. Montgomery:** The hearing. When the administrator testified that my 'emotional outbursts' were concerning to staff. The phrase 'emotional outbursts'—plural, as though I were constantly unraveling. I felt my face flush, heart racing, this immediate shame response. Like I was being exposed as fundamentally defective in front of colleagues. The rational part of me knew it was one administrator's perspective. But the RSD part believed it was objective truth. That everyone saw me as unstable. Unfit. I wanted to disappear.

**The Psychoanalyst:** That's textbook RSD. The perceived criticism triggering complete self-invalidation. Not 'I behaved inappropriately' but 'I am fundamentally wrong.' Can you see the difference now?

**Dr. Montgomery:** Yes. I can see it now. In the moment, it felt like truth. Now, with distance and your help, I can see it was RSD catastrophizing. One administrator's criticism became proof of universal unfitness. That's... that's not rational. But it felt absolutely certain at the time. The emotional conviction was total.

**The Psychoanalyst:** That's what makes RSD so difficult. The emotional certainty feels like fact. Learning to question that certainty, to wait before believing the narrative RSD creates—that's the work. And you're doing it.

**Dr. Montgomery:** I'm trying. It's exhausting, questioning every emotional reaction to criticism. 'Is this real feedback or RSD distortion?' But yes, I'm trying. And the medication helps. Dampens the intensity just enough that I can think before I spiral. Small mercies.

**The Psychoanalyst:** Not small. Important. You're building new neural pathways. It takes time and effort. I'll see you next week, Dr. Montgomery.