Emotions & Shame

The Fear of Failure Is Real — and Profound

“Researchers have ignored the emotional component of ADHD because it can’t be measured. Yet emotional disruptions are the most impairing aspects of the condition at any age.” Powerful insights into rejection-sensitive dysphoria.

Young woman with ADHD experiencing Emotional Dysphoria in garden
Young woman with ADHD experiencing Emotional Dysphoria in garden

You cannot manage the impairments of ADHD until you understand how you process emotions and shame. Researchers have ignored the emotional component of ADHD because it can’t be measured. Yet emotional disruptions are the most impairing aspects of the condition at any age. Fortunately, medications like Intuniv can provide some relief.

Nearly everyone with ADHD answers an emphatic yes to the question: “Have you always been more sensitive than others to rejection, teasing, criticism, or your own perception that you have failed or fallen short?” This is the definition of a condition called rejection-sensitive dysphoria. When I ask people with ADHD to elaborate on it, they say: “I’m always tense. I can never relax. I can’t just sit there and watch a TV program with the rest of the family. I can’t turn my brain and body off to go to sleep at night. Because I’m sensitive to my perception that other people disapprove of me, I am fearful in personal interactions.” They are describing the inner experience of being hyperactive or hyper-aroused. Remember that most kids after age 14 don’t show much overt hyperactivity, but it’s still present internally, if you ask them about it.

The emotional response to the perception that you have failed, or even the fear of failure, is catastrophic for those with the condition. The term “dysphoria” means “difficult to bear,” and most people with ADHD report that they “can hardly stand it.” They are not wimps; disapproval hurts them much more than it hurts neurotypical people.

If emotional pain is internalized, a person may experience depression and loss of self-esteem in the short term. If emotions are externalized, pain can be expressed as rage at the person or situation that wounded them.


One Foot. The Other. Repeat.


In the long term, there are two personality outcomes. The person with ADHD becomes a people pleaser, always making sure that friends, acquaintances, and family approve of him. After years of constant vigilance, that person becomes a chameleon who has lost track of what she wants for her own life. Others find that the pain of failure is so bad that they refuse to try anything unless they are assured of a quick, easy, and complete success. Taking a chance is too big an emotional risk. Their lives remain stunted and limited.

For many years, rejection-sensitive dysphoria has been the hallmark of what has been called atypical depression. The reason that it was not called “typical” depression is that it is not depression at all but the ADHD nervous system’s instantaneous response to the trigger of rejection.

Until recently, all that a person with ADHD could do was to wait for his dysphoria to dissipate over time. Clinical experience has found that up to half of people with rejection sensitivity can get some relief from the alpha agonists, either clonidine (Kapvay) or guanfacine (Intuniv). More investigation and research are called for, but if you think that you may have rejection-sensitive dysphoria, talk with your doctor about it.

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