Rejection Sensitive Dysphoria

Rejection Sensitive Dysphoria and ADHD

For people with ADHD or ADD, Rejection Sensitive Dysphoria can mean extreme emotional sensitivity and emotional pain — and it may imitate mood disorders with suicidal ideation and manifest as instantaneous rage at the person responsible for causing the pain. Learn more about potential treatments here.

A woman with rejection sensitive dysphoria hiding her face with her hand
Woman showing hand stop sign while standing at night


What is Rejection Sensitive Dysphoria?

Rejection sensitive dysphoria is an extreme emotional sensitivity and emotional pain triggered by the perception — not necessarily the reality — that a person has been rejected, teased, or criticized by important people in their life. Rejection sensitive dysphoria (RSD) may also be triggered by a sense of failure, or falling short — failing to meet either their own high standards or others’ expectations.

Dysphoria is Greek for “difficult to bear.” It’s not that people with attention deficit disorder (ADHD or ADD) are wimps, or weak; it’s that the emotional response hurts them much more than it does people without the condition.

When this emotional response is internalized, it can imitate a full, major mood disorder complete with suicidal ideation. The sudden change from feeling perfectly fine to feeling intensely sad that results from RSD is often misdiagnosed as rapid cycling BPD.

It can take a long time for physicians to recognize that these symptoms are caused by the sudden emotional changes associated with ADHD and rejection sensitivity, while all other object relations are totally normal.

When this emotional response is externalized, it looks like an impressive, instantaneous rage at the person or situation responsible for causing the pain. 50% of people who are assigned court-mandated anger-management treatment have previously unrecognized ADHD.

[Self-Test: Could You Have Rejection Sensitive Dysphoria?]

RSD can make people with ADHD anticipate rejection — even when it is anything but certain. This can make them vigilant about avoiding it, which can be misdiagnosed as social phobia. Social phobia is an intense anticipatory fear that you will embarrass or humiliate yourself in public, or that you will be scrutinized harshly by the outside world.

Rejection sensitivity is hard to tease apart. Often, people can’t find the words to describe its pain. They say it’s intense, awful, terrible, overwhelming. It is always triggered by the perceived or real loss of approval, love, or respect.

People with ADHD cope with this huge emotional elephant in two main ways, which are not mutually exclusive.

1. They become people pleasers. They scan every person they meet to figure out what that person admires and praises. Then, that’s the false self they present. Often this becomes such a dominating goal that they forget what they actually wanted from their own lives. They are too busy making sure other people aren’t displeased with them.

[ADHD, Women, and the Danger of Emotional Withdrawal]

2. They stop trying. If there is the slightest possibility that a person might try something new and fail or fall short in front of anyone else, it’s just too painful and too risky to even consider. So, these people just don’t. These are the very bright, capable people who become the slackers of the world and do absolutely nothing with their lives because making any effort is so anxiety-provoking. They give up going on dates, applying for jobs, or speaking in meetings.

Some people use the pain of RSD to find adaptations and overachieve. They constantly work to be the best at what they do. Or, they are driven to be above criticism/reproach. They lead admirable lives, but at what cost? They strive for perfection, which is never attainable, and are constantly driven to achieve more.

How do I get over RSD?

Rejection sensitivity is part of ADHD. It’s neurologic and genetic. Early childhood trauma makes anything worse, but it does not cause RSD. Often, patients are comforted just to know there is a name for this feeling. It makes a difference knowing what it is, that they are not alone, and that almost 100% of people with ADHD experience rejection sensitivity. After hearing this diagnosis, they know it’s not their fault, that they are not damaged.

Psychotherapy does not particularly help patients with RSD because the emotions hit suddenly and completely overwhelm the mind and senses. It takes a while for someone with RSD to get back on his feet after an episode.

There are two possible medication solutions for RSD.

The simplest is to prescribe the alpha agonists guanfacine and clonidine together. These were originally designed as blood pressure medications. The optimal dose varies from half a milligram up to seven milligrams for guanfacine, and from a tenth of a milligram to five tenths of a milligram for clonidine. Within that dosage range, about one in three people feel relief from RSD. When that happens, the change is life altering. The treatment can make an even greater difference than a stimulant does to treat ADHD.

One study by Harvard University found that raising the dose of guanfacine to four milligrams and clonidine to seven or eight tenths of a milligram (above the dosage limits the FDA approves), achieved a 40% higher response rate. However, this comes with side effects that can include dry mouth, mild sedation, and sometimes orthostatis, or becoming dizzy when you stand up too quickly.

The second treatment is prescribing monoamine oxidase inhibitors (MAOI) off-label. This has traditionally been the treatment of choice for RSD among experienced clinicians. It can be dramatically effective for both the attention/impulsivity component of ADHD and the emotional component. Parnate (tranylcypromine) often works best, with the fewest side effects. Common side effects are low blood pressure, agitation, sedation, and confusion.

MAOIs were found to be as effective for ADHD as methylphenidate in one head-to-head trial conducted in the 1960s. They also produce very few side effects with true once-a-day dosing, are not a controlled substance (no abuse potential), come in inexpensive, high-quality generic versions, and are FDA-approved for both mood and anxiety disorders. The disadvantage is that patients must avoid foods that are aged instead of cooked, as well as first-line ADHD stimulant medications, all antidepressant medications, OTC cold, sinus, and hay fever medications, OTC cough remedies. Some forms of anesthesia can’t be administered.

[Exaggerated Emotions: How and Why ADHD Triggers Intense Feelings]

Dr. William Dodson is a member of ADDitude’s ADHD Specialist Panel.

Updated on June 12, 2019

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  1. I feel very torn by this view. On the one hand – it’s not conventional, not fully researched and not fully developed.
    On the other hand – I CAN NOT get over how validated I feel by it. An intense gut feeling is telling me there is something to this. This leads me to ask;
    Has anyone tried the mentioned medications?
    What was the result?
    Please share publicly or privately – jaydubb0011@gmail.com

    Thank you.

    1. I can speak to this personally. I was diagnosed with ADHD as a child and have been taking stimulants for 20+ years. While the stimulant helped immensely with executive function, I could never fully get control of the emotional regulation component.

      I restarted treatment about a year and a half ago when I decided I wanted to prep for starting a family. However, I knew I didn’t want to have a child until I could get better control of my emotions. We made some fantastic progress in therapy, however I still struggled with the emotional aspects when things escalated.

      My therapist and I had been using both DBT and CBT techniques to try and help with my emotional outbursts, but it just wasn’t enough. I was starting to really think we’d never be able to get a handle on it. During an episode I would know I needed to count to ten, breathe, get an ice pack, etc. But I couldn’t stop myself. It was like an out of body experience where I’d be watching myself lose it completely and I couldn’t calm myself down. Nothing seemed to be working.

      Last fall my psychiatrist stumbled on a research paper around RSD and sent it to me. I suddenly felt understood in a way I’d never been before. So we decided to give the recommended medicine a try.

      I’m currently taking 1 mg of guanfacine er and 15mg of adderall xr. I noticed an almost immediate reaction when I started the new med (guanfacine). Suddenly everything felt very clear–like a fog had been lifted. Things still annoy me, sure… but I no longer go off the deep end in a matter of seconds. I can see myself getting worked up and I now have the clarity of mind to slow down. Often I can say to my husband “Hey, we need to table this conversation for a later time when I’m not so tired and emotional.” Or “Hey, stop. I’m going to get some ice so I can calm down.”

      It’s also helped with my anxiety. I used to be constantly paranoid that I was being judged or upsetting other people–I was a mega people pleaser. I now am able to see most of that was in my head. And even if it’s not, I don’t particularly care anymore. I know i’m doing my best to live a good life and I’m super lucky to have friends and family who support me. I couldn’t see that before and I definitely can now. I feel very lucky.

      It’s worth noting that meds alone did not solve my problems. I’ve had to work very hard to build skills and I have a therapy team I see regularly for maintenance. But I’ve been able to cut back on the therapy significantly this year and find myself functioning at a much higher level. I’m also very excited to bring my first child into the world next year. 🙂

      This diagnosis was a huge turning point in my life. I just wish I’d known about it sooner and I’m hopeful more doctors will contribute to this research.

  2. As a person who has struggled with ADHD all my life, I believe that RSD is real. When you’re always in trouble, you would think that you’d get used to it, but I think it’s the opposite. Acceptance is such a huge piece of child development that a person who has experienced a great deal of rejection as a child is not going to get over it easily, no matter what age they are. People who don’t get in trouble often tend to receive compassionate treatment because the person correcting them tends to be more gentle. When you have ADHD, nobody seems to understand your thought process and often frustration figures into correction. It is rarely gentle and can oftentimes be abusive. With those kinds of experiences will go a long way to avoid rejection.
    Most of my interactions come from two needs: 1. Keeping the peace and 2. Keeping myself out of trouble. I try not to lie about things; instead I act incredulous. As I become more comfortable in a situation, I might let the “real me” get out, but I tend to be wary because I don’t want to face any more rejection. As an adult, often I find myself in situations where I seem to be doing something well with someone who is supportive and accepting whom I begin to trust. I let down my guard. I actually tell the truth. And then, somehow, I do something wrong, usually without knowing what it was or why it was so important. And then I get into trouble. I’m told I’m immature, unmotivated or irresponsible. And that shakes me to the core because I thought I was doing the right thing. And because I’ve let down my guard, I am totally surprised; I have no reasons for why I did the wrong thing, no rebuttal for the allegations against me. So then I have to rethink everything. Are my perceptions accurate? What if I AM irresponsible, unmotivated or immature? I sure was working hard NOT to be those things. Is my energy going to the right place? Should I rethink doing this thing that I thought I was good at? Should I go find something else to do? What’s going to happen if I do that and then I get in trouble again?
    So it’s never just a feeling of not being able to let go when something bad happens, or not being able to take criticism well. It is so much more than that, rooted in lifelong feelings of rejection.

    1. I understand this deeply. And have repeated this pattern/cycle again and again to the point that, now crippling anxiety has completely taken over.

      I have messed up beautiful opportunities due to this. And also gotten completely shattered in a complex long relationship where all these symptoms were taken and called out as weakness, cowardice immaturity and I could go on. Due to lack of long term motivation to escape from this I went down a path of alcoholism and some other substance abuse.

      Currently just trying extremely hard to get back on track with the help of knowledge, medications, therapy and some good new friend(s). But you know how it is. Painstakingly slow progress with troughs and stagnation aplenty.

      There I went and poured it all out.

      But yeah cheers to you mate. Take care of yourself

      1. Reading this and @Jshelleyw’s reflections brought me near to tears. It’s not often I see a clear mirror in someone else’s experiences. Words & phrases I use like “getting in trouble,” or “shattered” stand out. I even wrote “Shatterproof” on my mirror as a reminder of my fragile strength, even if I am made of glass – emotionally. 🙂

        “Gentle” is also one of my favorite words to help me meditate on what I want to be and do, and it helps often to make a proactive step. Blessings!

    1. I don’t have personal experience with Syrian Rue, but it is an MAOI -monamine oxidase inhibitor and as this author mentions, there is research showing that MAOI medications may help. WebMD states that 3 to 4 grams can act as a stimulant and also produce hallucinations; also states: Serious side effects affecting the nervous system, heart, liver, and kidneys, as well as death, have been reported.

  3. My 40 years of experience, personal and professional, is different from Dr Dodson’s. I’ve found Rejection Sensitive folks with ADHD quite responsive to a blend of Interpersonal [Yalom]/psychodynamic/Gestalt/CBT/ADHD coaching group therapy, with the emphasis on relationships within the group. I’m not a physician or pharmacist, however aside from ADHD-specific drugs, very few of my clients need or benefit from psychoactive medications. And the complications: side effects – both short and long term, interactions and Trouble withdrawing from them suggest using them only when absolutely necessary.

    My outcomes may be partly a function of my personality and personal ADHD, however there must be other group therapists with good results. dr bob dick

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