Rejection Sensitive Dysphoria

How ADHD Ignites Rejection Sensitive Dysphoria

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 ways to manage RSD 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 (RSD) is extreme emotional sensitivity and pain triggered by the perception that a person has been rejected or criticized by important people in their life. It may also be triggered by a sense of falling short—failing to meet 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. No one likes to be rejected, criticized or fail. For people with RSD, these universal life experiences are much more severe than for neurotypical individuals. They are unbearable, restricting, and highly impairing.

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. The sudden change from feeling perfectly fine to feeling intensely sad that results from RSD is often misdiagnosed as rapid cycling mood disorder.

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 aspects of relating to others seem typical. RSD is, in fact, a common ADHD symptom, particularly in adults.

When this emotional response is externalized, it looks like an impressive, instantaneous rage at the person or situation responsible for causing the pain.

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

RSD can make adults 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 they present that false self to others. 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 becomes too painful or too risky to make the effort. These bright, capable people avoid any activities that are anxiety-provoking and end up giving up things like dating, applying for jobs, or speaking up in public (both socially and professionally).

Some people use the pain of RSD to find adaptations and overachieve. They constantly work to be the best at what they do and strive for idealized perfection. Sometimes they are driven to be above reproach. They lead admirable lives, but at what cost?

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’re relieved to know it’s not their fault and 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 solution is to prescribe an alpha agonist like guanfacine or clonidine. 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. Sometimes this treatment can make an even greater impact than a stimulant does to treat ADHD, although the stimulant can be just as effective for some people.

These two medications seem to work equally well, but for different groups of people. If the first medication does not work, it should be stopped, and the other one tried. They should not be used at the same time, just one or the other.

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.

Rejection Sensitive Dysphoria: Next Steps

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

Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

119 Comments & Reviews

  1. I think it is unlikely that only those with a ADHD diagnosis suffer from rejection sensitivity. I think people with all sorts of mental health issues suffer from it as well. In addition, I know many people with ADD who do not suffer from rejection sensitivity. ADHD seems to me to be more and more of a grab-all diagnosis for which there appear to be more and more medications that are recommended whether they are FDA approved or not. We need a major overhaul of the entire diagnosis rather than this shot-gun approach that comes up with more and more symptoms, more and more patients and more and more pharmaceutical treatments that may, or may not, be effective. It has gotten out of hand.

    1. RSD is a very real ‘condition’ that can be comorbid with ADHD. I speak from personal experience with my husband. For years I have been trying to figure out why he turns angry within an instant of the slightest rejection from me regarding an idea he has or how he thinks something should go. It’s like he forgets I’m his wife and I don’t criticize him. I have to be so careful how I word offering another idea to the table. I’m a special education teacher, so I have a lot of experience with unstable and displaced emotions with individuals, but I just could not find a root cause for his severely hurt and angry outbursts with my slightest nonagreement with something he has suggested. Until….I read about RSD. It was like my husband was being described in detail. I have been studying dyslexia this summer and see big connections between RSD’s perceived understanding of a false reality and a person’s perceived reality with dyslexia. When they get get triggered into frustration, whether it be emotions or letters or numbers, that confusion causes the person to perceive a false sense of reality. So, my point and realization is that I see a strong connection between ADHD, RSD, and dyslexia….in very intelligent and capable individuals.

      1. I too have struggled for 34 years with an amazing man who I felt had an anger management problem. Then anxiety and depression. Once I read about RSD this summer, like you, I felt it was describing exactly what we’ve been going through for 34 years, often I’d want to divorce a man who truly felt I was trying to bring him down but he was such a wonderful man otherwise. I felt I was living with a Jekyll/Hyde it was such an extreme change in personality. He is still having a hard time wrapping his head around having ADHD and RSD, he still wants to point and find something wrong with me as the issue, but I feel we can get somewhere with a therapist now. Marriage counseling never worked, it would highlight a few issues but never get to why these explosive reactions kept occurring on a very regular basis, with days of agitation and anger as he kept trying to verbalize what was happening, and all he could say was why was I trying to tear him down all the time which is exactly opposite from what I’ve always done for him. I have in fact given up most of my career, friendships, family ties etc to be what made him feel safe. He intellectually knows how much I love him but every day feels anxious that I will leave him which I’ve promised never to do. Though I do tell him we may have to separate, live on the same property in different dwellings and date but never divorce because I am getting to the point I’ve given up all I wanted to do with my life to make this wonderful man feel secure and I’m still getting emotionally and verbally abused because of his extreme RSD. This is not a wimpy man, he in fact owns and operates an excavation company. We’ve never gotten any support for this because everyone just chalked it up to it being a marital issue which I knew it was not. I’ve been so frustrated and desperate to determine what is going on, not get him medicated, but to give him an answer that doesn’t make him feel he’s stupid which is what he’s always felt. I really hope we do not get a therapist like bruce.macleod I really hope we get a therapist who will listen and trust us and not try to tell us what we’ve experienced. One who will help my husband decide if medications are good for him and support him if he decides not to medicate. I do believe psychotherapy can help if someone does not want to medicate, but it can often be hard to get an appointment quickly to process the situation with the therapist so I understand why the author said it may not be effective.

    2. Walk a mile in our shoes. I was diagnosed almost 30 yrs ago with ADD/ADHD. I have spent most of my life telling people I don’t care what people think about me and secretly worrying myself sick and losing sleep over rejection or the perception of rejection. I have basically no friends because when I talk, tell a story or describe something I ramble or include too much detail. I have seen the way someone looks at me while I am talking and assume they are bored or think I am stupid. So at 39 I have basically stopped trying to make friends because that seems easier and less painful than seeing that look again. At work I am a perfectionist and when something goes wrong I am so affected I would rather quit than have to come in and see my boss with a questionable look on their face. Since reading this article I feel like I might have a chance to take control of my life again. Knowing I’m not just a crybaby to be a crybaby makes me feel a little better. I don’t feel like I can give up my ADHD medication to test this because I know I would end up jobless inside 1 week, either getting fired or quitting because I don’t feel like working. So it’s not about pills, pills, pills. It just means my enemy has a name.

    3. Having been a 34 year spouse of an ADHD sufferer long undiagnosed this is so exciting for us to hope we can see the chaos that RSD has caused us finally be explained. We are fortunate to still be together 34 years because it’s been excruciating the pain and trauma it has caused. Knowing what it is will help even if he decides not to take medications. Just knowing what is happening to him is going to change our lives immensely!!

    4. Salum comment is absolutely correct about the blanket diagnosis of ADHD.
      Lmao to all the adder comments slamming him before thinking.. 😂😂
      I have adhd and I also recognise RSD in my behaviour.
      My ex has BPD. After supporting her through 4 years of DBT for her Bpd she then went on her own. Within 9 months the psycologist in her wisdom changed the diagnosis to ADHD! I objected the diagnosis and begged them not to give her the stimulant as she was just manipulating them to change the diagnosis. (because they had now taught her what she needed to show them after 4 years of DBT) But they knew better than the one person who lived with her and they prescribed Ritilin! Let me tell you stimulants an BPD dont mix well! Over the next Year she covertly had my 11 year old step daughter diagnised with OCD and ADHD (all symptoms caused by sleep deprivation and malnutrition) The result was a prescribed drug induced psycotic episode and she nearly killed herself! After her admission she has had no medication and lives happily with dad fulltime.
      Misdiagnosis is out of control in Australia and the psycological profession has a lot too answer for! But they get to hidenjoy behind the confidentiality code and mental health legislation.
      It has destroyed our family beyond belief and now I am fighting the family court system as well!

  2. I actually disagree. I believe that Dr. Dodson’s description of RSD (and other emotion-focused characteristics of AD/HD) are extremely accurate and represent my and many others’ greatest challenge of the disorder. While I agree that diagnostic criteria, and conceptualizations of the disorder need an overhaul, I very much favour extending the popular understanding and the clinical model of AD/HD to include the dysregulation of emotion rather than focussing solely at the cognitively inattentive and behaviourally hyperactive symptoms that currently are highlighted.

  3. can’t wait to tell my next client with ADHD/RSD – it’s ok, your not damaged. your defective. that will make such a difference. the idea that psychotherapy is not effective for so called RSD is a flagrant abuse of his authority as a psychiatrist and expert on ADHD. the whole article is an advertisement/promotion for old drugs in search of a new markets.

    1. I find it hard to understand why a mental health professional would choose words like “damaged” or “defective” to describe patients. Having a “name” for something, and using it as a lens through which a person can better understanding behavior or symptoms they have experienced throughout their entire life, can be highly empowering. This label/lens model of disease treatment is critical for all areas of medicine; it’s the difference between treating “cancer” or a highly-specific and genetically-based subtype of breast cancer, or even the distinctions in treating MDD and Bipolar depression.

      I also don’t understand your interpretation of the author’s discussion of possible treatment options. Patients experiencing RSD would almost certainly benefit from psychotherapy to help manage co-morbid disorders or even simply as supportive care, but knowing that approach may not effective treat for RSD directly is critical information. And identifying old and inexpensive medication options hardly seems like a drug sell, especially since the negative side effects are clearly mentioned and the author proposes that this type of treatment may negate the need for stimulant medications in some patients.

      And I agree that we need better diagnostic and treatment methods for ADHD. I find Dr. Daniel Amen’s work with SPECT brain imaging and it’s potential to clinically confirm and further specify subtleties in psychological and neurological disorders to be truly revolutionary for the
      future of ADHD, and brain science in general.

      1. Ok Jennifer “I find it hard to understand why a mental health professional would choose words like “damaged” or “defective” to describe patients”. Let me explain.
        first off, Dr Dobson offers this drivel as expert opinion with no reference to research other than some old studies that validated drugs with sedentary side effects (unlike trauma, sedation makes anything that involves consciousness less bad). So his pronouncement that.. “Rejection sensitivity is part of ADHD. It’s neurologic and genetic. Early childhood trauma makes anything worse, but it does not cause RSD.” is simply a statement made by a guy who is advertising some older medications that are not currently used for ADHD.
        In making the statement it is genetic (with no evidence)he is in fact saying that it is a genetic defect, just like my red hair. obviously I would not say this to a client, as you should have been able to tell from my statement. But saying you are not damaged (which can be repaired) you have defective genes shouldn’t be much comfort to anyone. Particularly the clients I see with early severe parental rejection.

        If this had been a report on RSD with some research to support, it would have provided useful focus for treatment with Psychotherapy. Dr. Dobson cut that off with his statement that psychotherapy is not effective, a pronouncement made with no research to back it up. Interesting as I work effectively with clients who have sensitivity to rejection every day.

      2. Do you seriously believe that every well-accepted commonplace in psychology has to be documented, annotated, and footnoted every time it’s mentioned? The solution here is not for the author to better document things which are not in dispute. It’s for you to do enough reading to know that they’re so generally accepted that doing what you suggest would be meaningless- and remedy your ignorance a bit, eh?

      3. Thank you, Bruce, for trying to shed some light on the huge problems with this piece—and the resulting copycats throughout the Internet.

        I am receiving reports from adults with late-diagnosis ADHD that their mental-healthcare providers are “stupid” because the providers don’t realize they have RSD — and some have never heard of it.

        This demagoguing of psychiatric issues should frighten everyone, and it is pervasive on the Internet given the simplicity of the message.

        Gina Pera

    2. I find it hard to understand why a mental health professional would choose words like “damaged” or “defective” to describe patients. Having a “name” for something, and using it as a lens through which a person can better understanding behavior or symptoms they have experienced throughout their entire life, can be highly empowering. This label/lens model of disease treatment is critical for all areas of medicine; it’s the difference between treating “cancer” or a highly-specific and genetically-based subtype of breast cancer, or even the distinctions in treating MDD and Bipolar depression.

      I also don’t understand your interpretation of the author’s discussion of possible treatment options. Patients experiencing RSD would almost certainly benefit from psychotherapy to help manage co-morbid disorders or even simply as supportive care, but knowing that approach may not effectively treat RSD directly is critical information. And identifying old and inexpensive medication options hardly seems like a drug sell, especially since the negative side effects are clearly mentioned and the author proposes that this type of treatment may negate the need for stimulant medications in some patients.

      I do agree that we need better conceptions of ADHD. I find Dr. Daniel Amen’s work with SPECT brain imaging and it’s potential to clinically confirm and further specify subtleties in psychological and neurological disorders to be truly revolutionary for the
      future of ADHD diagnosis and treatment, and brain science in general.

    3. Dr Macleod,
      Although I appreciate your candor in your commentary on the veracity and credibility of Dr. Dodson’s statements, I can not stop myself from feeling that your analysis has several critical flaws as well.
      I do not understand the basis of your assertion that the author is saying that ADHD patients who suffer from RSD are “defective”, rather than “damaged”. He neither expressly states so nor even uses the word in his entire piece. I further contend that what he is trying to say, based on the context, is that patients many times feel relief when told that there is educated consensus that what they have been suffering from their entire lives is a result of physiology and genetics, as opposed to something that could have been avoided had circumstances of their upbringing and influences been different: that they had not missed out on an opportunity to avoid what many times has caused severe unhappiness in their lives through lack of due dilligence on their part. I think that it is “not their fault”, nor anyone else’s, that they suffer comes with a strange sort of but not insignificant relief. As an MD neurologist whom also suffers from ADHD and now recognizes the symptoms of RSD being present in my entire life, this article has had that exact effect.

      You also mention several times that he presents his conclusions with no accompanying evidence. But this does not seem to be an appropriate forum to present an argument in that form, with pages of references longer than the article itself. The intended audience of this article seems to be lay people with loved ones whom, or even themselves, suffer from the symptoms of RSD and not those trained in evidence based practice. I admit that I have not looked up Dr Dodson’s body of work nor any other systematic studies on RSD in the context of ADHD, but I question whether you have reviwed the literature as well. Are you sure that Dr Dodson just woke up one morning and decided to pull these arguments out of his… yeah…? If you are instead accusing him of lacking intellectual rigor or academic dishonesty, I would caution you that those be fightin’ words and that Enigo Montoya would Not be happy about that.

      What is truly confounding me is that you also say that Dr Dodson is advertising new uses for old medications that are not used for ADHD. First I point out that guanfacine is first line treatment for ADHD in the pediatric population. Clonidine is second or third line I believe, and I myself was trained in its use during my training. Admittedly my current practice is in vascular and interventional neurology, with little to no exposure to patients with ADHD as their chief complaint, but your assertion that these medications are not used to treat ADHD is baseless. I also wonder what exactly you mean that he is “advertising” for the use of obsolete medication over more modern and therefore better meds. I can not think of anything that a physician would gain from advocating for the use of drugs of which the patents have long since expired, other than mitigating the suffering of their patients. I can understand that you may have inherent bias when someone suggests greater efficacy of an approach to a problem over the methodology that you may practice. I find myself suffering from that exact bias when I hear Dr Oz advocating for the use of some exotic potion collected from the sweat glands of pigmy walruses during a full moon over conventional therapeutics. But it is WALRUS derived… Or, do you know of a drug company that gives free lunches and kickbacks for clonidine? Hook a brother up then because the neurosurgeons do some of the same things that I do but get paid three times as much. No lies.
      I would appreciate any feedback you would have. But I still feel the need to emphasize one thing. I apologize to whomever else may be reading this about the all-caps, but DO YOUR F******G HOMEWORK BEFORE YOU OPEN YOUR MOUTH.

      1. I would appreciate any feedback you would have. But I still feel the need to emphasize one thing. I apologize to whomever else may be reading this about the all-caps, but DO YOUR F******G HOMEWORK BEFORE YOU OPEN YOUR MOUTH.
        How quickly you descend into personal attack. no point in continuing this, I said and clarified what I think and have no interest in engaging or changing your mind.

      2. Exactly! We lay person’s are just trying to find information to help the ones we love and keep our marriages from being yet another divorce statistic. I literally have gotten good information from every single person who commented EXCEPT YOU. So please just be quiet and go away. Obviously not a single person here is happy with your input.

  4. I am a 68 yo female, who was diagnosed with ADD when I was in my 40’s. I did not do well in school. My parents moved, so that I could attend high school where there were a lot of Jewish girls and make friends with them. I am Jewish. Wearing brand names didn’t make me accepted by them. They were snotty bitches. A lot of them became friendly in the early years, because they grew up in certain neighborhoods, went through elementary, middle and high school together. I was a Hebrew School drop out. At age 17, my parents took me to a neurologist, child psychologist and child psychiatrist. College was out of the question. The neurologist told my parents that I was capable of making C’s or better in high school. I had trouble focusing,listening and paying attention. Then, how come my GPA was 1.73 when I graduated in 1967? All I can remember about the psychologist is her saying that I had no motor and cognitive skills. The psychologist asked me what don’t put all your eggs in one basket means? I said that one could easily break. I’ve had trouble in all of my jobs as a secretary, because I was constantly late. The tasks were difficult. My evaluations were far from perfect. My father told me that I’d be lucky if I got a job in a dime store as a cashier, that I wouldn’t amount to anything. He didn’t understand. His IQ was 140. I lack self-confidence and don’t like myself. I am a failure, who is weak and gets taken advantage of. I’m tired of people telling me that I use ADD as an excuse. If they don’t have it, they don’t know what’s it’s like living with it.

    1. You are not crazy. My husband says that a lot and it breaks my heart. He is an amazing person! Smart, funny, loving, supportive he’s so much better than most men yet he is plagued with this. I’m so sorry you are, I’m so sorry you are feeling that low. I do know that our close relationship with Christ has been the absolute number one thing that helps my husband know that he is not alone. I hope you have faith or a close friend you can turn to, I’ve never met a person with ADHD that wasn’t smart. My husband is very smart in physics but he did not do well in school so he was never able to achieve his full potential. At some point you have to realize we don’t all get to make our lives what we wanted but we can find good in the daily living. Please find a good therapist, support group and a friend. It’s not too late for you to find joy in life, I so pray that you will and I’ll be keeping you in my prayers if that’s ok with you.

  5. One more thing. My parents rented a pool for me to have a pool party when I was 13. I invited some of those bitches. They weren’t decent enough to respond. One guy I had a crush on, came. Children can be cruel, but adults are worse. I live in a resort city. Some of the residents are rather snobby and rude. They have their clicks. I truly have a distaste for snobs. There are people who don’t have a pot to piss in but, when they suddenly get money, they change for the worse. It’s time to hit the sack. One psychotherapist I saw said that normal people see him. It’s the sick ones who don’t.

  6. Speaking of second and thied line meds and their effect on ADHD and RSD disabilities, I am 72 yrs old and A recently diagnosed severe ADHD combined type. As so kany others are I was diagnosed withsevere depression following 14 day hospital evaluation and prescribed Venlafaxine and for a very short tim ranrisparadone 5 years ago. The venlafaxine initially increased to 150 mg and later reduced to 75 mg took amore than a few months and a third divorce to achieve its greatest effects. They were however awesome. Things slowed dwn enough fir me to note the similarities of what i was going thru to my sons and grandson who were both diagnosed with AdHD and as adults were on medication. online tests followed by a full evaluation folllowed and my drug regime had concerta and amitryptilene added which didnt really help as i returned to being more aggressive. And were discontinued.
    The results so far have been a major increase in working memory, in not losing things, in accomplishing tasks on my todo lists ( this still needs work) in patience notoriously LFT , and in accepting and encouraging criticism. And the complete disappearance of what I now fecognize was RSD. Things helped but not as much include Timeliness better but not all that good,
    Downside Recently I ran out of Venlafaxine after giving the Pharmacy a months notice to contact my doctor and then another 4 days notice. They sent him a fax but neglected to follow up. My Family Physician had recently left the city and his brother in the same clinic became my FP. A few hours after the first missing dose I went balistic at an email that dared to assume i knew the user ID and PW for a site that would provide a set of instructions to forward to others. Although i had correponded with them 3 weeks before I completely forgot who they were and was totally upset and felt they were implying i was auditioning for their approval. One of the nastiest emails i can recall was sent to them saying everything but that their mother wore army boots. It was bad enough and scary enough that they fired me from a vlounteer choir. Anyway believe everything you have heard about withdrawl on this med. it is however very good at eliminating the RSD issues. In fact I would never have been in that choir in the first place fearing rejection. As two of my divorces are directly related to RSD i wish i had met this diagnosis and treatment two divorces and a million dollars ago.
    Love those second and third line meds.

    1. Thank you for saying this because I’ve spent God knows how long on this particular webpage reading the article then all the tons of comments thus far, all the while it’s been eating at me wondering why this is being portrayed as something exclusive to ADHD!? I have inattentive type ADHD & while I can somewhat relate to this so called “RSD” I’m still on this page bc it described my fiance (whom I’ve been with going on 8 yrs) to a “T” and he has only recently confided to me that he was diagnosed with autism at one point during his childhood. I haven’t done hardly any research on autism but I can say this article described him exactly and he does NOT have ADHD. He grew up with an alcoholic abusive father and also struggles with anxiety. Did your DH perhaps have a similar childhood? Just curious bc I wonder if that aspect has anything 2 do with my mans RSD.

  7. Many people can have one or a few of the traits associated with ADD., and not have ADD. Everyday I’m see new traits that I have that have impacted my life severly and that fall under my ADD diagnosis. My diagnosis has explained my entire screwed up life to me finally. If you treated each trait that we have, we would be taking pills non stop all day long, which with the stimulants I already feel like I do take pills all day long.

    My point is, a true ADD diagnosis has so many traits associated with it that you can’t possible treat them all.

    If anyone wants to do some really helpful research, figure out how we can get a grip on this crap while it’s happening and purposefully turn it around while it’s happening. Impulsive comments, intense feelings of rejection before an actual rejection, brain freeze, overwhelm and lack of motivation, just to mention a few. Fact is stimulants affect the biggest one, focus.

  8. These symptoms are similar to those of Borderline Personality disorder – fear of abandonment causes people pleasing behaviour, perceived or real rejection can cause angry outbursts and the person being vilified even for a small misdemeanour. There is a feeling of no sense of self, no,real identity as mentioned in this article as the person is constantly trying to please/form attachments and therefore they don’t connect with what they want and need. BDP can be comorb with ADHD/ASD. I think that all of these developmental disorders have common connections, lack of impulse control, emotional dysregulation, anxiety, low mood, lack or organisation. With ASD people are constantly reading social cues to try to make sense of the social world, with BDP people are constantly trying to please to make sense and belong in the social world, with ADHD people are constantly trying to curtail their impulses to fit in to the social world. In all cases the difficulties fitting in to the social world causes anxiety, sometimes depression, sometimes depersonalisation, sometimes loss of identity. The key is to treat people earlier as children and help them as children with anxiety control such as exercise, Mindfullness, CBT. They can’t comtrol others but they can learn with these interventions how to control their reactions to others and hence miniimise their anxiety feelings of low self worth,

    1. I agree with you but we have to come up with a clinical inexpensive test or vacine that accomplishes. While I was not diagnosed until I was seventy I grew up in a family of with 11’siblings and countless neices and nephews almost my age. The tremendous support given by olders and the neighborhood grapevine worked better than any facbook or twitter info line and i was fortunate to have such a system that very few today benefit from. The key iss in a. Clinical a,larm test since so many will slip thru the other safeguards we have.I was also fortunate to inherit the families genius level IQ. Unfortunately having the patience to correct all these errors or mis intuitive spelling suggestions on this ipad doesnt come with my set of genes.

    2. I am one of those unfortunate people that got misdiagnosed with Borderline Personality Disorder by a psychiatrist after a few minutes in her office. It did not matter that I have stable Whole Object Relations and Object Constancy. Because of my emotional flooding I self harmed and that was that – in her eyes I was borderline. It did not matter to her that I have a strong sense of self, I do not split; I do not do the ‘I love you, I hate you’s’; I do not sabotage my relationships; I do not ‘push pull’; and I am a black, white and all shades between thinker.

      I have rejection sensitive dysphoria (RSD) but because it’s not in the DSM it is not considered part of ADHD. Dr. Dobson might be the lone voice on this but his articles and on-line talks have helped me understand what is going on. His lone voice and the countless other ADDers talking about how they too grapple with this ‘emotional flooding’ has helped me in a major way deal with my RSD.

  9. O it does exist. You can have it but never let it determine how you respond to others becauseof how they make you feel.

    You can beat this but the solution comes from an very unexpected source. The 7 habits of highly effective people, The 17 laws of teamwork, Thinking for a change, 21 laws of leadership, Intentional Living, etc and any other book on managing and leading in the business and church environment.

    Regardless of what position or work you do, learn to lead yourself first well by learning how to lead others well. people may start to listen you and even follow you and you will have no idea why.

    after 19 years after going no where I went from teacher to principal in only 7 years. This despite being no confirm diagnosis of being ADHD.

    Being appointed as a Principal and diagnosed in the same week may have been a bit of a shock to everybody else’s system.

    What happen when you despite all odds you have made it to a position like mine and with it your ability to do things improve suddenly beyond even your own understanding.

    Does this create further success? I take 90mg concerta. Perfect recall, good listening skills, on time, etc etc. everything everybody else is that has some measure of success. So what can go wrong.

    A people pleaser wants to do the right thing at all times and never wants to disappoint. so they refuse to compromise their values and their integrity.

    Put yourself in a a position where everybody else is hurting and you are the only one that understands why.

    Let us just say I no longer work and just because i think differently.

    So the moral of the story is. If you worry you die and if you don’t worry you die. So let no ever take your dignity from you and if they do, Knowledge couple with Character with a dose of integrity will always pull you through.

    This from a John Maxwell team member with ADHD. With or without medicine being ADHD is going to set you apart from the rest. The choice always remain ours how we will be remember for the choices we made. Rather be the exception than the rule.

    When you lose everything just because your are ADHD then being a person of character and if you are a person of faith and surrounded with the an inner circle of support we will not be defeated by who we are are. It is can also be our biggest asset if channeled correctly.

  10. If there is lots of grammar mistakes and words left out etc it proves that even on medication our brain is a very busy place. We don’t have place for obnoxious people who do not know better.

  11. Thank you so much to each of you that has shared. I’m sitting here with tears flowing down my 53 year old face. I have hope my marriage can last, hope my lovely man can get some peace, hope our family can help others with this too. I’m thrilled more doctors are pushing their patients to get diagnosed even if they don’t want meds. Knowing what is happening to you is the first step in breaking free from its constraint’s and finding a new way to deal with it can save you and your family.

  12. Having been diagnosed privately and treated with Meds for ADHD as NHS will not support diagnoses and after going through a lot of info on Additude site does anyone know if you can get meds in the UK for ADHD and Rejection Sensitive Dysphoria (Privately) NHS has had me on various SSRI for depression for years but have now decided to come off them slowly. NHS now looking at Post Traumatic Stress Disorder and have been on waiting list to see psychologist for approx 9 months and also think I have ME but won’t even discuss or test for ADHD.

  13. Rejection Sensitive Dysphoria makes sense. After being diagnosed with ADHD @ age 63 I realized that I’ve spent much of my life preparing daily for failure and rejection. Perhaps best described as a continuum of trauma and fertile ground for Complex PTSD.

  14. > “50% of people who are assigned court-mandated anger-management treatment have previously unrecognized ADHD.”

    Is there a source for this? Google returned other blog posts and no research on the matter.

  15. I’d like to believe what’s written in the article, but I find it suspicious that the only one with any informative information on the topic is the author, whether it’s from this article, or from the website of the author’s practice.

    1. While I agree with you on his lone voice, and understand the place of skepticism in light of that, the fact that he explained my life without ever meeting me in this very short article trumps any doubt for me. He’s clearly a practitioner, not a researcher, and a brilliant one to be able to put this together through his own observation of his patients. I say that as someone with ADHD who read this and found more explanatory power than pretty much anything I’ve ever read on ADHD. Enough that I consider flying to Boulder and paying his consultation fee to get a bit of his time.
      If you have ADHD and this doesn’t resonate with you, try working it backwards. When you lash out at someone you love, consider whether maybe you were feeling something akin to “rejection”, suggestion of failure or not being good enough when you lashed out. When you find yourself depressed after a difficult experience, again, what was the trigger? When you withdraw or stop trying, ask yourself why? Or if you’re avoiding commitments or being pleasing to avoid disappointing other people, ask yourself why you might be doing that. In my experience, he was spot on. I hope that researchers will pick up on this and put it to the test. When someone like Dr Dodson says “nearly 100%” of patients have this symptom, the academics and researchers should listen, call him, inquire, and put together a decent study. But I guess when academic types here him say “I’m not a believer in the executive function theory… I don’t find it helpful,” they probably write him off, because they don’t have ADHD and they’ve never experienced the futility of finding a planning system “that works” 🙂

      1. I totally agree with you Dr Dodson absolutely has it figured out and has explained me better than I could have put into words myself. It’s depressing that both my psychiatrist and my kids paediatrician don’t know even a tiny bit of this stuff. I would pay $$ to see this doc if i could arrange it for my kids treatment I’m desperately trying to figure out how to not screw up my newly diagnosed kids treatment I don’t have mine under control even I’ve been medicated (sort of/subotimally) for years but only started really looking into this a couple years ago and I’ve learned so much from this site but dr Dodson especially

      2. Whats his replacement for executive dysfunction theory? It’s ruining my life and I’d love to have another way to frame it.

    2. Excellent comment. Extraordinary claims require extraordinary proof, and Dodson offers none.

      There are many explanations for what he idiosyncratically calls “RSD” and this pattern often responds to competent treatment for ADHD+

      The idea of recommending guanfacine, clonidine, and MAO inhibitors!! The special dietary limitations that MAO inhibitors pose make it a non-starter for most people with ADHD if their symptoms are not well managed.

      Gina Pera

      1. Gina,
        You will not find “official” studies about “Rejection Sensitive Dysphoria” because most, if not all of the research on ADHD is sponsored by the drug companies. Since the medications Dr. Dobson recommends are already on the market and do not cost nearly as much as the drugs used to treat ADHD, there is no interest by the pharmaceutical companies to do research.
        As for evidence that RSD is real, the fact that he actually listened to his patients for 25years and recorded their answers is evidence enough for me. Since you do not have ADHD yourself how can you be certain we as ADDers are making these feelings up? I have educated psychiatrist and psychologist about RSD and they have thanked me. The DSM-5 only looks at the symptoms of ADHD visible from the outside. Another place you will see rejection sensitivity is in the DSM-5 under severe depression and bipolar disorder so this is nothing new or made up. While the RSD differs from the rejection sensitivity found in these two disorders it is just as real. I trust Dr. Dodson’s instincts and experience and do not take his information lightly or feel misled. Please give the ADHD community more credit for being responsible enough to know the difference between internet click bait and real medical information. As for your poo-pooing the medications he recommends, the medical community has been using “off-label” approach for years for all kinds of conditions. Again, please give the ADD community credit for common sense and know that they will discuss any changes to their medication ritual with their medical provider.

      2. Agnes Green, before you attack someone publicly, you really should try to understand their position and to have your facts.

        You have done neither.

        Facts do matter.

        Dodson has quite irresponsibly convinced the online ADHD community—and by extension the plethora of amateur sites on ADHD+—that this Rejection Sensitivity Dysphoria is part and parcel of ADHD and then he guarantees the three medications he recommends will fix it. That is highly irresponsible.

        Experts, including myself, understand the full complexity of ADHD (especially late-diagnosis ADHD) and therefore the emotional dysregulation component of ADHD along with the “emotional baggage” that can accrue during years of no diagnosis, misdiagnosis, and/or poor treatment—including expecting to be rejected by the world.

        It is no state secret. It has been written about exhaustively, including in my own books and the chapter Dr. Russ Barkley asked me to write for his “gold standard” clinical guide.
        People who consume solid information on ADHD might read an article in an online consumer magazine by a physician who operates on the fringes and conclude: “Oh he understands me! He alone understands this!”

        That’s the problem with being poorly educated on ADHD and reading only online articles by self-promoters: One can be led astray. And that means the chances of finding appropriate treatment diminishes.

        What “sounds good” isn’t always true. The research done on RSD and ADHD has shown no increased presence of RSD:

        Everyone in the ADHD community should be concerned about this. But online, opinions and understanding tends to be superficial and scattershot.

        To solve problems, we need to understand the nature of the problems. And that means being respectful of truth.

      3. To correct a typo.

        This: People who consume solid information on ADHD

        Should read: People who consume NO solid information on ADHD

      4. I really appreciate your comment and reminder to be careful with what we read. Is it your opinion that RSD doesn’t exist or that it is a separate disorder independent from ADHD? I’d like to learn more about these symptoms — what are the names of the books that you mentioned? Thank you

      5. Kady — sorry that I am just now seeing your response. Also, this interface won’t allow me to respond to you directly.

        You might want to read the comment I wrote to Ivan.


      6. Gina – The doctor who wrote this article actually states that the medications he listed are “possibly” effective and that to the 1st two meds “guanfacine and clonidine”, only 1 in 3 respond. He does not state they are “guaranteed” to fix RSD. He also does not state that MAOI’s are a “slam dunk” and that the study for use was done in the 60’s. I find it interesting that you would misquote a doctor’s article to suit your own outlook/attitude/feelings/research on the subject of ADHD and RSD. When other “professionals” are not open to the comments/opinions/findings of other “professionals” we all lose out. It is the coming together of minds (practitioners and sufferers) that heals us all. There is always something to learn or to take away from each other on any subject, including a subject you feel you are a SME on. You couldn’t possibly know or understand all there is to know on this subject. You are only one person and I’m sure there are thousands (if not hundreds of thousands) of other voices that agree and/or disagree with your outlook/attitude/feeling/research on ADHD and RSD. And someone is not necessarily “working on the fringes” just because they have an opinion about RSD and ADHD that differs from yours.

        Using misquotes to try and get your own point across only causes you to lose credibility with your audience/readers. Well, I can’t really prove that, but I can agree that is how I think/feel after reading your rants. (I call them rants because of all the exclamation points you use in your comments. Like CAPS, it felt as though you were yelling.)

        As someone who suffers from ADHD finding an article about RSD and the symptoms associated with it were eye opening whether or not you can find RSD in the DSM-V (it got me to thinking that maybe I’m not introverted or a-social, but in fact have Rejection Sensitivity since I can agree with all 9 of the symptoms and I don’t agree with “all” the symptoms on any of my other diagnosis-es). Just because it isn’t there doesn’t mean it shouldn’t be. I’m sure if you look through the years of the DSM you find that it evolves (sometimes much too slowly for sufferers). Studies are being done every day, some that are long overdue. Being open to what Dr. Dodson is saying will open the doors to study so that others like yourself may or may not get on board. But knowing that his findings are from his observations with his patients lead me to believe that he is a caring doctor who wants his patients to succeed in life. I don’t believe his personal findings in his own practice are meant to mislead or confuse anyone.

        Every article/book on-line or published should be read with an open mind and not taken for gospel. If you find something that resonates with you, do your own research and of course discuss it over with people you trust, including your doctor.

        P.S. Here is a handout that was given at the annual CHADD conference in 2017 by Dr. Dodson. It gives more detail and sources for his thinking/information. I hope it benefits those that are open to hearing it.


  16. Also bang on with my serious rage problem. After a bout of severe depression and hospitalization I was given Van la faxine a norepinephrine and serotonin reuptake inhibitor and the results over time have been spectacular. Primarily because they have removed the total fear of failure at times. Although i sang i was very reluctant to sing loud enough to be heard unless of course there were many others ..Being singled out for anything would result in that rejection induced rage. The times i raged at my wives were all because of that rejection fear. Thanks to the New SNRI i no longer feel that need to pounce. PS now i have the opposite problem singing too loud lol.

  17. As a youngster i vividly remember my brother approaching to show me how i was practice punting a football wrong. I left immediately to avoid the sheer humiliation of him zeoing in on my mistakes. In school i learned to channel the rage at the teacher when they would point out any of my mistakes . With a genius I Q and a family history of political involvement in some of our countries vital moments discussed regularly at the dinner table it was only too easy to point out their faux pas. No Noth America has more than three countries ( grade three) the answers to quadratic equations when he copied them wrong on the blackboard grade 11 two weeks before they expelled me for failure to do any homework. 8 older siblings and parents and not one of them brought home work. In my mind if it couldnt be done in school they should reduce the work or increase the time. I had no trouble finishing it in detention. In the real world work was not done at home.
    This however did not hinder me in the job market because i worked for those same family members in the real world from the age of 12. Every summer, spring break, and had no trouble getting jobs when i was 16. A week after school ended. And another after xmas when the first provd unable to earn a decent wage and again 9 months later when i joined the armed forces to continue my education in a foreign land (Montreal).

  18. This is me in a nutshell. I’m a people pleaser and then when I screw up, I stop trying. In 20 years of ADHD advice, treatment and research, I’ve NEVER heard of RSD. I’m going to talk to my Doc about it ASAP.

  19. I’ve tried to respond with links to other articles but they don’t display here. Maybe they have to be approved.

    Try googling ‘deficient emotional self-regulation (DESR)’. DESR describes similar symptoms to RSD and there are many scholarly articles available. Particularly see Surman or Barkley.

  20. I have a 4-year old who is not diagnosed but exhibits many characteristics of ADHD. There is no history of trauma and we have been very intentional not to use shaming or physical punishment as forms of discipline. I do notice a heightened sensitivity to correction and that often looks like rage. You mention medication as a way of addressing RSD but are there other things we can be doing to help my son with his socio-emotional development that takes RSD into consideration that does not involve medication?

    1. I would highly recommend implementing strategies from and which out of all therapies and supplements have been the most successful over time for us. Be ready to put in the work and change your entire concept of parenting and behavior. But you will be rewarded with a much better relationship with your child in the long run. (Keep a journal to track progress over time so you can see the results of your awesome work). Best!

  21. Does anyone experience depression instead of rage, when rejection hits? I’ve heard depression is anger turned inward, and that would make sense.

    Most of the time I get sad and withdrawn, not outwardly angry. Which is also in line with people pleasing, even with giving up.

    Don’t offend or I’ll be rejected even more. Or somehow it’s all my fault, so who am I to get angry. Actually, that’s what really fits. How wimpy, irritating that sounds–to me! And I’m the one feeling it!

    The depression-not-rage thing is the only way this doesn’t entirely fit for me. Otherwise, it’s like someone took a look into my interior landscape and described it perfectly.

    1. Hi, Concentrate. I’m right there with ya!!
      I’ve never heard of this but it explains a “spell” I had last year… and why therapy and regular anti-depressants didn’t work!

    2. I have never been diagnosed, however the article fits me and I experience depression and anxiety attacks as a result. If I could get this diagnosed & treated so I do not feel like I’m going to die every time I need to ask for help my life could be so much better. I hate my job but I can’t get myself through the application/interview process without major meltdowns and I hate it so much. I am smart enough to get through college but I can’t function in the real world, I’ve been somewhat satisfied to hold down my job for the last 6 years but I could contribute so much more and be so much happier.

      1. Consider the strong possibility that you would be diagnosed as positive if you were to get in front of an appropriate clinician. This is the same place in the process that catches so many of us with ADHD and RSD. We do not want to even be rejected by those monitoring the rejection symptoms. Thankfully not everyone with our afflictions suffer the lack of following up and thru the process. I do.

        So recommendation: find that neuro typical or fellow ADHD’er and come clean. Share the situation and share the road block. Even having someone to be accountable to can serve as a motivation to power thru.

        It can be a powerful assistance. I found that person. You can too. Good luck.

    3. I’m blown away that RSD is really a thing. But I experience the same depression instead of anger. I’ve also been diagnosed with bipolar but it seems that the symptoms are so similar that I wonder if my depression is more from ADHD and not really bipolar. This article gives me a new direction to discuss with my psych. Concentrate, thank you for being so open, I can relate to your fear of rejection or not so nice comments from the community.

      1. I got diagnosed with that too, and was given a drug that made me crazy. It is likely that you do not have rapid cycling bipolar.

  22. Yes I have turned the rage inward in one particular case.
    .My first comment up above mentioned being in hospital for a major depression. This occurred as my wife was packing to leave permanently and leaving boxes of her stuff in our dining room each weekend. 5 years before i had lost it and yelled at her and hung up on the doc she was trying to contact. ( i was going through a thyroid storm at the time and she was attempting to call for help. I was paranoid. She followed this by calling police to report domestic abuse. Even 10 years ago our police had a Zero tolerance policy and would evict you the first time and convict you on the second call.
    After this instead of flying into a rage I would turn silent and quit communicating. This tale spin ended up with me voluntarily admitting myself to the psych ward for a 2 week evaluation. And ultimately the major depression diagnosis and the Ven lafaxine prescription. Which have been so good for this. Ultimately the ADHD diagnosis Concerta and Ami trytilene added to the mix.

  23. Decades lost due to an ignorant Psychiatrist labeling me as BPD now the new Psychiatrist has come along to prove it was always ADD.

    Of course now, thanks to this illuminating article it’s clear I’m blessed with a generous helping of RSD.

    There is no doubt that “Sometimes Dead Is Better”

    1. Same here. Almost 30 years misdiagnosis and treatment. Gender bias? Who knows. I reported year after year my symptoms, still “depression/PTSD” diagnosis then morphed to “bipolar disorder” to possible “borderline personality disorder”… pump the brakes… this is my life. A quality of life none of the educated professionals would want for themselves or their own daughter’s. Somehow, they deemed the frustrated, futile existence I lived wad all I could hope for. I was “born that way”. Thankfully, I never, never, ever completely gave up on myself. 18 months ago, I was formally tested for ADHD. I did not believe ADHD to be applicable to me, or even “real”. I am learning to rebuild my life, forgive myself, and others. I have stopped looking to others to tell me who I am and/or show me how to live. The meds work, I am completely without friends or family, yet I have seen in small and increasing ways daily that I have never had a better chance than I do right now. “Retirement” age right around the corner and I am flat-broke, rejected, and homeless. Yet, “dead is better” cannot be the answer for me. I now know myself, my mind, and my heart. They all finally are synched up. Thank you, Additive for the life-line you offer me. xoxo

  24. Is external rage a definitive characteristic in the RSD evaluation? Specifically, for those who internalize rage and express restrained/discrete anger, but never outward rage, in conflict/rejection scenarios, would RSD still be a fitting descriptor?

  25. I would like to point out an obviousness. It’s not not how ADHD triggers RSD. By that framing of the problem, we are skipping past the real elephant in the room. We are STILL only treating the symptoms if we approach our issues with RSD playing a secondary role!!!

    Have we become so accustomed to our work-arounds that set-up the real stumbling block as a secondary issue! Please revisit your own preconceived notions. It is bad enough when our ‘health professionals’ feign ignorance at the relevance of RSD in our lives, please don’t buy into that pack of lies so quickly, like I did for most of my life.

    I tell kids all the time “stay in school, get a real job” because I believe it could be better for them. My lack of understanding what truly needed to be address for 16 years is appalling. No wonder why I stopped and restarted stimulants so many times. They never solved the problem for me, they did a great job of distracting me from the truth.

    Highly functioning, rejection sensitive craziness. A person once described herself to me as 37 kinds of crazy. But what happens if we can zero in on that one kind that is an under pinning. Might not change the world, but highly likely will dramatically change life for those of us built this way.

    Nearly 100% they say experience RSD? Doesn’t sound like anything close to a ‘secondary’ problem does it! Yes that was not a question.


  26. I must protest at Dodson’s—and Additude’s—relentless pairing of ADHD and RSD. Without the slightest bit of evidence.

    Moreover, Dodson over-confidently asserts “the cure” — Guanfacine, Clonidine, or MAO inhibitors!

    No citations. No evidence.

    Why is Additude giving this man free reign to spin his idiosyncratic theories? These theories spread through the Internet, serving only to further confuse people with ADHD and their loved ones.

    Don’t we have enough of that?

    Please be more responsible.

    Gina Pera

    1. I have taken both MAOI’s and stimulants (separately & together). The “dangers” concerning MAOI’s are ridiculously overblown. The fact you find them so terrifying shows how uneducated you are on this type of medication.
      I discontinued therapy with stimulants years ago and stuck with the MAOI as I found them far more effective in treating my ADHD & comorbid disorders. This has also allowed me to eliminate the need for several other medications as they address all my symptoms. The only side effect I experience is insomnia, which is easily managed with the occasional use of a hypnotic.
      Additionally, MAOI’s are not neurotoxic like amphetamine.
      There is already enough misinformation about this class of drug online, and people who can potentially benefit from MAOI’s do not need this uninformed scaremongering.


  27. I’ve not been diagnosed with adult ADHD Ms Pera, but the things I’ve read on this site – including articles by Dr Dobson – have resonated more strongly with me than anything the medical community has come back with over the years.

    What hasn’t resonated at all are the medically trained naysayers who don’t have the condition themselves (whatever they consider said condition to be) and who’ve insisted on “evidence”, using this as the basis to poo-poo alternative ideas, all the while sounding like every other medical professional I’ve ever heard from – and Big Pharma.

    It’s not the need for “evidence” that’s prompted forum users to respond so favourably; it’s the resounding *resonance* of the explanations of symptoms which mirror users’ experiences that has done so.

    It leads to hope, where before there was none.

    1. Oh, and btw Ms/Dr. Pera; Agnes Green didn’t “attack” you at all in her post dated 13 July.

      She politely asked why you couldn’t give credence to x,y or z, and to give forum users some credit for being able to analyse their feelings and arrive at their own conclusions, rather than blindly following what they’re told by medics.

      The only “attacking” that I’ve felt has occurred has been from (as one would expect) those in the medical/pharmaceutical industry desperately trying to dissuade forum users from taking on board anything that could draw treatment options (= $) *away* from Big Pharma…

      1. Ivan, have you actually read Dodson’s piece here? And, have you read solid books by experts that describe this phenomenon but don’t reduce it to a catchy phrase and some off-label Rx?

        Do you realize Dodson argues that, basically, it’s a slam-dunk to treat this alleged “Rejection Sensitivity Dysphoria” with MAO inhibitors? Do you know what those are? You cannot eat many common foods when taking MAOI, due to severe interactions. (Guess what? People with ADHD forget!)

        Most responsible psychiatrists and other prescribers view MAOI as “last resort” and not at all for ADHD.

        So, your anti-pharma paranoia should be better placed in reaction to that than to legitimate treatments for ADHD.

        I understand that SENTIMENTS of what Dodson writes here might resonate for you. But ADHD experts have explained the same phenomenon, without giving it the wrong name that leads to the wrong treatments—and thus even more rejection and distress.

        What Dodson is “dumbing down” is a much more complex phenomenon — and one that nothing to do with the term “Rejection Sensitivity Dysphoria.” That is a term that only he (in the entire medical community) uses to describe the phenomenon vis a vis ADHD. But now every for-profit and many ADHD coaches’ website and bloggers state it as if it were established fact. It is NOT. It is Fake News.

        It is no state secret: Left untreated/unrecognized, ADHD can lead to social isolation, feeling misunderstood, rejected, and a failure. There are three compounding phases:

        phase 1:
        Folks grow up not knowing they have ADHD (or if they do, what it really means). All they know is that the world is treating them very unfairly.

        phase 2:
        In faction, these folks develop thoughts about this world and the people in it, the people who are so harsh and mean and unfair to them.

        phase 3:
        Those thoughts form their “worldviews” and inform their emotions. They stand ready to be hurt or angered by the next action of rejection, harsh judgment, or admonition. They expect it. Because it has happened so consistently.

        It’s horrible.

        One misses social cues. One loses track of the conversation. One feels embarrassed, ashamed. Friends’ likes and dislikes or important events aren’t remembered or asked about, so friends cut things off and sometimes in an angry way, born out of hurt.

        But these folks’ thoughts about the world are skewed by lack of knowledge about ADHD, their role in these poor outcomes, and, in many cases, lack of medical treatment that can help them better function and more realistically perceive the world as not being “entirely against them.”

        Caught up with one’s own distractions and difficulties, it can be impossible to put oneself in the shoes of another person and to understand why their negative reactions or criticisms are justified. And how to make positive changes that will minimize rejection.

        Folks with untreated/unrecognized ADHD can go through life never knowing when they will slip on that imaginary banana peel. Despite the best of intentions, they find themselves the subject of criticism and tongue-lashings for their failure to remember, follow-through, show signs of caring, etc.. It’s a “high anxiety” way to go through life. “Rejection sensitive” doesn’t begin to describe it…or to describe the way out.

        Higher-order brain functions can be hampered. That includes emotional regulation, which can cause outsized responses to reactions from others, including perceived rejections. But also empathy. So, while some folks with ADHD might think they feel great empathy, they might fail to understand: They do not show it with actions and words. In fact, they might show the opposite: self-centeredness and “it’s all about me.”

        But some, in fact, don’t feel much empathy at all. It’s a dopamine thing (see link below). Low empathy can lead to a narcissistic self-involvement, where there is little concern about the impact of their behavior on others. They are always the victim. No matter what. They might make a giant mess at work or catch the house on fire but as long as their intentions were good, they feel they are treated unfairly if anyone criticizes. Again, they don’t have an objective perspective on their problematic behaviors: They grew up with ADHD and know nothing different.

        With treatment, more “connections” are made between cause and effect. Between the behaviors required for good friendships and other relationships and the ability to display those behaviors. Between the ability to feel only one’s own emotions and empathizing with another person who has grievances against you.

        With increased empathy, the person sees that what might have previously been viewed as a “rejection” is actually more complicated.

        This is a quick attempt to explain the problem with this dangerous over-proliferation of “Rejection Sensitivity Dysphoria” as being something apart from ADHD, something that is treated differently. I write about this more extensively in my first book (Is It You, Me, or Adult A.D.D.?), including perspectives from ADHD luminaries such as Dr. Robert Brooks and Dr. J. Russell Ramsay.

      2. Rationalizing Rejection Sensitivity Dysphoria with logic and reason is great. So we have just made ourselves sensitive? So what I just read makes me think that the writer thinks we can make ourselves feel better by understanding that we really are not dealing with RSD but our own perception. That’s a load off (tongue in cheek). If those of us with these borderline severe cases could ‘work around’ our difficult to bear situations we would have. We tend to be bright people with creative solutions dealing with these things that are so often front and center.

        Glad for you that you can get such a good handle on it for yourself. This not always such an easy thing for some of us. We need help or we will go to great lengths to add to our distractability and really get ourself twisted up in a knot so we do not need to feel rejection (real or imagined). Imagine being born without an epidermis. That is an extreme example but no less applicable. When a person feels like that then great pains will be taken to avoid bumping into items that will cause such feelings.

        Who cares if there are numerous contributing factors and that we heighten the situation ourselves or not. Perception becomes the reality.

        So many want to beat up the few people that talk about RSD as a real thing. Hats off to them that they are taking a stand to describe something that is huge and extremely wide spread. Once there were few if any that talked about ADHD yet that is a reality too.

        If we can rationalize away RSD could we not rationalize away our varied situations with ADHD. Of course we can not, leaving RSD still an issue to be dealt with.

      3. Bill Dobson is a board certified psychiatrist and specializes in treating adults with ADHD for over three decades in his own clinic. Dr. Dobson’s description of RSD is his medical opinion based on practical, real life clinical experience.

        Gina Pera writes a blog, claims to be a journalist, gives talks, and admits to having no degrees that will quality her to diagnose or treat people with ADHD. She is an expert on her own opinion.

        I think I will listen to Dr. Dobson on this one.

      4. Rather cruel and unnecessary reply isn’t it? You also aren’t suggesting any solutions that I can see, so what’s the point? If people try those medications and they don’t work they can stop. It’s hardly the same as the opioids people in America seem to prescribe in such vast quantities.
        Perhaps the RSD drives the self centredness rather than vice versa? Perhaps knowing that you are less likely to consistently be able to deliver what is needed when it’s needed causes you to shut down and turn inwards because the rejection just hurts too much?
        If you’re suggesting therapy then all I will say is that I’ve had several long bouts of it, at great cost, and it did not help ONE BIT. The only thing that has ever helped is various medications, which are not perfect. I’m on excellent ADHD meds and have taken SSRIs but they only blunt this – and when it crops up its crippling.
        I meditate now, and that helps, but again it’s a tiny drop in the ocean. To have an expert describe in minute detail what is going on and how I can POSSIBLY fix it may well be the most life changing thing I, and anyone else on here with ADHD, has ever found.
        So you have made up my mind for me. I will get these medications, from a doctor if I can, from the internet if I can’t, and monitoring side effects and dosages will titrate up to the optimal dosage. If it doesn’t work I will at least know I tried.
        I don’t need drug trials to believe in this. Only a fool thinks that anything covered by a trial works and anything that isn’t doesnt.

  28. Hi, I’m Dave,from Ireland, 55 years old and sole parent to 3 still quite young ones…

    Last year my youngest son Adam, still 8 yrs old now, was diagnosed with ADHD. I spent most of last year researching ADHD and therapies, will I medicate, what is the best response.

    Like many adults/parents,I discovered what was “wrong” with me all my life, quite by accident and after hundreds of hours of research and reading all the usual Bestseller AHDH books… I had a eureka moment last December 2017 when I read about adults diagnosed as ADHD.. Like most I spent a month or two in tears of relief and regret. Relief and delight mostly. All the books dealt with the typical old story narrative of ADHD as a young male toddlers illness. In all cases they were magically cured after reaching their 18th birthday and girls just didn’t suffer from the same illness.

    Every single sentence, every single word, every single fullstop in every article by Dr Dodson, in particular, described me … Symptoms I would never in a million years have uttered to a doctor or psychiatrist as being my problems, as they were too weird, too subtle, too off the wall, but to me they were crippling, they were me… and I was a one off.

    I had the usual hyperfocus ( I called it getting in the zone, with a few drinks to get work done up to and including patent applications), zoning out ( my buddies knew I just needed a few minutes to zone out – I was happy out but needed time out – overloaded I was ), the constant simultaneous thoughts in my brain from before I opened my eyes in the morning to… I guess while I was sleeping ( I never slept more than 4/5 hours in my life and mostly blocks of 1-2 hours), the staring at people I’m talking to and being in a different world and being able to jump back enough to their talking that I could fool them that I was actually listening – I was away – far far away mostly and sometimes I’d look quickly somewhere else as I’d just notice a tarpaulin flapping on a truck a 1/4 of a mile away…

    My memory is shocking, I think lately that is’s because if you had 4 or 5 or 20 thoughts non stop and simultaneously, all your life… which one would your brain remember as being the thought for that one moment ? The name of the person you talked to for an hour and what they said and their story… or one of the very real things you were simultaneously thinking about – which one is what you were doing just then ? Which one does your brain chose ?

    Exhausting, these “normal” symptoms of ADHD, and as an undiagnosed adult living these 2 lives, the responsible one who must behave “normally” despite the screaming boredom of doing so, the genuinely very social (and seen as a very social, smart funny guy) but who craves isolation to recover, the not understanding people and why they are so rules based and seem to love these rules – what’s wrong with them ??? 🙂

    The utter kindness of ADHD, the empathy of ADHD, the love and minding of loved ones of those of us with ADHD… the absolute and overwhelming overload of thoughts and emotions of those with ADHD which cripple us, drown us, shake our heads like dogs trying to get the multiple thought out, to reduce them to one, to find calm and focus, ….. We so want to help with our kindness, our empathy and in many cases our amazing gift of insight and problem solving.

    So, Dr Dodson… every word he writes is gold.


    1. Typical ADHD, I actually forgot to elaborate on the emotional sensitivity, the rejection sensitive dysphoria ….. well, seriously these are some of those “things” I would never have thought to mention to a doctor or psychiatrist (and I didn’t and like many undiagnosed ADHD I was at one time diagnosed by a psychiatrist with Atypical Depression, in other words – no known cause, well it was ADHD and RSD and mild Aspergers and SPD, mainly the first 2 though 🙂 ).

      RSD is real, oh so real (surreal 🙂 ), sorry, I’ve felt it all my life, I’ve been that people pleaser and sometimes the tough f u but only when I could not do anymore, I’ve felt it, I felt it when it was not real, I anticipated it just to be sure I wouldn’t be blindsided by it, it is a life changer, it is horrible, it is crippling.

      Emotional sensitivity for me was always about … empathy (good but time consuming and probably related to emotional sensitivity and constantly scanning for potential problems that I should be aware of but normal people aren’t and sometimes being totally wrong as I read into something that wasn’t there – you either get this or you don’t), scanning for potential rejection, scanning for non agreement and trying to negotiate an agreement – nonsense I know now, ramping up emotionally on the suspicion or incorrect reading of a response as being an attack.. often.. strike that, 99% just a normal comment, sometimes a difference of opinion.

      Intense emotions, rejection sensitive dysphoria etc are very real and debilatating symptoms of ADHD

      1. I would also comment that if someone does not have ADHD, then they have never experienced ADHD, they have never experienced RSD. I would have no idea why they would be here exclusively to disagree with those of us who do.. why would someone do that ? What is their gain ? Is it attention seeking ? It seems such an unlikely disagreement that someone with ADHD might also have RSD… these should be just random letters to one who has neither – I suspect a troll, a hidden agenda, an undiagnosed case. I would ask that they exit and join another forum.

      2. You could not have said it better, Dave. It actually makes me quite angry because potentially they could stop someone from getting the help they need. It wasn’t that long ago that people were saying exactly the same thing about ADHD itself.

      3. Kudos davecarroll01 – she sounds like a troll to me too. Confrontational attirudes are unnecessary in such a forum. This isn’t facebook.

  29. 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 – [email protected]

    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. Personally- I upped my Omega 3s EPA & DHA both over 2000mg. The suggested dose is at least 2000mg up to 4000mg.
      I did this about 2 months ago & have noticed a HUGE difference in my depressive episodes. I’m not as sensitive to what people say & don’t really think about what the aren’t saying. I used to perceive people not calling me as rejection. Now it doesn’t bother me as much. If you want more information – check out Dr Daniel Amen. He suggested it as a fix. It worked for me. I’d rather take a supplement than another medication any day.

  30. 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 states: Serious side effects affecting the nervous system, heart, liver, and kidneys, as well as death, have been reported.

  31. 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

  32. Many years ago, when I was 10 years old, I realised that many if not most of the other kids were trying to fit in to something I didn’t understand.
    I wondered why they were trying to fit in with a bunch of immature idiots and being silly themselves.
    The little competitive games were actually supports of the status quo and not really competitive.
    I ignored the silly kids, and in later life the silly adults, and just got on with my life and a few friends.
    I have recently found a phrase that describes this — “the trash takes itself out”.

    These days when people try to be insulting, I just ignore them. The only problem with this is that they sometimes get insulted themselves, almost RSD, because I am not playing their game. Some friends say that the look on my face shows my feeling about them.
    I was only diagnosed as ADD in my fifties.

  33. I have a friend who is married to a man with anger issues and is manipulative. He read about RSD and thinks he has it. She is afraid that he is latching on to this DX as an excuse for his actions, and trying to “suck her back in”. They are currently separated.

  34. Dr. Dodson, could you please site the literature supporting this claim: “Rejection sensitivity is part of ADHD. It’s neurologic and genetic. Early childhood trauma makes anything worse, but it does not cause RSD.”

    I look forward to your response.

    Thank you very much.

  35. I’m 39 and was diagnosed with ADHD 1 year ago. I’ve always been hyper emotional, especially when faced with rejection or disapproval. I’ve always wondered why. How come other people didn’t react the way I did when faced with a similar set of circumstances? I assumed I was flawed or weak. This makes sense to me.

  36. I find the lack of knowledge about MAOIs frustrating. None of the ADHD articles I read even talk about the newer REVERSIBLE MAOIs. This might be because they are not licenced in the USA, but here in the UK, I am precribed Moclobemide, which is one of these newer types, which DO NOT interact with matured foods, the way the older ones do. I have been very impressed with this medication. I was diagnosed with ADHD earlier this year in my late 30s, and suggested to try this medication, after finding that several others, including SSRIs and SNRIs had side effects including making me feel more hyperactive. I have found this medication brilliant, I just feel normal and calmer. I don’t know why they are not licenced in America, but it is very affective, low side effects. and it definitely helps both anxiety/reactivity and also I feel more focused I think. But could the people at ADDitude mag and the podcast look into these details about MAOIs.

  37. I’m 35 as of typing this and have professional diagnoses of ADD (at ages 6 and 30,) and Asperger’s/ASD-1 (30,) and just use your imagination to imagine how RSD and autistic meltdowns play out for someone trying to hold a job with un-diagnosed Asperger’s… That said, I personally have found that whether I’m on (stimulant) ADD meds or not makes a *huge* difference in being able to maintain control. (Straterra…I get more effects than placebo, but it’s just not very effective for me and I was having RSD-triggered meltdowns as often while on it as unmedicated.) I’m more prone to meltdowns, RSD or otherwise, when my sensory “buffers” are overloaded, and ADD meds to seem to take some of the edge off of that and allow those buffers to fill at a slower rate.

    I also actually *did* find keeping in mind what I’d learned in CBT helped, though the text of the article makes it sound like my results in that regard are less common… I’ve been at my current job for a little over half a year and there’s been several situations where I would’ve melted down in the past, (or booked it to a stall in the women’s room to meltdown ASAP afterwards,) where I didn’t, and I honestly think it’s a mix of Adderall (I find the side-effects less troublesome than Ritalin’s, but that’s just my body,) and CBT.

    I remember that, around 4th grade or so, my parents tried Chlonodine (with Ritalin,) possibly for this very condition, (the documentation is long since gone and my parents can’t remember that sort of detail at their ages,) but it didn’t help with spit and I came close to passing out so often that they stopped. (Granted, this was right around the time that Asperger’s was entering the DSMIV-TR, so there was this whole other factor that was never being addressed. Add on that autistic brains don’t always handle Brain Medicine like non-autistic brains with the same condition do… I don’t begrudge anyone–just wish we knew then what we know now.)

Leave a Reply