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 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 (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.


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116 Comments & Reviews

  1. There are a few problems with this article (and other internet material I have seen on RSD):

    1. What is described as RSD is claimed to be exclusive to ADHD, but similar experiences have been described in conditions such as borderline personality disorder; also, what is described as RSD can describe symptoms of early childhood trauma. The material I have seen thus far online, including this article, do not sufficiently address this or account for the possibility that RSD is actually a manifestation of trauma.

    2. Dr. Dodson does not differentiate between RSD directly caused by ADHD versus RSD that may actually be caused by children with ADHD having an increased exposure to trauma, and/or kids with ADHD possibly being more sensitive to their environments. In terms of trauma, we know that kids with ADHD are more likely to experience mistreatment. One may argue that RSD is the result of ADHD mediated through trauma, but this would be problematic because ADHD does not cause child maltreatment (people who maltreat are responsible). It is quite likely that kids with ADHD are more sensitive to their environments, but this paints a more complicated picture of ‘nature’ and ‘nurture’ interacting than the implication that RSD is ‘nature.’

    3. Dr. Dodson does not present research supporting his claims on RSD. This article, and other material I have seen on RSD thus far, does not point to scientific literature. While an article written for a public audience will not go into detail, it is common for educational material written for a public audience to reference peer reviewed studies on a topic when they exist. I searched for peer-reviewed articles from Dr. Dodson on this topic and came up empty-handed. I have not seen other researchers examine Dr. Dodson’s claims either. Granted, I did do a minimal search in only one database, but that search pulled up irrelevant articles, which I have found is a pretty good indication that literature on a topic is lacking.

    Presumably Dr. Dodson’s work on RSD is informed by his clinical interactions with patients. Not all clinicians have training or inclination to do research, but one would hope that there would at least be some case studies in the literature. Case studies are a low bar as far as scientific evidence is concerned (they are generally good for identifying topics for more research and cannot get at the issue of confounding, which is the issue I have raised regarding RSD possibly being caused by trauma) but case studies would at least provide a foundation for research with better methods.

    Some clarifications:

    A. I am not saying that RSD is not distinct to ADHD, and I am not saying that RSD is caused by trauma. I am saying that: 1) the material I have seen on RSD thus far does not sufficiently distinguish RSD from similar experiences that have been described outside of people with ADHD; and 2) the material I have seen on RSD thus far does not sufficiently address the possibility that RSD may be caused by ‘nurture’ rather than ‘nature.’

    B. I am not disputing the experiences of those who report RSD. I am just saying that we do not know if those experiences are best described as an inevitable or fundamental part of ADHD. (Re-read point A above.)

  2. It has been my experience that RSD is not the full picture. I feel it encompasses a larger set of traits. Most ADHD adults I have encountered that have RSD also do not take unanticipated compliments well. I myself will deflect them with a self deprecating remark.

    It is as if we are casting aside a compliment from someone because that they are trying to connect without having been vetted first. And that vetting is simply “Are you judgmental?”

    In order to have the sense of controlling judgement, I will throw out a wildly disturbing joke know that there will be people who say “You are terrible” to people who try not to laugh but lose total control.

    When I met my wife for dinner she texted me that there was a 30 minute waiting period. My wife gives amazing hugs, so when I found her she gave a full melt hug and said “I am comfortably numb. You’re like Cosby but without the quaaludes ” and someone behind me told me how awful I was and I just smirked, because I knew there would someone I would offend. I was ok because I felt in control of their judgement.

    I you are coaching a kid with RSD and you establish that when you deliver consequence it will be without the tone of judgement, it is so easy to get them to pivot. Works every time.

  3. Like a couple of commenters above, I was misdiagnosed with BPD by one doctor during a hospitalization. I was diagnosed with AdD & ADHD at about 2 1/2 years of age and was on medication for it from age 3 to around sometime in my preteen years (the fact that I vividly remember the start of it may be an indication of either how many meds I was on by the time they were stopped, but is just as likely the hectic stress of those preteen years). Later in life, I would be diagnosed with autism spectrum disorder (it was still Asperger’s in that version of the DSM), which was much more appropriate. I remember my frustration with the BPD diagnosis because the doctor wasn’t listening, and I did not have the identity issues of BPD; I’ve always had a strong and constant sense of self. I also did not have the history of abuse often seen with BPD. I don’t want to go through all the symptoms I didn’t have; fortunately future doctors were better and there is no BPD diagnosis following me around. However, the rejection fear is real. It is a learned fear, I believe., because my social skills are off-putting and making friends and forming relationships has been a miracle when I managed to make it happen. The idea of losin one of those presents extreme trauma. As a person dependent on routines in every sense, the disruption is as bad as the isolation. When I moved here nearly five years ago, I had also experienced such a relationship loss of my best friend and roommate of 8 years, who had moved out and briefly stopped talking to me as a result of how unwound I became because of the distress I was left in. I haven’t made any friends since I moved here, because the overtures I’ve tried were rebuffed and I can’t go through the rejection again. I can’t handle the disruption again. Friends move away, but growing up, I would lose my only friend after a couple of years because I said something wrong: awkward, unintentionally rude, too embarrassing, and no amount of apologies or begging would fix it. These weren’t mean or offensive kind of things, the worst I recall was that I told Rosie M. That she was getting a mustache. I didn’t know she was sensitive about it and I was just making an observation. When she was upset, no sincere apologies did any good; her mother even tried to intercede but Rosie was immovable. And so it was many times. You learn not to say or do a thing that would never strike you as horrible, but you don’t know the rules so it’s a minefield. So I think rejection sensitivity comes from this kind of reinforcement. I had never heard it associated with ADD/ADHD or ASD and so post misdiagnosis with BPD that one time, I was afraid to even talk about fear of rejection because I know it goes to BPD so quickly. Seeing that it exists under the ADD/ADHD umbrella will give me the courage to bring it up in a therapeutic setting. Thanks.

  4. Cross-posting from another website I commented this on as it feels appropriate, and that it contributes to the discussion:

    Can’t wait until people start recognizing ADHD as being linked to dissociation spectrum disorders.
    These are not novel symptoms. This is not unexpected. This is exactly what you’d expect to see from someone benefitting from/struggling with dissociation. ADHD is highly correlated with trauma in a lot of ways, it really needs to stop being its own subclinical diagnosis.

    This is the reason that a purely categorical system is so dangerous for the mental health narrative in the US & etc. Van der Kolk and co have worked a ton at bringing complex trauma into the narrative, but the politics of the scene really don’t allow for that as much, at least at the broader levels that I can see.

    What you get with a purely categorical system is reinventing the wheel many times over without being able to connect seemly disparate concepts, a common problem with attempting to model a higher dimensional problem with a lower dimensional projection. You lose your locality constraints because things can’t reasonably live “next to” each other, and so you get branching tree structures that are clones or near-clones of each other.

    Someday we’ll move past this. RSD is just another name for a protector response, which is generally mediated by the lack of the prefrontal cortex operating as much as it does normally paired with the fight-or-flight (+ the other fs) resulting from an engrained trauma response. You also get shutdowns, etc that aren’t accurately described by RSD, because it fails to capture the breadth of what’s actually going on behind the scenes there.

    Unfortunately the state of mental health in America is rather barbaric at the moment, it’ll in all likeliness be the thing we look back on in 50 years like we do at smoking. However, it’s a good reminder that even though we’re at the latest year we’ve ever been to as a world, we’re not “all the way there” on things, and never quite/exactly will be.

  5. I have no doubt that Rejection Sensitive Dysphoria is a thing, but I’m having trouble finding academic sources. Does anyone have any references to academic Journal articles about RSD?

  6. Oh also: my son has it, I married someone with it, both of my grandparents have symptoms of it, my great grandfather most likely had it, my cousins kid has it, it’s all over my family. Jenny Blanchard, DO

  7. Dr Dobson is usually spot on over a long time and on multiple subjects. Weigh his logic and reach your own conclusions but as someone who reads with critical thinking skills and a lifetime of experiences with the subject I would assume he’s right about what he says until something pretty powerful and overwhelming makes a lot more sense than Dr. Dobson. That goes for Drs Hallowel and Ratey. If you devote your professional life to diagnosis and treatment of people with issues chances are almost certain the comments they make are well intended and any small perceived error in communication or tone from word choices ought to be overlooked and ignored. its the big picture that matters. All those people are as good as it gets in the world of adhd. Be grateful for what they share and what they’ve learned. Disagree civilly and i’m now off my soapbox. Happy Holidays to everyone.

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