How ADHD Ignites Rejection Sensitive Dysphoria
The extreme emotional pain of perceived rejection is a feeling unique to people with ADHD/ADD, and it can be debilitating. Learn how RSD may be impacting your patients.
Rejection sensitive dysphoria (RSD) is an extreme emotional sensitivity and emotional pain triggered by the perception — not necessarily the reality — that a person has been rejected, teased, or criticized by important people in their life. RSD may also be triggered by a sense of failure, or falling short — failing to meet either their own high standards or others’ expectations.
Dysphoria is Greek for “difficult to bear.” It’s not that people with attention deficit disorder (ADHD or ADD) are wimps, or weak; it’s that the emotional response hurts them much more than it does people without the condition.
When this emotional response is internalized, it can imitate a full, major mood disorder complete with suicidal ideation. The sudden change from feeling perfectly fine to feeling intensely sad that results from RSD is often misdiagnosed as rapid cycling BPD.
It can take a long time for physicians to recognize that these symptoms are caused by the sudden emotional changes associated with ADHD and rejection sensitivity, while all other object relations are totally normal.
When this emotional response is externalized, it looks like an impressive, instantaneous rage at the person or situation responsible for causing the pain. 50% of people who are assigned court-mandated anger-management treatment have previously unrecognized ADHD.
RSD can make people with ADHD anticipate rejection — even when it is anything but certain. This can make them vigilant about avoiding it, which can be misdiagnosed as social phobia. Social phobia is an intense anticipatory fear that you will embarrass or humiliate yourself in public, or that you will be scrutinized harshly by the outside world.
Rejection sensitivity is hard to tease apart. Often, people can’t find the words to describe its pain. They say it’s intense, awful, terrible, overwhelming. It is always triggered by the perceived or real loss of approval, love, or respect.
People with ADHD cope with this huge emotional elephant in two main ways, which are not mutually exclusive.
1. They become people pleasers. They scan every person they meet to figure out what that person admires and praises. Then, that’s the false self they present. Often this becomes such a dominating goal that they forget what they actually wanted from their own lives. They are too busy making sure other people aren’t displeased with them.
2. They stop trying. If there is the slightest possibility that a person might try something new and fail or fall short in front of anyone else, it’s just too painful and too risky to even consider. So, these people just don’t. These are the very bright, capable people who become the slackers of the world and do absolutely nothing with their lives because making any effort is so anxiety-provoking. They give up going on dates, applying for jobs, or speaking in meetings.
Some people use the pain of RSD to find adaptations and overachieve. They constantly work to be the best at what they do. Or, they are driven to be above criticism/reproach. They lead admirable lives, but at what cost? They strive for perfection, which is never attainable, and are constantly driven to achieve more.
How to Treat RSD
Rejection sensitivity is part of ADHD. It’s neurologic and genetic. Early childhood trauma makes anything worse, but it does not cause RSD. Often, patients are comforted just to know there is a name for this feeling. It makes a difference knowing what it is, that they are not alone, and that almost 100% of people with ADHD experience rejection sensitivity. After hearing this diagnosis, they know it’s not their fault, that they are not damaged.
Psychotherapy does not particularly help patients with RSD because the emotions hit suddenly and completely overwhelm the mind and senses. It takes a while for someone with RSD to get back on his feet after an episode.
There are two possible medication solutions for RSD.
The simplest is to prescribe the alpha agonists guanfacine and clonidine together. These were originally designed as blood pressure medications. The optimal dose varies from half a milligram up to seven milligrams for guanfacine, and from a tenth of a milligram to five tenths of a milligram for clonidine. Within that dosage range, about one in three people feel relief from RSD. When that happens, the change is life altering. The treatment can make an even greater difference than a stimulant does to treat ADHD.
One study by Harvard University found that raising the dose of guanfacine to four milligrams and clonidine to seven or eight tenths of a milligram (above the dosage limits the FDA approves), achieved a 40% higher response rate. However, this comes with side effects that can include dry mouth, mild sedation, and sometimes orthostatis, or becoming dizzy when you stand up too quickly.
The second treatment is prescribing monoamine oxidase inhibitors (MAOI) off-label. This has traditionally been the treatment of choice for RSD among experienced clinicians. It can be dramatically effective for both the attention/impulsivity component of ADHD and the emotional component. Parnate (tranylcypromine) often works best, with the fewest side effects. Common side effects are low blood pressure, agitation, sedation, and confusion.
MAOIs were found to be as effective for ADHD as methylphenidate in one head-to-head trial conducted in the 1960s. They also produce very few side effects with true once-a-day dosing, are not a controlled substance (no abuse potential), come in inexpensive, high-quality generic versions, and are FDA-approved for both mood and anxiety disorders. The disadvantage is that patients must avoid foods that are aged instead of cooked, as well as first-line ADHD stimulant medications, all antidepressant medications, OTC cold, sinus, and hay fever medications, OTC cough remedies. Some forms of anesthesia can’t be administered.
Dr. William Dodson is a member of ADDitude’s ADHD Specialist Panel.