Rejection Sensitive Dysphoria

Rejection Sensitivity Is Worse for Girls and Women with ADHD

Too many women with ADHD choose isolation to avoid the emotional pain of rejection — an unhealthy sacrifice with health repercussions. Acknowledging that rejection sensitivity is a common experience, not the reflection of character flaws, is the first step toward accepting support and pursuing treatment for RSD.

Depression, fatigue, mental stress, pain, frustration, overwhelmed, too much, concept. Young depression frustrated stressful woman or girl cartoon character holding head. Fatigue psychological problems or headache bad news.
Depression, fatigue, mental stress, pain, frustration, overwhelmed, too much, concept. Young depression frustrated stressful woman or girl cartoon character holding head. Fatigue psychological problems or headache bad news.

A lot of attention has been focused on rejection sensitivity — sometimes called rejection sensitive dysphoria (RSD)— and many women with ADHD identify with the experience.

Studies link rejection sensitivity to depression, anxiety, borderline personality disorder, body dysmorphic disorder, bipolar disorder, and autism, but it appears to be most strongly associated with attention deficit hyperactivity disorder (ADHD or ADD). Impaired executive functions and emotional dysregulation increase the tendency to personalize ambiguous social interactions, interpret them negatively, and be unable to regulate an emotional reaction to the interaction that prompted it.

Rejection sensitivity is not a formal diagnosis or disorder, but many women report that the inability to control their reactions to rejection is one of the most undermining aspects of their ADHD.

Some highly sensitive women experience perceived rejection in superficial interactions (“I had to ask our waiter for water twice — he doesn’t like me”), but the most devastating incidents involve rejection from those closest to them. It can take hours to recover from a wounding interaction, and many women ruminate about the incident, sometimes waking in the middle of the night to relive it. Their quality of life is affected by anxiety, distress, shame, and avoidance.

ADHD Rejection Sensitivity and Gender

Society supports the idea of female obligation to accommodate others’ needs. Girls with ADHD feel this responsibility early, but find they are poorly wired to be attuned to the feelings of others. They are often bullied and ostracized by peers for being overly sensitive, easily confused, and for missing social cues. Many girls with ADHD behave in ways that others find frustrating and become targets for criticism. Their inability to conform to societal demands resonates with their learned expectation of rejection.

Extreme stimulation causes the brain to adapt in extreme ways, even at the cost of compromising other functions. Many women with ADHD have experienced chronic negative feedback in their childhoods, with countless episodes of harsh punishment, bullying, exclusion, and humiliation from family, peers, and teachers.

The resilience of girls with ADHD is chipped away by early traumatic experiences that are unpredictable, inescapable, and repeated. These damaging messages can affect normal development and alter brain chemistry by increasing the release of adrenaline and cortisol. For many girls with ADHD, the repeated threat of rejection triggers primitive survival mechanisms; too vulnerable for fight or flight, they often freeze up, unable to act. These episodes set the stage for the expectation of future social adversity.

[Could You Have Rejection Sensitive Dysphoria? Take This Test To Find Out]

Anxiety Is Amped Up in Women with ADHD

After decades of further rejection, women with ADHD feel like impostors, fearing that their perceived failures will be discovered and provoke rejection. Well-documented gender differences describe these women as having less confidence, lower self-esteem, and more distress than men with ADHD or women without ADHD.

It makes sense, then, that women with ADHD are primed to expect criticism, internalizing their anxious and fearful reactions to rejection. Men are more likely to externalize their responses with defensiveness, anger, and projecting blame on others. Studies show that anxious reactions increase the likelihood of anxiety about future interactions. Those with angry responses experience decreased anxiety about future interactions.

Many women interpret these rejections as a judgment of their value, and are devastated by the idea that they continually disappoint others. Studies show that anticipatory anxiety creates a self-fulfilling prophecy in which their fearful reactions elicit more negativity, reinforcing the sense of rejection. Their emotional volatility may be seen as melodramatic overreaction, further invalidating their pain. Some women believe that their behavior merits rejection, that they are, indeed, unworthy. If they feel they can do nothing right, despair can lead to substance abuse, eating disorders, self-harm, and suicidal thoughts.

Avoiding Situations That Might Lead to Rejection

Most undiagnosed women gradually internalize the decades of negative messages. With shattered self-esteem, they judge themselves harshly for their outbursts of rage, panic, or tears. Ashamed of their inability to control their impulsive responses, some focus on people-pleasing, flying under the radar, and censoring their opinions.

Even while catering to others, they justify, defend, and apologize for their reactions. Others go further, taking on a rigid, perfectionist facade, with the goal of hiding their volatility. This defense demands hypervigilant self-monitoring that comes at the cost of relentless anxiety and emotional exhaustion.

[Read This: How Rejection Sensitivity Casts a Cloud Over My Marriage]

Ultimately, many women learn to avoid situations in which they anticipate rejection. They conclude that withdrawal will protect them from the painful rejections that seem inescapable, and they develop social anxiety. They find that hiding decreases their anxiety, and they accept distance and disconnection as a tolerable trade-off. Choosing isolation is a sacrifice no one should have to make. Women may feel protected, but it prevents them from being seen, heard, and known.

The bottom line is that these powerful emotional reactions wreak havoc on relationships. Their intensity derails communication with partners who tire of de-escalation duty. Some women resort to radio silence with friends who judge them as overreacting. Many feel shame and despair at their loss of control and question their efficacy as a woman in the world.

Managing Rejection Sensitivity with ADHD

The tendency to experience rejection sensitivity is part nature and part nurture. In addition to the role genetics play, the physiology of rejection sensitivity is related to the neurobiology of emotional dysregulation. These reactions may respond to guanfacine, a non-stimulant medication that has demonstrated some success in decreasing symptoms.

The nurture component involves the traumatic history of early rejections, as well as the current environments reinforcing the negative messages. A therapist can help women understand their triggers and recognize high-risk situations. Therapy helps them re-evaluate their beliefs about their self-worth, and reframe the importance of the appraisals of others. The knowledge that rejection sensitivity is a common experience, not the reflection of character flaws, is often the first step toward accepting support and pursuing treatment.

Ellen B. Littman, Ph.D., has been involved in the field of attention disorders for more than 30 years. She is the co-author of Understanding Girls with ADHD. (#CommissionsEarned)

Rejection Sensitivity with ADHD in Women: Next Steps

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