Understanding Rejection Sensitive Dysphoria (RSD) & ADHD

Understanding RSD

Someone with Rejection Sensitive Dysphoria has a heightened sensitivity to rejection or criticism. Although the rejection or criticism may be minor or nonexistent, it can cause intense emotional pain and distress. As a result, a person with RSD may react suddenly and emotionally, which can be overwhelming for themselves and the people around them. Since feelings of social rejection have been shown to share brain areas with physical pain, it’s not uncommon for someone with RSD to experience actual physical pain from feelings of rejection or failure.

RSD can have a serious impact on a person’s life, disrupting a person’s relationships, work, and overall well-being. The behavioural, physical, and emotional symptoms can hinder academic or professional success and cause a person to withdraw or isolate themselves. Over time, a person with RSD may feel self-conscious or inadequate, leading to deep sadness, anxiety, and low self-esteem. People with RSD often engage in compensatory behaviours leading them to work excessively to get in someone’s good graces for that feeling of approval. RSD commonly contributes to burnout in people with ADHD.

The link between ADHD and RSD

Studies have estimated that around 35% to 70% of people with ADHD struggle with emotional dysregulation. In other words, due to wiring differences in the brain of someone with ADHD, the way they process emotions differs from a neurotypical person. For instance, a person with ADHD may overreact to a minor setback and stay calm and collected when disaster hits. Brain mapping research has shown that problems related to emotional regulation networks in ADHD may predict the severity of the disorder into adulthood.

Difficulty managing emotions can lead to mood swings and extreme feelings in the face of perceived rejection or criticism. People with emotional dysregulation might feel intense feelings such as rage and shame and experience extreme emotional outbursts over seemingly minor challenges or obstacles. They may also feel intense feelings of despair in response to their own perceived failure or shortcoming.

Researchers are still investigating how ADHD may be linked to RSD. But genetic and environmental factors remain high on the list of possible causes of ADHD and RSD. For example, studies have shown that variations in the oxytocin receptor gene are linked to higher cortisol (stress hormone) levels and social reactivity. These changes may be passed on through close family members, increasing the risk of developing RSD. It is also common for people who experience emotional neglect and trauma early in life to experience RSD and ADHD. 

Can RSD be diagnosed?

Rejection sensitive dysphoria is not a condition formally recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Instead, a healthcare provider may describe RSD as a symptom of ADHD. A mental healthcare provider may refer to your RSD based on a complete medical history and symptoms you may be experiencing. Although you are unlikely to get a formal diagnosis of RSD, it is still valuable to discuss and explore this condition with your healthcare provider. 

Labelling RSD may involve asking about your experience with rejection or criticism in the past. A person who has experienced neglect or abuse in the past, whether from a loved one or a peer, may be more likely to experience RSD. If a past experience was traumatic enough, you might be more prone to respond to rejection or criticism in a debilitating way. 

Because the symptoms of RSD can often overlap with those of ADHD and other mental health conditions, such as borderline personality disorder and depression, it can sometimes be difficult to parse apart the different symptoms. Sudden emotional changes may be confused for bipolar disorder or Intermittent explosive disorder. When talking to your healthcare provider, be sure to clarify how your symptoms are in response to rejection, failure or criticism, which can help better understand your pain’s source. You may also be asked about the duration of discomfort and how quickly you can recover. There tends to be a lot of overlap between RSD and other conditions, but there are also many treatment options that can help target clusters of symptoms.

Symptoms of RSD

The symptoms can range in severity and are usually emotional, physical, or behavioural. These symptoms may include:

• Overwhelming feelings of anger, sadness, or anxiety

• Persistent fear of being rejected or criticized

• Low self-esteem or feelings of worthlessness

• Physical symptoms such as trouble sleeping, restlessness, headache, muscle tension, upset stomach

• Putting yourself last and excessively engaging in approval-seeking behaviour

• Aggression or irritability in the face of perceived failures 

• Sudden emotional outbursts after being hurt or rejected

• Struggles to maintain positive relationships with others

• Avoidance of social situations, important tasks, or specific projects for fear of being rejected or not meeting excessively high standards

• Feeling frozen or unable to start something due to fears over not being good enough

• Creation of excessively high standards or perfectionism

• Overcompensation or “people-pleasing” behaviours

Although these symptoms may indicate RSD, it can sometimes be hard to explain what RSD feels like. For many people with RSD, symptoms can be emotionally painful and intense to the point of paralyzing distress. For others, symptoms may be mildly disruptive but manageable. 

The symptoms of RSD can often turn into a vicious cycle of negatively reacting to a situation, which creates a feeling of rejection. This negative thought pattern, or bias, may create a perception of the very thing they are trying to avoid. 

Treatment options

Depending on the severity of symptoms and other health conditions a person may have, treatment for RSD may be recommended. Treatment options may include medication, psychotherapy, and lifestyle changes. However, speaking with a therapist or other mental health professional is always a good idea to determine the best way to treat RSD. 

Medication

RSD is typically not medicated on its own, but your prescriber may choose medications for your other conditions that may also help alleviate some RSD symptoms. These medications are not approved by the Food and Drug Administration (FDA) for RSD, but when RSD occurs with a condition like ADHD, treatment with medication can be helpful for both conditions. In extreme cases, a healthcare provider may prescribe off-label medication based on clinical expertise and supporting research. 

Medications used to treat symptoms of RSD with ADHD include:

Centrally acting alpha agonists: Clonidine (Kapvay) and guanfacine (Intuniv) are potential options to relieve RSD symptoms. Clonidine and guanfacine are classified as centrally acting alpha agonists used to treat high blood pressure but are also approved for treating ADHD. The exact way they work is not fully known, although they are believed to increase the activity of certain neurotransmitters or chemicals in the brain. Intuniv, in particular, has been noted to be helpful for many people with RSD and ADHD, and it can be taken alongside many other medications. 

Stimulants: Stimulant medications such as amphetamines (e.g., Adderall) and methylphenidate (e.g., Ritalin and Concerta) may help with emotional regulation difficulties, which can help alleviate symptoms of RSD. Reduction in ADHD symptoms can also improve social relationships, which can reduce the pain and self-fulfilling cycles associated with RSD. For some people with RSD, stimulants may increase anxiety which can worsen RSD. 

Anti-anxiety medication: Some prescribers may recommend small doses of benzodiazepines, such as diazepam, which can help rapidly alleviate symptoms of RSD. They should be used cautiously and in combination with therapy. 

Psychotherapy

Also known as talk therapy, psychotherapy involves working with a mental health professional to identify thoughts and behaviours contributing to RSD. A therapist can help a person with RSD reframe their thoughts and beliefs to process and cope with RSD. For instance, a person with RSD can learn to recognize when a specific situation of criticism or rejection might trigger them. They can then learn different processes to reduce the intensity of negative emotions. 

Examples of psychotherapy include cognitive behavioural therapy and acceptance and commitment therapy. However, various reports suggest that these therapies might not do much to help relieve RSD, as RSD is often characterized by sudden episodes of emotional distress. Still, a therapist can help a person with RSD learn to manage criticism and rejection in a positive way. 

Rather than traditional therapies, many people with RSD find that they respond especially well to therapy that targets their attachment style. Therapies such as Family Systems, Schema Therapy, and Dialectical Behavioral Therapy can help you better understand the source of certain pain, your expectations about the world, and how to find healthier ways to redefine and navigate your current relationships. Learning what secure attachment styles look like and how you can begin to build that in your own life can bring a great source of relief. 

Lifestyle changes

Certain lifestyle changes may be beneficial for coping with RSD. Mindfulness and meditation can help people with RSD become more aware of their triggers and emotional reactions, which can help them learn to respond more productively. Regular exercise, a healthy diet, and restful sleep may also help improve mood, reduce stress, and promote overall well-being. Stress can often amplify emotional responses to different situations. 

With these lifestyle changes and coping strategies, a person with RSD can work to reduce the intensity of their emotional reactions. It’s also important to have social support, whether friends, family, or healthcare providers, who can make it easier to manage and live with RSD. 

Overcoming RSD

With the right combination of therapy, medication, and coping strategies, individuals with RSD can improve their emotional well-being and daily functioning. By addressing RSD symptoms and their underlying causes, it is possible to lead a happier, more fulfilling life. However, addressing RSD early on is important to help manage and prevent symptoms from worsening.

Left untreated, RSD may lead to long-term consequences on mental health, relationships, and overall quality of life. If you’re living with RSD, you’re not alone. Overcoming RSD doesn’t have to be extremely difficult, and treatment is often accessible in many forms. You can seek support from a mental health professional to get the treatment you need, whether online or in person.