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Rejection sensitive dysphoria

Rejection sensitive dysphoria (RSD) is a triggered, wordless emotional pain that occurs after a real or perceived loss of approval, love or respect. RSD is a feature of ADHD, however it is not included in the diagnostic criteria for ADHD and therefore often overlooked.

The concept was introduced by ADHD expert Dr. William Dodson in 2005. He describes RSD as “an extreme emotional sensitivity and emotional pain triggered by the perception or imagination by the person with ADHD that they have":

• been rejected;
• been teased;
• been criticized;
• disappointed important people in their lives;
• withdrawn their own approval of themselves when they failed to attain their own standards or goals’’.

The emotional pain experienced in people with RSD is extreme. The term dysphoria is derived from the Greek word dysphoros, which means ‘hard to bear’.

Effects on emotions

Many humans tend to worry about wether they belong or not because the help and support of other humans is necessary for our survival on difficult days. If someone were to be outcast from their group, it could put them in physical danger. To prevent this from happening, people developed physical and psychological reactions to rejection. This makes that for some, rejection is considered a distressing experience.

It can physically hurt people: social rejection activates the same part of the brain as physical pain does. Some people are more sensitive to rejection than others and those people perceive being rejected more often than they actually are.

Those who are more sensitive to rejection could suffer from Rejection Sensitive Dysphoria (RSD): they often experience extreme and intense pain. The pain experienced is described as horrible, terrible, catastrophic and destructive. Some describe the pain as the feeling of being punched or stabbed in the chest and could be compared to the feeling of a "physical wound." When people with RSD try to explain the pain, most individuals bend over or clutch their chest.

The emotional reactions of RSD are distinguished from normal emotional reactions because these reactions are more extreme.

People with RSD have a strong emotional reaction to negative judgement, criticism and exclusion that sends them into a mental tailspin and won’t let them move forward with the rest of their day. They feel like failures and can’t comprehend what just happened. They often exaggerate how much people dislike them, are against them or carry shame.

In an attempt to keep themselves loved among others they might overcompensate. Someone with RSD could be seen as someone who is overly perfectionistic, overly reactive or over-sensitive to the mildest criticism. Their unfulfilled feelings to belong result in constantly having an expectation of being rejected. This can lead to emotional reactions such as anger and hurt, and certain behaviors such as hostility and social withdrawal. These expectations could lead to mental, health and social problems. Some examples include loneliness, depression, jealousy and controlling behavior in relationships or relationship dissolution and domestic violence.

Symptoms

A person with Rejection sensitivity dysphoria has an extreme emotional reaction to rejection or criticism. They often isolate themselves to avoid social settings.

Other symptoms are fear of failure, high expectations of self, anxiety, feelings of hopelessness, approval seeking behaviour and low self-esteem. Their self-esteem is dependent on what others think of them.

People with rejection sensitivity dysphoria can behave aggressively after being hurt or rejected. Certain uncomfortable situations can also trigger aggressive behaviour. For example, when they don’t ‘fit in’, when they are being misunderstood or when they are afraid they have said something wrong. In addition, some are triggered to feel guilt or shame.

Symptoms of rejection sensitive dysphoria can be confused with other conditions, but a distinguishing factor is that the symptoms are brief and triggered by emotional cycles rather than an actual event.

Health conditions with which RSD can be confused include depression, social phobia, bipolar disorder, borderline personality disorder, post-traumatic stress disorder and obsessive-compulsive disorder.

Diagnosis

When making a diagnosis, the doctor must first rule out if it’s a symptom of an underlying mental health condition. Rejection sensitive dysphoria isn’t a recognized diagnosis under the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there is no set of empirically-quantifiable criteria to determine whether someone "officially" meets a diagnosis for RSD.

Rejection sensitive dysphoria and ADHD

While the diagnostic criteria for ADHD do not include problems with mood regulation and emotion, people with ADHD may experience issues regarding this. However, emotional dysregulation is not unique to ADHD.

Rejection sensitive dysphoria is not included in the DSM-V for Attention Deficit Hyperactivity Disorder (ADHD). And it isn’t a formal symptom of ADHD, but emotional dysregulation (ED) is however included in one of the six fundamental features used to diagnose ADHD in the European Union.

ED or RSD may not be included into the DSM-V for ADHD because RSD/ED is not always present in ADHD and it is only triggered in episodes. And when RSD/ ED is present in ADHD, it cannot be measured, and therefore it cannot be researched.

As a consequence, emotional dysregulation was excluded from the diagnostic criteria for ADHD in the DSM-V. But by the end of 2019, the concept of adult emotional dysregulation gained attention in Europe. The European Psychiatric Association (EPA) revised its Consensus Guidelines on Adult ADHD, and it newly included difficulty with emotional regulation as one of the six fundamental features of ADHD

1. Inattention and hyperfocus;
2. Impulsivity;
3. Hyperactivity;
4. Emotional dysregulation;
5. Excessive mind wandering;
6. Behavioral self-regulation.

The EPA chose the broader term of emotional dysregulation (ED) instead of RSD, but the key concepts are the same. The EPA described emotional dysregulation as:

“ The type of emotional dysregulation seen in ADHD has been characterized as deficient self-regulation of emotional symptoms such as irritability, frustration and anger and low frustration tolerance, temper outbursts, emotional impulsivity, and mood lability. In ADHD, emotional symptoms tend to reflect short-lived exaggerated changes, often in response to daily events, with rapid return to baseline within a few hours. ” — EPA

RSD is estimated to affect 99% of adolescents and adults with ADHD. These people exhibit greater sensitivity than most to rejection, and one‐third consider it to be the most difficult aspect of ADHD.

Treatment

Therapy can help people recognize when their RSD has been triggered. A therapist can help people reduce their overall stress and manage their perfectionist tendencies. Helping to reduce these issues can make RSD episodes less frequent.

In therapy, a person may work on developing coping skills or dealing with rejection-related problems in a relationship. They may also learn how to minimize rumination, which is a common theme among people with RSD.

Psychotherapy on the other hand has not been particularly helpful to 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.

Another treatment includes medication. RSD often triggers an extreme response in the body’s HPA-axis, which controls the body’s stress hormone cortisol. For this reason some people with RSD use medications to address this biological aspect. The most used medication is a prescription of an alpha agonist like guanfacine or clonidine. Around one in three people feel relief from RSD with this medication. The effectiveness of the different medications is equal, but for different groups of people. If the alpha agonist doesn't work, other medication could be tried.

Another widely used 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 effective for both the attention component of RSD and the emotional component. MAOIs were found to be as effective for RSD as methylphenidate in one head-to-head trial conducted in the 1960s.

Furthermore, methylphenidate (Ritalin) and dextroamphetamine-amphetamine (Adderall) are highly effective in managing the core symptoms of ADHD. And may also help with RSD.

People living with RSD may be able to develop skills and strategies for processing emotions in therapy or support groups. Some strategies that might help include education, if a person knows that they have RSD, this may help them to put their feelings into context. Learning more about the condition might help understand how to process information. Another strategy used is delayed responses. People with ADHD sometimes behave impulsively. Pausing to think about how to respond may help reduce potential conflicts. Another one could be talking about rejection sensitivity. If a person experiencing RSD makes their friends, family, and other loved ones aware of it, the knowledge may help people choose their words and responses more carefully when interacting. And lastly, it could be helpful to choose the ‘right’ relationships, certain relationships, especially those involving abusive or critical people, may make RSD even worse. People in emotionally abusive relationships are encouraged to consider leaving if they feel able to do so. Those with highly critical partners may find that couple counselling helps.

Scientific research

Because RSD is not classified as a real disorder within the DSM V it has often been overlooked since it’s introduction in 2005. It has not been until around 2016 that awareness regarding the topic of emotional components in ADHD has caused new research to be conducted.

The papers published about RSD are various and differ in concerns. But the topics which are most prevalent, were in connection to the demographic of the people with rejection sensitive dysphoria; people with ADHD. A clear example of this is that on the popular website “Google Scholar” there are thousands of results when searching for rejection sensitive dysphoria and ADHD.

For example a study conducted in 2019 sought to find out the underlying mechanisms of why children with ADHD experienced more peer difficulties. After receiving feedback on a game it was found that the children with ADHD experienced higher sensitivity to peer rejection. Proposing an explanation of social dysfunction regularly found in those with ADHD.

Regulating emotions may be difficult for those with ADHD and therefore often been used by researchers to try and explain why socializing has been known to be a frequent problem. This combined with the notion that these children often report peer rejection and victimization  has been proposed to worsen the symptoms of RSD. But for any concrete conclusions to be made, more research on the subject is needed.

A more extensively researched idea is that of rejection sensitivity, which has previously been described by Downey and operationalized by Kathy R. Berenson. Rejection sensitivity in contrast to RSD, which is solely linked to ADHD and could therefore be considered a secondary disorder, is a more widely accepted concept.