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The Connection Between Rejection-Sensitive Dysphoria (RSD), ADHD, and Other Neurodivergent Conditions

Updated: Jul 14

Many experiences are universally experienced by all.


One of these experiences is rejection. You will inevitably experience this at least once in your lifetime. 


No one likes this feeling of rejection, whether it is in a friendship, a romantic relationship, or at work. 


These circumstances can cause unpleasant emotional and physical feelings, but most of us can find ways to manage and cope with these feelings. 



But for some individuals, rejection causes a heightened emotional and physical pain that’s difficult to control and manage which experts call rejection-sensitive dysphoria (RSD).


This may cause heightened emotional outbursts, negative self-talk, rumination, and withdrawal from social situations.  


We often look at ADHD from the perspective of inattention, impulsivity, and hyperactivity, but RSD is also more common in ADHD individuals and other neurodivergent individuals. 


If you are experiencing the traits of RSD, a virtual ADHD rejection-sensitive dysphoria coach may be of support to you.


Read on to discover more about RSD, how it is linked with ADHD and other neurodivergent conditions, and ways to manage RSD. 


What Is Rejection-Sensitive Dysphoria?


Rejection-sensitive dysphoria (RSD), also known as hysteroid dysphoria in Europe, is not an officially recognized diagnosis in itself but can occur along with other conditions. 


This involves a brain-based symptom of other conditions, especially neurodivergent conditions such as ADHD. 


It is a manifestation that occurs as a result of emotional dysregulation and involves a heightened response to rejection or criticism. 


The “dysphoria” aspect of the word is derived from ancient Greek roots and means strong or unbearable. 


This is to say that this rejection can cause a severe emotional response and physical pain. 


Moreover, these emotional and physical reactions do not only occur with real rejection, criticism, or teasing.


Imagined rejection can also produce the same responses from individuals with RSD.


Even a vague interaction, such as an “ok” to an email, can cause someone with RSD to imagine if they did something wrong.


Everyone experiences negative responses to rejection, but the difference here is that these responses are stronger and more difficult to control.  


The response that those with RSD experience is usually out of proportion with the nature of the situation at hand. 


RSD may also interfere with a person's work or school life, relationships, or overall well-being. 


Individuals with RSD often feel inadequate and deal with low self-esteem, depression, and anxiety. 


This is followed by counter behaviors such as pleasing people and perfectionism to try to avoid rejection, criticism, and these painful feelings that follow.


Rejection-Sensitive Dysphoria vs. Sensitivity to Rejection


We all have many different brain areas that differ in their functions. 


As you age, your brain learns how to properly integrate all the signals from each of these brain areas to manage your emotions. 


If you experience emotional dysregulation however, you are unable to properly regulate the areas of your brain that are involved in emotion. 


Your emotions become overwhelming and difficult to manage. 


This emotional dysregulation happens with both rejection-sensitive dysphoria and sensitivity to rejection, but there is a core difference between the two. 


Dysphoria does not occur with sensitivity to rejection. It only occurs with RSD. 


While individuals with RSD and sensitivity to rejection can experience anxiety due to rejection or overreact due to rejection, only those with RSD will experience the severe emotional pain or discomfort aspect of rejection.


History of Rejection-Sensitive Dysphoria and its Associated Emotional Dysregulation


RSD is related to emotional dysregulation, which is a term that goes back decades. 


Dr. Paul Wender, in the 1960s and beyond, was a pioneer in the study of emotional dysregulation and its connection to ADHD.


He was the first to recognize that emotional dysregulation is a pervasive and impairing symptom of ADHD. 


Before he recognized this as emotional dysregulation, however, he labeled this experience as atypical depression due to society’s lack of understanding of these experiences at that time. 


Later, we came to understand that Dr. Wender was referring to RSD in ADHD individuals. 


Once widely ignored, emotional dysregulation and RSD are becoming more widely recognized and studied features of ADHD. 


In the 1990s, these studies were further elaborated on, and rejection-sensitive dysphoria was then coined at Milton E. Hershey Medical Center by Dr. William W. Dodson. 


He used this term to describe how some of his patients had extreme mental and emotional pain due to the mere perception of rejection. 


Now, these experiences are commonly recognized by ADHD and other neurodivergent individuals to describe their intense responses to rejection.


What Triggers Rejection-Sensitive Dysphoria?


The intense emotional and physical responses that occur in RSD are usually a reaction to one of the following triggers:


  • Abandonment from a loved one

  • Teasing

  • Criticism

  • Real or perceived rejection or disapproval

  • Self-criticism or negative self-talk


These feelings related to these triggers can be externalized or internalized and present with various symptoms as a result of this. 


If internalized, the response typically looks like that of a sudden bout of depression that can include suicidal thinking. 


On the other hand, rage and anger outbursts typically occur when these emotions to the triggers are externalized. 


What Causes Rejection-Sensitive Dysphoria?


So far, experts don’t know the exact cause of RSD. 


There are theories that it has to do with the parts of the brain that respond to and manage rejection, failure, and criticism, which are the amygdala and the prefrontal cortex. 


The amygdala is the part of your brain that is emotional, while the prefrontal cortex is more the controller for important cognitive processes.


As you age, your brain should develop in such a way that you are less likely to be controlled by the emotional areas of the brain and more likely to be controlled by more cognitive areas of your brain. 


For some individuals, this does not happen. 


Instead, your brain is unable to properly manage the signals from your amygdala and prefrontal cortex, and your emotional areas of the brain take over, making negative emotions extremely painful and unbearable. 


This causes emotional dysregulation, which is an inability to manage these negative emotions and is linked with RSD.


Researchers also believe genetics may play a role in the development of RSD and that those with mental health conditions or neurodivergent conditions that run in families may be more likely to develop it. 


More research is needed to understand the connection between genetics and RSD. 


Signs of Rejection-Sensitive Dysphoria


The key sign of RSD is intense emotional pain from real or perceived rejection or criticism. 


The feeling of RSD will differ for every individual who experiences it. 


Moreover, individuals who experience RSD may have a difficult time explaining what the experience is like because it differs from other forms of pain. 


Individuals with RSD often describe it as feeling like an open wound. 


Some common signs of rejection-sensitive dysphoria include:


  • Becoming easily embarrassed when criticized in public

  • Low self-esteem

  • Persistent fears of being rejected

  • Physical discomforts such as a heavy chest or a tight stomach

  • Trouble controlling emotions when you experience rejection (either real or perceived)

  • Rumination and perseveration

  • Defensive reactions to rejection such as anger or aggresion

  • Relationship issues

  • A snap onset of depression or anxiety to the experience of rejection

  • Avoidance of task initiation or social situations to avoid criticism or rejection

  • Lack of self-care and burnout

  • Withdrawal from or avoidance of social situations

  • Negative self-talk and thoughts of self-harm


The symptoms of RSD often create a negative feedback cycle. 


Individuals with RSD may engage in behaviors to try to limit rejection.


This could include pleasing people or the desire to be everything for everyone so that you don’t get rejected. 


Another common behavior is perfectionism, to make it so that you are less likely to be criticized to begin with.  


Rejection is likely to still occur occasionally regardless of if you engage in these behaviors or not because no one can be 100% right all the time.


A person may then negatively react to rejection and then again respond by trying to counteract it with perfectionism and people pleasing. 


What Is ADHD, or Neurodivergence?


ADHD is a neurodivergent condition and neurodevelopmental disorder diagnosed through an ADHD assessment


“Neuro” means brain, and “divergent” means that your brain diverges from some average point. 


This means that ADHD individuals have differences in the way their brain develops, and their brain functions differently for some reason. 


In ADHD, these differences are typically involved in the symptoms of inattention, impulsivity, and hyperactivity that occur in the condition that often benefit from an ADHD coach.


There are also emotion-based traits that occur with ADHD such as ADHD waiting mode, which is when an ADHD individual becomes overwhelmed when waiting.


Along with ADHD, there are many other neurodivergent conditions. 


Differences in the brain and the way a person interacts with the world around them occur in anxiety, Tourette’s syndrome, depression, learning disabilities, and autism, among other conditions. 


Is Rejection-Sensitive Dysphoria a Symptom of ADHD?


Rejection-sensitive dysphoria is not officially recognized in the DSM-5 as a symptom of ADHD. 


There are many barriers to recognizing RSD in ADHD. 


For starters, the DSM-5 criteria fits well with elementary school-aged children, but there is limited understanding of its use for those over the age of 16 (Pliszka, 2007). 


The criteria also tends to ignore or minimize emotion, thinking styles, relationships, and sleeping issues while focusing more on behavioral symptoms. 


Both ADHD emotional dysregulation and ADHD rejection-sensitive dysphoria have begun to be more widely studied over the past 10 years. 


Despite there being an increase in knowledge, RSD may not be officially recognized in the DSM-5. 


This may be because RSD is not always present in those with ADHD, and it’s difficult to measure RSD. 


Though RSD is not recognized, in 2019, emotional dysregulation, which shares many facets with RSD, was recognized by the European Union as one of the six facets of ADHD. 



ADHD individuals may therefore react differently to emotions than how a neurotypical person would. 


The most minor of criticism may cause someone with ADHD to experience a severe emotional response. 


Despite all the increases in research and understanding, there is still work needed to have emotional dysregulation and RSD recognized by the US in the DSM-5 as core facets of ADHD. 


Can Rejection-Sensitive Dysphoria Occur with Other Neurodivergent Conditions?


Just like with ADHD, there is limited research on the connection between rejection-sensitive dysphoria and neurodivergent conditions. 


Despite this, there is some understanding that RSD may be more common among individuals with neurodivergent conditions, including autism, learning disability, depression, anxiety, and CPTSD, among other neurodivergent conditions. 


More research is needed to understand why this is the case. 


Can You be diagnosed with Rejection-Sensitive Dysphoria?


RSD is not an officially recognized condition and, therefore, not something you can be officially diagnosed with using the DSM-5. 


Instead, clinicians may suspect that you have RSD based on your symptoms and the presence or absence of other neurodivergent conditions. 


They will consider your responses to rejection and whether or not you have experienced harsh criticism in the past or at the present time. 


The symptoms of mood disorders and other mental health conditions can often overlap with those of RSD, so it can be difficult to understand what is and isn’t RSD. 


Support for Rejection-Sensitive Dysphoria


RSD is not something that has a cure, but rather something that can be managed. 


How it is managed will depend on your individual needs and can involve a combination of medications, coaching, and lifestyle changes.


Medications


Medications can play a crucial role in managing your RSD symptoms. 


Currently, there are no specific medications approved to treat RSD specifically. 


Instead, medical providers may use medications that treat other conditions associated with RSD, such as anxiety, depression, or ADHD. 


They may also use off-label prescribing to prescribe a drug for an intended purpose other than what it was originally approved for. 


Centrally acting alpha-agonists are an example of this.  


Clonidine (Kapvay) and guanfacine (Intuniv) were originally intended to be used to treat high blood pressure but are potential options to treat RSD because they treat ADHD. 


Other medications, such as stimulants used to treat ADHD and anti-anxiety medications used to treat anxiety, may also be prescribed by a doctor off-label for RSD. 


Counselling


Another common form of treatment for RSD is counselling, which can help you process and manage the emotions associated with your RSD and learn to cope when an RSD episode is triggered. 


You will also learn what triggers your specific episodes of RSD and what processes help manage the emotions that occur as a result of them. 


Support for aspects of your identity that may be criticized by society such as sexual orientation is also an option. This is because societal criticism of who you are may be more likely to trigger RSD symptoms.


Individuals with RSD have also been known to respond well to therapies targeting attachment style such as International Family Systems and Dialectical Behavioral Therapy, which help you make sense of the sources of your RSD. 


This counselling will also involve neurodiversity-affirming practices that seek to find accommodations to help you manage RSD, rather than try to fix you.



Lifestyle changes


Lastly, lifestyle changes through life coaching, such as stress management techniques to manage your stress levels and emotions, can support those with RSD.


This can include mindfulness meditation, breathing exercises, restless sleep, and proper nourishment of your body. 


Here are some suggestions from neurodivergent individuals:


Reinforce your strengths 


Acknowledge your positive traits and what you do well at. Reward yourself when you do well. This can help build your confidence. 


Use positive affirmations


Affirmations and mantras can help to reduce the negative thoughts that come with RSD and counter those thoughts. 


Validate your emotions and practice self-compassion


Remind yourself that your emotions are a valid experience. Let yourself feel them, and be kind to yourself to allow yourself time to cope with rejection. 


Shift focus


Name one good thing and one bad thing each day. Try to shift focus to the good while acknowledging the bad. 


Supportive People


Reach out to people in your life who can reaffirm how awesome you are and build up your confidence to counter the negative feelings. 


Distractions


Find yourself an activity or object that distracts you and brings you comfort. This could be a fidget spinner or some music. 


Book a Free Consultation With Blue Sky Learning


MORE ABOUT BLUE SKY LEARNING


Blue Sky Learning team members embody values of compassion, empathy, and person-centered approaches. 


Blue Sky Learning provides the opportunity for students, professionals, parental guardians, and educators to connect with them regarding individual concerns and areas of growth. 


Blue Sky Learning strives to provide a service where clients feel safe, supported, and intersectionality understood. 


Blue Sky Learning aims to reduce stigma and shame cycles, deepen client understanding of internalized ableism, and empower areas of avoidance to increase your value of motivation.


Free 20-minute consultation WITH a rejection-sensitive dysphoria COACH


Are you a neurodivergent individual experiencing RSD and seeking the support of a virtual rejection-sensitive dysphoria coach or therapist?


Blue Sky Learning is here to support you with their team of coaches and therapists who offer free consultations to find out if blue sky learning is the right fit for you.  


Book a free 20-minute consultation with one of the Blue Sky Learning team members by emailing hello@blueskylearning.ca or heading on over to the website.





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