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Rejection Sensitive Dysphoria (RSD)

Rejection Sensitive Dysphoria is an extreme emotional sensitivity to either real or perceived criticism or rejection.

Man in the mountains

What is Rejection Sensitive Dysphoria (RSD) (Higuera, 2021)?

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  • Rejection Sensitive Dysphoria (RSD) is referred to as extreme emotional sensitivity to either real or perceived criticism or rejection

  • Those with RSD are far more sensitive to rejection than someone who does not have RSD

  • RSD sufferers often perceive comments, gestures, criticism, etc. as rejection even though there was no real rejection present or intended

  • Normal rejection, criticism, and failure is often too much to bear for RSD sufferers which negatively affects their daily life (DuBois-Maahs, 2020)

  • RSD often gets mistaken for social anxiety

    • What differentiates the two is that RSD often causes anxiety during the social setting, while anxiety and discomfort occurs before arriving to the social setting in social anxiety

 

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What are the causes and symptoms of RSD (DuBois-Maahs, 2020)?

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  • Researchers are still trying to determine the actual cause of RSD

    • One possible explanation for RSD would be a history of rejection or neglect early in life

      • Having a parent who is overly critical or neglectful impacts how an individual perceives themselves, leading to sensitivity to rejection

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  • RSD symptoms are very complex and difficult to identify as these symptoms can often resemble other mental health conditions like:

    • Depression

    • Social phobia

    • Bipolar disorder

    • Borderline personality disorder

    • Post-traumatic stress disorder

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  • Common symptoms of RSD include:

    • Low self-esteem

    • Social setting avoidance

    • Fear of failure

    • High self-expectations

    • Frequent emotional outbursts after being rejected or criticized

    • Feelings of hopelessness

    • Approval-seeking behavior

    • Negative self-talk

    • Relationship problems

    • Anger and aggression in uncomfortable situations

    • Anxiety

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  • Because RSD symptoms mimic other mental health conditions, it is important to know that the distinguishing factor is that RSD symptoms are brief and triggered by an experienced event, instead of emotional cycles

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  • RSD is often misdiagnosed with a mood disorder. Refer to the chart below that describes the differences between a mood disorder and RSD (Dodson, 2022):

    • Mood disorder​

      • Mood changes are untriggered and out of the blue​

      • Moods are independent of what is going on in the individual's life

      • Mood shift is gradual over weeks

      • Offset of mood episode is gradual and over a period of weeks to months

      • Duration of episode must be > 2 weeks

    • RSD

      • Mood changes always​ have a clear trigger

      • Moods match the perception of the trigger

      • Mood shift is instantaneous

      • Episodes end quickly in a manner of hours

      • Episodes rarely last more than a couple of hours

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RSD in Attention-deficit hyperactivity disorder (ADHD) & Autism

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  • ADHD

    • Nearly 100% of individuals with ADHD also suffer from RSD

    • Though difficulty with emotional regulation is not a diagnostic criterion for ADHD, many people with ADHD have trouble regulating emotions

      • Studies show that the nervous system in those with ADHD immediately responds to a sense of rejection, whether it is perceived or real

        • A 2019 study showed that those with ADHD displayed higher levels of sensitivity when receiving feedback on a virtual game than those without ADHD (Renton, 2022)

    • Researchers also believe that hyperactivity is associated with the immediate reaction to rejection (Renton, 2022)

    • There are certain factors of ADHD that make a person more prone to experience rejection. These factors include (George, 2021):

      • Stimuli triggers the central nervous system differently in those with ADHD altering how rejection is perceived and their response to the rejection

      • The diagnosis of ADHD itself leads to increased rejection from neurotypical people as non-ADHD sufferers can be overly critical if someone with ADHD does not conform to “social norms”

      • The impulsivity that is linked with ADHD can cause inappropriate responses to situations leading to even further rejection

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  • Autism

    • Similar to ADHD, researchers also believe that there is a link between RSD and Autism

    • Autism is a neurodevelopmental disorder that affects the individual’s nervous system triggering a wide variety of symptoms (Higuera, 2021)

      • Autistic individuals suffer from emotional dysregulation and hypersensitivity to both physical and emotional stimuli

        • As a result of this, real or perceived rejection or criticism causes the individual to become overwhelmingly upset

 

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How is RSD managed?

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As RSD often stems from ADHD, the treatment of RSD is similar to the treatment of ADHD

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  • There are 3 ways in which RSD can be treated and managed (Higuera, 2021):

    • Cognitive Behavioral Therapy (CBT)

      • This is a type of talk therapy that teaches coping mechanisms

      • In CBT, you will learn coping mechanisms to handle stressful situations (like rejection), resolve relational conflicts, improve communication, and overcome emotional trauma or abuse

    • Medication

      • Medications that are prescribed for ADHD and Autism are often utilized to manage RSD symptoms

        • One common medication utilized for RSD is guanfacine

          • This is normally prescribed to lower blood pressure but, this medication targets specific brain receptors reducing hyperactivity and emotional responses – helping managing rejection sensitivity

    • Lifestyle changes

      • Get regular exercise (at least 30 minutes per day)

      • Eat a healthy balanced diet

      • Reduce stress levels – this will help assist with staying calm

      • Get at least 8 hours of sleep per night

      • Attempt to understand that what you may perceive as rejection may not actually be real rejection

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  • One tool that is beneficial to use in managing RSD is referred to as the “4 R’s”. Using this tool allows us to recognize the intensity of our emotions and respond appropriately (Maguire, 2022):

  1. Recognize – identify where you are emotionally; cognitive ability decreases as our emotions increase:

    1. Is your face flushed?

    2. Are you holding back tears?

    3. Is your fist clenched?

    4. Etc.

  2. Respond – once you recognize where you are at on the intensity meter, respond to the appropriate strategy. Below are the levels of intensity:

    • GREEN:  You are in control of your emotions - increase positive emotions and engage in activities that increase dopamine production such as doing crafts, meditating, walking bare foot (grounding method), etc.

      • Implement daily preventive coping strategies

    • YELLOW: emotionally heightened state – you may have some control over your emotions at this level but engaging in conflict is not advised

      • It is important to have strategies ready to calm your limbic system to avoid moving into Fight, Flight, or Freeze mode

        • Tactics to calm your limbic system include deep breathing, mindfulness activities, walking, exercising, etc.

    • RED: you are entering Fight, Flight, or Freeze mode and may have a hard time keeping emotions in control – do NOT engage in conflict at this level

      • Physical symptoms may arise such as increased blood pressure, breathing troubles, or rapid heart rate

      • Strategies to utilize when in the RED level include cuddling a pet, jogging, medication, jumping jacks, and any activity that excerpts energy

      • It is best to expel energy to increase serotonin and dopamine levels

   3.  Reflect – Reflect on your experience​ (Is this true? Is this what the other person wanted me                            to perceive? etc.)

   4. Reframe – attempt to reframe your thoughts; far too often what is perceived as rejection is                                just a conflict of needs

 

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Personal Story: Accepting Yourself ADHD and All: Rejection Sensitive Dysphoria

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I was diagnosed with ADHD and Auditory Processing Disorder when I was five years of age. In school, I approached tasks differently and found it hard to start a project and stay with it until I was finished. I was known for being quite the daydreamer. I also struggled to manage my emotions and would have legendary tantrums (I had quite the reputation in my family!). I would become frustrated when trying to focus my attention in school, and I was keenly aware when my classmates would finish their work before me. Even though I would hold it together in the classroom, I would meltdown at home when faced with even minor problems.

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“My emotions were so intense, and I found it difficult to put my thoughts into words.”

As I’ve gotten older, I’ve learned coping strategies to manage my emotions, but the intensity of these feelings really hasn’t changed. By middle and high school, like most kids, I became more aware of and concerned with others’ perceptions of me. I became particularly sensitive to criticism directed at me. In retrospect, this included perceived criticisms that in reality were probably innocent comments.

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Even now, when I feel as if I’m being criticized, it can be overwhelming. I can move quickly to the edge of tears, a heavy weight sinks into my gut, and I fill with self-doubt. In the aftermath of these moments, I have to fight spiraling into a mindset of shame and fear – shame about mistakes I’ve made in the past and fear that I could make more mistakes in the future.

“These were all struggles that I kept to myself because I didn’t know why I suffered, and I had no idea that many others with ADHD shared similar experiences.”

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Rejection Sensitive Dysphoria (RSD) is a condition that causes extreme emotional sensitivity to being criticized, whether that criticism is real or perceived. Although this mental health condition is gaining more attention, it is still relatively new and is not included in most diagnostic manuals. This means that there aren’t “official symptoms” that certify that someone has RSD, but there are symptoms that are heavily associated with having RSD. Some of the symptoms are setting ridiculously high self-expectations for goals along with heightened sensitivity about potential rejection.

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Experiencing pain and heartbreak from rejection – even an invented rejection- can lead to sudden emotional outbursts, negative self-talk (sometimes thoughts of self harm), low self-esteem, self-sabotage or being your “own worst enemy,” and avoidance of social situations or situations that may trigger those unbearable feelings of rejection. People with RSD describe this emotional pain as a short, intense burst, like a “stab or punch” to the chest.

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Researchers have discovered an association between RSD and ADHD, especially Emotional Dysregulation. Even though this area impacts many people with ADHD, it has sort of been put on the back burner because it is challenging to research an area that centers around an individual’s subjective experience, especially for adults with ADHD.

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“The criteria for diagnosis for ADHD fits well with children who are 6-12 years of age, but as children grow older, ADHD can affect them in ways that are not as widely acknowledged, such as the impact on emotions, thinking styles, relationships, and trouble with sleep.”

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Personally, information about the impact of RSD resonates with me. As a college freshman who is living on her own for the first time, I can attest to experiencing these issues. I have struggled with balancing responsibilities and interests. I can become so involved with my school work and other obligations that I don’t get the sleep I need, have 3 weeks worth of laundry all over my floor, and forget to tend to important relationships in my life. This can have a terrible effect on my mood and productivity. My quick reaction is to be extremely critical of myself, anxious, compare myself to others, and feel like a total failure. Together, this vicious cycle and its effects can make me feel like I have no control over my life, which couldn’t be further from the truth.

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“Although I do struggle in some ways, there are also many areas in which I thrive. My ADHD has allowed me to come up with unique and creative solutions to problems.”

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For example, I use artwork, color, and visual symbols on my calendar to keep track of assignments. I also thrive in creative environments and love to collaborate with others and create projects. I’m an Acting major, and when I’m involved in a play or musical, or I’m inspired to create, that is when I am most focused and feel the most free. When I am triggered by perceived criticism, although my emotions feel intense and uncontrollable in the moment, I have found that contrasting the situation with the bigger picture helps. I have found I can reassure myself that life will go on and mistakes will help me grow.

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“Even though we cannot magically snap our fingers to make our problems disappear, we can learn to manage them and adopt healthy habits to make the problems shrink.”

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These can range from establishing a good morning routine to keeping a gratitude journal. Perhaps it’s listening to music, exercising, or practicing yoga. Medication can help as well. Keep in mind that every person is different, and each person’s journey to self-acceptance is unique. Two sayings that I’ve learned in theatre keep me motivated and provide a healthy perspective: “You can’t move forward if you’re looking to the side.” and “Fail Forward.” In the end, accepting yourself can be one of the most challenging of personal journeys; it is a long and winding road to loving who you are.

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Retrieved from: https://www.ncld.org/news/engaged-and-empowered/accepting-yourself-adhd-and-all-rejection-sensitive-dysphoria/

 

 

 

Crisis Resources:

  • NAMI HelpLine

  • NAMI Crisis Text Line

    • Text NAMI to 741-741

  • COPE (Hennepin County)

    • Adult: 612-596-1223

    • Child: 612-348-2233

  • Ramsey County

    • Adult: 651-266-7900

    • Child: 651-266-7878

  • Text Connect (Crisis counseling via text)

    • Text “HOME” to 741741

 

 

 

 

References

 

Dodson, W. (2022, July 11). New insights into rejection sensitive dysphoria. ADDitude Magazine.

     https://www.additudemag.com/rejection-sensitive-dysphoria-adhd-emotional-dysregulation/

 

DuBois-Maahs, J. (2020, October 2). Rejection sensitive dysphoria: Causes, signs, & treatment.

     https://www.talkspace.com/mental-health/conditions/rejection-sensitive-dysphoria/

 

George, V. (2021, August 1). Understanding the link between ADHD and Rejection Sensitive   

     Dysphoria. The ADHD Nurse. https://theadhdnurse.co.uk/rejection-sensitive-dysphoria/

 

Higuera, V. (2021, November 19). What is rejection sensitive dysphoria? HealthLine.

     https://www.healthline.com/health/mental-health/rejection-sensitive-dysphoria#adhd-and-     

     autism

 

Maguire, C. (2022, March 8). Rejection sensitivity: Managing feelings of overwhelm and rejection 

     as an adult with ADHD. Attention Deficit Disorder Association. https://add.org/rejection-

     sensitivity/?gclid=EAIaIQobChMIrpDW4vzN-QIV8PbjBx1qBgKPEAAYBCAAEgLJXvD_BwE

 

Renton, C. (2022, February 22). Rejection sensitive dysphoria and ADHD: What to know.

      VeryWellHealth. https://www.verywellhealth.com/rsd-adhd-5211765

 

Washington, N. (2021, April 27). What to know about ADHD and rejection sensitive dysphoria? 

     Medical News Today. https://www.medicalnewstoday.com/articles/adhd-rejection-sensitive-

     dysphoria#summary

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