woman experiencing rejection dysphoria syndrome
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Summary: Rejection sensitivity disorder in ADHD describes extreme sensitivity to actual or perceived criticism that causes significant emotional distress and/or dysphoria.

Key Points:

  • Rejection sensitivity dysphoria (RSD) is not a clinical mental health disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM).
  • RSD is a common phenomenon in people with some mental health conditions and associated with autism spectrum disorder (ASD) and attention deficit-hyperactivity disorder (ADHD.
  • RSD in attentions deficit-hyperactivity disorder (ADHD) is associated with emotion dysregulation.
  • In people with ADHD, RSD can cause significant emotional, psychological, and physical pain and distress.

Identifying Rejection Sensitivity Dysphoria in ADHD

The authors of the study “Rejection Sensitivity Dysphoria (RSD) in Attention-Deficit/Hyperactivity Disorder: A Case Series” define RSD as follows:

“Rejection Sensitivity Dysphoria (RSD) [refers to] episodes [that] begin with the experience of perceived rejection, demonstrating rejection sensitivity, [and] progresses into a nearly instantaneous dysphoric mood, which causes significant distress and impairment.”

While many people – probably everyone – experiences rejection, with negative emotions attached, not all people experience what mental health professionals describe as dysphoria in response to rejection. Here’s how the American Psychological Association (APA) defines dysphoria:

“A mood characterized by generalized discontent and agitation.”

That’s also something almost everyone experiences. However, when we refer to rejection sensitive dysphoria in ADHD, it’s important to understand that many people with ADHD and people who identify as neurodivergent also experience something called emotional dysregulation, which not everyone who experiences rejection or dysphoria experiences. Here’s how the APA defines emotional dysregulation:

“Emotional dysregulation is an extreme or inappropriate emotional response to a situation, such as outbursts and/o deliberate self-harm, and is often associated with bipolar disorders, borderline personality disorder, autism spectrum disorder, psychological trauma, or brain injury.”

That definition leaves ADHD out of the definition. However, research indicates that emotion dysregulation is a component of ADHD, which helps explain the presence of rejection sensitivity dysphoria in ADHD. Here’s how the authors of the study “Emotional Dysregulation and Attention-Deficit/Hyperactivity Disorder” describe emotional dysregulation in the context of ADHD:

  1. Emotion dysregulation is common in ADHD and “a major contributor to impairment.”
  2. In ADHD, emotion dysregulation is associated with differences in recognizing and/or allocating attention to emotional stimuli.”
  3. For providers, recognizing the combination of emotional regulation and differences in attention to emotional stimuli may help improve treatment for ADHD.

We’ll add that recognizing the impact of combined emotion dysregulation and differences in managing attention to emotional stimuli are what likely result in what we call rejection sensitivity dysphoria in ADHD.

Symptoms of Rejection Sensitivity and Rejection Sensitivity Dysphoria

First, let’s review the symptoms of rejection sensitivity without emotional dysphoria and without a diagnosis of ADHD:

  • Elevated fear of rejection/anxiety before possible rejection
  • Interpret neutral reactions from others as negative reactions
  • Overreaction to rejection: anger, sadness, increased anxiety

When a person experiences emotional dysphoria in combination with rejection sensitivity, the result is an elevated level of emotional pain associated with rejection. People with rejection sensitivity + dysphoria, i.e. rejection sensitivity dysphoria, may show the following symptoms:

  • Easily embarrassed
  • Extremely self-conscious
  • Low self-esteem/self-belief
  • Difficulty managing emotional responses to rejection: anger, rage, sadness, and crying are common
  • Direct emotional reactions in response to rejection inward, toward self, very quickly, often misidentified as symptoms of bipolar disorder or borderline personality disorder
  • Go to great lengths to please others and avoid rejection
  • Avoid engaging in tasks or activities – from work/school assignments to social situations – out of fear of rejection.

That’s what rejection sensitivity and rejection sensitivity dysphoria look like without ADHD. Now let’s take a look at how it appears in people with ADHD.

Rejection Sensitivity Dysphoria in ADHD

To learn what rejection sensitivity dysphoria in ADHD looks like, we’ll review information from two recent publications on RSD in ADHD:

  1. Rejection Sensitivity Dysphoria (RSD) in Attention-Deficit/Hyperactivity Disorder (link above)
  2. The Lived Experience of Rejection Sensitivity in ADHD: A Qualitative Exploration

The first study identifies the common triggers for RSD in ADHD:

  • Rejection
  • Teasing
  • Criticism delivered in any manner at all
  • Self-perception of failure

The first study foregrounds two symptoms of RSD that occur in response to rejection:

  • Intensity of emotion, described as: “awful, terrible, catastrophic, devastating”
  • Physical pain: emotional pain in RSD in ADHD often manifests physically, with people with ADHD reporting they often “hunch over, grimace, and clutch their chest”

It’s easy to see how RSD in ADHD can cause significant disruption and elicit behavioral responses that may exacerbate a sense of rejection and increase emotional distress. The second study identifies three common responses to rejection among people with ADHD and RSD.

Rejection Sensitivity Dysphoria in ADHD: Three Common Responses

  1. Withdrawal:
      • Anticipation of rejection can cause people with ADHD to withdraw from “friendships, family and romantic relationships, [social] life, and job opportunities.”
      • People with ADHD + RSD report the “expectation of rejection causes more dysphoria than rejection itself”
      • Anticipation of failure or rejection also causes people with ADHD + RSD to fail to complete or turn in school assignments or work deliverables.
  1. Masking:
      • People with ADHD and RSD may have difficulty recognizing what’s a joke/banter, and what’s actual criticism
      • In response, they hide – a.k.a. mask – their responses behind a show of toughness, pretending nothing bothers them.
      • They report that this can result in masking their emotions from themselves, resulting in increased emotional dysphoria over time.
  2. Physical sensations:
      • Perceived rejection in RSD in ADHD can evoke overpowering and painful physical sensations.
      • Sensations may include stomach pain, nausea, a stab in the heart, throat closing up, a chair being pulled out from under you, burning sensation in chest or gut, a feeling of being paralyzed.
      • The most frequently described physical responses to perceived rejection were related to the gut: nausea, pain, feeling “gut punched.”

We’ve shared what RSD in ADHD is, how its triggered, and how people with ADHD respond to perceived or actual rejection.

But how can clinicians help people with ADHD who also have RSD?

Treatment for RSD in ADHD

There’s a compelling reason for providers to address rejection sensitivity in people with ADHD. The authors of the “Lived Experience” study above observe:

“Our findings indicate that rejection sensitivity is a multidimensional experience; encompassing emotional pain, negative cognitions, and unpleasant physical sensations. The findings also indicate that rejection sensitivity could be a contributing factor in the psychosocial problems often faced by [people with] ADHD.”

Experts on ADHD indicate that first-line treatments for ADHD can also improve RSD in ADHD. In addition, multimodal strategies that improve skills to compensate for ADHD differences can help people with RSD, with an emphasis on emotion processing and emotion regulation skills. Therefore, treatment for rejection sensitivity dysphoria in ADHD may include:

Pharmacological treatments:

  • Stimulant medication
  • Alpha 2 receptor agonists such as clonidine and guanfacine

Psychotherapeutic and complementary treatments:

  • Cognitive behavioral therapy (CBT)
  • Mindfulness

While RSD is not an official clinical diagnosis on its own, or a subtype of ADHD, providers treating patients with ADHD have recognized the phenomenon for decades. We encourage patients with ADHD who have extreme sensitivity to rejection to understand that they’re not alone. In fact, a significant number of people with ADHD experience RSD. We encourage these patients to avoid masking their experience from providers and to be open about what they experience. With awareness, empathy, and understanding, an experienced, skilled therapist can tailor ADHD treatment to effectively support patients with rejection sensitivity in ADHD.

About Angus Whyte

Angus Whyte has an extensive background in neuroscience, behavioral health, adolescent development, and mindfulness, including lab work in behavioral neurobiology and a decade of writing articles on mental health and mental health treatment. In addition, Angus brings twenty years of experience as a yoga teacher and experiential educator to his work for Crownview. He’s an expert at synthesizing complex concepts into accessible content that helps patients, providers, and families understand the nuances of mental health treatment, with the ultimate goal of improving outcomes and quality of life for all stakeholders.