Rejection Sensitive Dysphoria

Rejection Sensitive Dysphoria and ADHD

For people with ADHD, Rejection Sensitive Dysphoria can mean extreme emotional sensitivity and emotional pain — and it may imitate mood disorders with suicidal ideation and manifest as instantaneous rage at the person responsible for causing the pain. Learn more about potential treatments here.

A woman with rejection sensitive dysphoria hiding her face with her hand
Woman showing hand stop sign while standing at night

What is Rejection Sensitive Dysphoria?

Rejection sensitive dysphoria is an extreme emotional sensitivity and emotional pain triggered by the perception — not necessarily the reality — that a person has been rejected, teased, or criticized by important people in their life. Rejection sensitive dysphoria (RSD) may also be triggered by a sense of failure, or falling short — failing to meet either their own high standards or others’ expectations.

Dysphoria is Greek for “difficult to bear.” It’s not that people with attention deficit disorder (ADHD or ADD) are wimps, or weak; it’s that the emotional response hurts them much more than it does people without the condition.

When this emotional response is internalized, it can imitate a full, major mood disorder complete with suicidal ideation. The sudden change from feeling perfectly fine to feeling intensely sad that results from RSD is often misdiagnosed as rapid cycling BPD.

It can take a long time for physicians to recognize that these symptoms are caused by the sudden emotional changes associated with ADHD and rejection sensitivity, while all other object relations are totally normal.

When this emotional response is externalized, it looks like an impressive, instantaneous rage at the person or situation responsible for causing the pain. 50% of people who are assigned court-mandated anger-management treatment have previously unrecognized ADHD.

[Self-Test: Could You Have Rejection Sensitive Dysphoria?]

RSD can make people with ADHD anticipate rejection — even when it is anything but certain. This can make them vigilant about avoiding it, which can be misdiagnosed as social phobia. Social phobia is an intense anticipatory fear that you will embarrass or humiliate yourself in public, or that you will be scrutinized harshly by the outside world.

Rejection sensitivity is hard to tease apart. Often, people can’t find the words to describe its pain. They say it’s intense, awful, terrible, overwhelming. It is always triggered by the perceived or real loss of approval, love, or respect.

People with ADHD cope with this huge emotional elephant in two main ways, which are not mutually exclusive.

1. They become people pleasers. They scan every person they meet to figure out what that person admires and praises. Then, that’s the false self they present. Often this becomes such a dominating goal that they forget what they actually wanted from their own lives. They are too busy making sure other people aren’t displeased with them.

[Exaggerated Emotions: How and Why ADHD Triggers Intense Feelings]

2. They stop trying. If there is the slightest possibility that a person might try something new and fail or fall short in front of anyone else, it’s just too painful and too risky to even consider. So, these people just don’t. These are the very bright, capable people who become the slackers of the world and do absolutely nothing with their lives because making any effort is so anxiety-provoking. They give up going on dates, applying for jobs, or speaking in meetings.

Some people use the pain of RSD to find adaptations and overachieve. They constantly work to be the best at what they do. Or, they are driven to be above criticism/reproach. They lead admirable lives, but at what cost? They strive for perfection, which is never attainable, and are constantly driven to achieve more.

How do I get over RSD?

Rejection sensitivity is part of ADHD. It’s neurologic and genetic. Early childhood trauma makes anything worse, but it does not cause RSD. Often, patients are comforted just to know there is a name for this feeling. It makes a difference knowing what it is, that they are not alone, and that almost 100% of people with ADHD experience rejection sensitivity. After hearing this diagnosis, they know it’s not their fault, that they are not damaged.

Psychotherapy does not particularly help 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.

There are two possible medication solutions for RSD.

The simplest is to prescribe the alpha agonists guanfacine and clonidine together. These were originally designed as blood pressure medications. The optimal dose varies from half a milligram up to seven milligrams for guanfacine, and from a tenth of a milligram to five tenths of a milligram for clonidine. Within that dosage range, about one in three people feel relief from RSD. When that happens, the change is life altering. The treatment can make an even greater difference than a stimulant does to treat ADHD.

One study by Harvard University found that raising the dose of guanfacine to four milligrams and clonidine to seven or eight tenths of a milligram (above the dosage limits the FDA approves), achieved a 40% higher response rate. However, this comes with side effects that can include dry mouth, mild sedation, and sometimes orthostatis, or becoming dizzy when you stand up too quickly.

The second 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 dramatically effective for both the attention/impulsivity component of ADHD and the emotional component. Parnate (tranylcypromine) often works best, with the fewest side effects. Common side effects are low blood pressure, agitation, sedation, and confusion.

MAOIs were found to be as effective for ADHD as methylphenidate in one head-to-head trial conducted in the 1960s. They also produce very few side effects with true once-a-day dosing, are not a controlled substance (no abuse potential), come in inexpensive, high-quality generic versions, and are FDA-approved for both mood and anxiety disorders. The disadvantage is that patients must avoid foods that are aged instead of cooked, as well as first-line ADHD stimulant medications, all antidepressant medications, OTC cold, sinus, and hay fever medications, OTC cough remedies. Some forms of anesthesia can’t be administered.

[Free Download: Inattentive ADHD — Explained]

Dr. William Dodson is a member of ADDitude’s ADHD Specialist Panel.

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  1. I feel very torn by this view. On the one hand – it’s not conventional, not fully researched and not fully developed.
    On the other hand – I CAN NOT get over how validated I feel by it. An intense gut feeling is telling me there is something to this. This leads me to ask;
    Has anyone tried the mentioned medications?
    What was the result?
    Please share publicly or privately –

    Thank you.

  2. As a person who has struggled with ADHD all my life, I believe that RSD is real. When you’re always in trouble, you would think that you’d get used to it, but I think it’s the opposite. Acceptance is such a huge piece of child development that a person who has experienced a great deal of rejection as a child is not going to get over it easily, no matter what age they are. People who don’t get in trouble often tend to receive compassionate treatment because the person correcting them tends to be more gentle. When you have ADHD, nobody seems to understand your thought process and often frustration figures into correction. It is rarely gentle and can oftentimes be abusive. With those kinds of experiences will go a long way to avoid rejection.
    Most of my interactions come from two needs: 1. Keeping the peace and 2. Keeping myself out of trouble. I try not to lie about things; instead I act incredulous. As I become more comfortable in a situation, I might let the “real me” get out, but I tend to be wary because I don’t want to face any more rejection. As an adult, often I find myself in situations where I seem to be doing something well with someone who is supportive and accepting whom I begin to trust. I let down my guard. I actually tell the truth. And then, somehow, I do something wrong, usually without knowing what it was or why it was so important. And then I get into trouble. I’m told I’m immature, unmotivated or irresponsible. And that shakes me to the core because I thought I was doing the right thing. And because I’ve let down my guard, I am totally surprised; I have no reasons for why I did the wrong thing, no rebuttal for the allegations against me. So then I have to rethink everything. Are my perceptions accurate? What if I AM irresponsible, unmotivated or immature? I sure was working hard NOT to be those things. Is my energy going to the right place? Should I rethink doing this thing that I thought I was good at? Should I go find something else to do? What’s going to happen if I do that and then I get in trouble again?
    So it’s never just a feeling of not being able to let go when something bad happens, or not being able to take criticism well. It is so much more than that, rooted in lifelong feelings of rejection.

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