Burning, dripping heart

Rejection Sensitive Dysphoria

Rejection sensitive dysphoria (RSD) is extreme emotional sensitivity and pain triggered by the perception that a person has been rejected or criticized by important people in their life. It may also be triggered by a sense of falling short—failing to meet their own high standards or others’ expectations.

How ADHD Ignites Rejection Sensitive Dysphoria

Rejection sensitive dysphoria is a triggered, wordless emotional pain that occurs after a real or perceived loss of approval, love, or respect.

Children with ADHD hear 20,000 additional critical or corrective messages before their twelfth birthday when compared with neurotypical children. This cannot help but have a tremendous impact on the emotions and sense of self of a developing child. People with ADHD are “the last picked and first picked on.” Most grow up with the feeling that they are less than, uncool, unwanted, defective, incompetent, and “damaged goods.”

The resulting shame and guilt often negate positive feedback and the formation of a positive self-image. Freud called shame the “master emotion,” because it dominates all other emotions and determines when and how the other emotions can be expressed or dealt with. By its very nature shame and guilt are hidden by the per- son and not confessed to even their closest friends. The resulting low sense of self-esteem is a constant torment and sucks the pleasure out of everything a person does.

RSD is 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  • withdrawn their own approval of themselves when they failed to attain their own standards or goals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 pain is extreme. “Dysphoria” is literally Greek for “unbearable.” The pain is so primitive and overwhelming that people struggle to find any words to describe it. They can talk about its intensity (“awful, terrible, catastrophic”) and cannot find words to convey the quality of the emo- tional pain.

If this emotional response is internalized, it looks like an instantaneous but triggered major depression. Most psychiatrists are trained to see depression and totally miss the ADHD. It is often mistaken for “rapid cycling” bipolar or borderline personality disorder due to the interpersonal nature of the catastrophic emotional response.

If the response is externalized, it manifests as a rage at the person or situation that wounded the person so severely. (Fifty percent of people who are court mandated for anger management treatment have previously unrecognized ADHD.)

This RSD phenomenon is often misdiagnosed as social phobia. Social phobia is an intense anticipatory fear prior to a public event that the person is going to do or say something embarrassing in public or be scrutinized harshly. Once the person is in the anxiety-provoking situation, the anxiety diminishes or even goes away. RSD is a triggered, wordless emotional pain that occurs after a real or perceived loss of approval, love, or respect.

About a third of adolescents and adults list RSD as the most impairing aspect of their ADHD. They have found ways around their academic or work performance is- sues, but they are still highly vulnerable at any moment to misinterpreting some minor slight or tone of voice as a devastating rebuke.

To some degree or another, most people with RSD be- come people pleasers. They quickly scan every person they meet and have a remarkable ability to figure out exactly what that person would admire or praise. They then pres- ent that very pleasing false self to the world. They are so intent on avoiding the possibility of displeasure from oth- ers and keeping everyone happy that they often lose track of their own goals and desires. By the time they get to their forties, they have built up a huge well of resentment about having given up their own lives to attend to the perceived needs of everyone else and getting nothing in return.

The other most common way of protecting oneself from the extreme pain of RSD is to give up trying any- thing new unless one is assured of quick and complete success. The notion of trying and failing or being turned down is just too painful to risk. They don’t go on dates. They don’t apply for jobs. They don’t speak in meetings or make their ideas and needs known to anyone.

There are some positive aspects of RSD. It commonly creates a desperate drive to achieve and excel. It creates a drive to be perfect or at least “above reproach.” But at what cost? Perfectionism is an unattainable goal. People with RSD become false shells or performers, but they must be constantly striving and achieving because they know that “today’s audience does not applaud yesterday’s performance.” They never experience “peace.”

Emotional Regulation and Rejection Sensitivity

For people with ADHD or ADD, 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.

How ADHD Ignites Rejection Sensitive Dysphoria

RSD can make adults 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.

How ADHD Ignites Rejection Sensitive Dysphoria

Rejection sensitive dysphoria is not a formal diagnosis, but rather one of the most common and disruptive manifestations of emotional dysregulation — a common but under-researched and oft-misunderstood symptom of ADHD, particularly in adults. Rejection sensitive dysphoria is a brain-based symptom that is likely an innate feature of ADHD. Though the experience of rejection sensitive dysphoria can be painful and even traumatic, RSD is not thought to be caused by trauma.

One-third of my adult patients report that RSD was the most impairing aspect of their personal experience of ADHD, in part because they never found any effective ways to manage or cope with the pain.

What Is Rejection Sensitive Dysphoria? ADHD and Emotional Dysregulation

The emotional response to perceived or real failure can be devastating to people with ADHD.

No one likes rejection or feeling like a failure. But for people with attention deficit disorder (ADHD or ADD), these feelings can be debilitating — and may manifest as either crippling sadness or uncontrollable rage.

There’s a name for this phenomenon: Rejection Sensitive Dysphoria, or RSD. In people with ADHD, RSD can lead to an all-encompassing need to please others, or it can result in someone with ADHD giving up on anything that is perceived to have a risk of failure.

Rejection Sensitive Dysphoria with ADHD: Symptoms & Treatment Options

Rejection sensitive dysphoria (RSD) is extreme emotional sensitivity and pain triggered by the perception not necessarily the reality that a person with ADHD has been rejected or criticized by people in their life. RSD is not a formal diagnosis, but rather one of the most common and disruptive manifestations of emotional dysregulation — a common but under-researched and oft misunderstood symptom of ADHD, particularly in adults. RSD is different than mood disorders, which are characterized by an unexplained, gradual shift in mood over weeks.

Rejection Sensitive Dysphoria with ADHD: Symptoms & Treatment Options

Rejection sensitive dysphoria (RSD) is an intense emotional response caused by the perception that you have disappointed others in your life and that, because of that disappointment, they have withdrawn their love, approval, or respect. The same painful reaction can occur when you fail or fall short of your rather high goals and expectations. RSD commonly occurs with ADHD, and causes extreme emotional pain that plagues both children and adults — even when no actual rejection has taken place.

Rejection sensitive dysphoria is difficult for people with ADHD to describe, but all who have it agree that it feels awful. Indeed, the term dysphoria is literally Greek for “unbearable.” Often those with RSD hide these intense emotional reactions from other people, and feel ashamed of their vulnerability. The condition often triggers a profound and wide-reaching sense of failure, as though the person with RSD hasn’t measured up to personal or external expectations.

Rejection Sensitive Dysphoria: Symptom Test for ADHD Brains

 The ADHD symptom of rejection sensitive dysphoria, for example, is triggered by the perception that a person has been rejected, teased, or criticized. An observer might not be able to point out the trigger, but the individual with ADHD can say, “When my mood shifts, I can always see a trigger. My mood matches my perception of the trigger.” In technical terms, ADHD moods are “congruent.”

Mood changes are instantaneous and intense in individuals with ADHD, much more so than in a neuro-typical person.

Distinguish Between ADHD’s Rejection Sensitive Dysphoria and Bipolar Disorder

An emotional sunburn completely disrupts your ability to self-regulate. It short-circuits your ability to produce a typical emotional response. That’s why my son’s tell is subtle. He’s frozen.

In technical terms, some researchers refer to this as_ rejection sensitive dysphoria_ (RSD). It’s very common in people with ADHD and sensory processing issues — both of which my son has. I have sensory processing issues, too.

People who experience RSD get very upset when there’s conflict or when they think they’ve been rejected. Just like sensory processing issues and ADHD can cause sensory overload, they can cause emotional overload, too.

Emotional Sunburn: What Rejection Sensitive Dysphoria Feels Like | Understood

Almost everyone is familiar with the sensation of sunburn. After a day of splashing and fun at the beach, you’re overexposed. Your skin is red and any tiny touch can feel overwhelming.

Now, let’s consider the idea of emotional sunburn. This is how some professionals characterize Rejection Sensitive Dysphoria(RSD), a condition that often appears in people with ADD and ADHD. After years of being criticized and critiqued for their behaviors, people with these conditions often feel raw and vulnerable. Because of that, they can react strongly to any real or perceived criticism, critique or failure.

Rejection Sensitive Dysphoria: What You Should Know About ‘Emotional Sunburn’

Rejection-sensitive dysphoria is like a thunderstorm. I see it coming, dark clouds in the distance telling me to run for cover. Just like I can’t stop pouring rain, I am powerless against the flood of emotions RSD brings on.

What You Need To Know About Rejection Sensitive Dysphoria

Like overflowing waters, those emotions can spill over, ruining the things it touches in its path. Once the storm is gone as quickly as it came, we are left to deal with the aftermath.

It is no secret that those of us with ADHD suffer from a certain emotional intensity. Feeling things more deeply is par for the course. However, rejection sensitive dysphoria is something a little different than that.

Rejection sensitive dysphoria is a sensitivity to rejection that causes people with ADHD to be hypersensitive to criticism, and rejection. The challenge is, that people who struggle with rejection sensitive dysphoria can perceive criticism, or dislike where there is none.

That is where the sensitivity comes in. We are hypervigilant, and a word, gesture, or deed can be taken out of context and misinterpreted. It’s frustrating!

Don’t think that means we are pulling offenses out of thin air. According to William Dodson, the average ADHD child receives 20,000 more “negative messages” in their lifetimes, on average. That means that many of us are seeing criticism or rejection because we are much more likely to receive it in the first place.

People spend much of their time offering up what they believe to be “helpful” criticisms of people with ADHD, but they’re often cruel. Once, when I was newly diagnosed, someone who I had a rather high opinion of listened to me describe the disorder and the symptoms, and replied with ” well don’t worry, even if nobody ever wants to put up with you, you’re a smart girl.”

What You Need To Know About Rejection Sensitive Dysphoria

The ADHD brain is turned up to 11; our neurotransmitters burn bright. On an emotional level, this means we feel the stabbing pain of rejection, frustration, and failure more acutely than do others. On the flip side, we also experience a meaningful and powerful zing of energy and esteem with every word of encouragement, praise, or approval we receive. The smallest gesture can power euphoria — and great accomplishments — for us.

The steep valleys of this emotional rollercoaster are well documented. Dr. William Dodson calls this common ADHD condition Rejection Sensitive Dysphoria, or RSD. To date, however, the soaring peaks of positivity and euphoria have been largely overlooked. This sister syndrome, which I’ve observed in my 69 years of living with ADHD and my 38 years of treating the condition in children and adults, is sweet and wonderful. It’s to be cultured and captured at every turn. It is our great friend, ally, and tool for growth and productivity. I call it “Recognition Responsive Euphoria,” or RRE.

ADHD Euphoria vs Rejection Sensitive Dysphoria

Further reading,