ADHD and Rejection-Sensitive Dysphoria, RSD

Many people with ADHD also struggle with emotional dysregulation. Another view is that people with ADHD often have Rejection-Sensitive Dysphoria (RSD). RSD is extreme emotional pain triggered by real or imagined criticism from important people in your life. Another view is that RSD involves a tendency to "anxiously expect, readily perceive, and overreact". It can be thought of as emotional hyperactivity or emotions in overdrive, not putting on the brakes. This may seem like being highly sensitive to criticism, but it is much more complicated than that. Simply being made to wait, for example, could be viewed as a rejection and met with extreme anger and hostility. RSD may cause individuals to hunker down emotionally and be reluctant to express opinions, to shy away or avoid arguments or controversial discussions, to be reluctant to make say how they feel or make requests or impose on others, to be easily hurt by negative feedback, or to become overly dependent on familiar surroundings and comforting situations to avoid possible rejection. RSD may cause people to try hard to gain acceptance from others. Or they might avoid social situations in which they might get hurt. RSD is a common symptom of ADHD, estimated to affect around 85% of people with ADHD.

People with RSD are:

  • More easily embarrassed

  • More easily angered

  • Have excessively high standards

  • Often struggle with low self-esteem

  • Have increased anxiety

  • Have problems with relationships

  • Withdrawn from social situations

They may feel like they don’t live up to others’ expectations, and this can get to a point where they might think about self-harm.

RSD is characterized by intense episodes that are easily triggered but do not last long. RSD is typically thought to be associated with overactivity of the central nervous system—just like those with ADHD—or having overly critical or rejecting parents, being bullied, or being mistreated during childhood. Any of these situations can lead to increased stress and excessive emotional reactivity to rejection. Rejection sensitivity might stem from early attachment relationships and parental rejection. Bullying, an extreme form of peer rejection, is likely connected to later rejection sensitivity. However, there is no conclusive evidence for any of these theories.

RSD can be confused with or lead to a diagnosis of Bipolar Disorder, Personality Disorder, PTSD, OCD, Depression, or Social Phobia. It occurs when people overinterpret criticism or a social snub, or overreact to an ambiguous health symptom. It is like exaggerating the importance or significance of an event that could be meaningless.  RSD associated with ADHD may play a role in the increased risk for anxiety and depression experienced by people with ADHD.

What Does RSD Look Like;

Sudden emotional outbursts following real or perceived criticism or rejection

Withdrawal from social situations

Negative self-talk and thoughts of self-harm

Avoidance of social settings in which they might fail or be criticized (for this reason, RSD is often hard to distinguish from Social Anxiety Disorder)

Low self-esteem and poor self-perception
Constant harsh and negative self-talk leads them to become “their own worst enemy.” Rumination and perseveration
Relationship problems, especially feeling constantly attacked and responding defensively.

RSD/ ED is not always present. It comes in triggered episodes.

  1. People with RSD are usually ashamed of their over-reactions and hide them so that they will not be further embarrassed and thought of as mentally or emotionally unstable.

  2. Even when RSD is present, it is difficult to measure; therefore, this research is limited.

According to Dr. William Dodson, emotional dysregulation was consciously excluded from the diagnostic criteria for ADHD and effectively forgotten for many years. Over the last decade, researchers have developed several new ways of looking at ADHD through its lifecycle. By the end of 2019, this re-evaluation of the very fundamental aspects of ADHD led the European Union to issue its 10-year update of the Consensus Guidelines on Adult ADHD, which redefined adolescent and adult ADHD to include difficulty with emotional regulation as one of only six fundamental features in the ADHD syndrome:

1. Inattention and hyperfocus

2. Impulsivity

3. Hyperactivity

4. Emotional dysregulation

5. Excessive mind wandering

6. Behavioral self-regulation (which they equated with executive function deficits)

How is Emotional Dysregulation Treated: Dr. William Dodson

Although the alpha agonist medications, guanfacine and clonidine, have been FDA-approved for the treatment of ADHD for decades, they were not directly associated with the terms of rejection sensitivity and emotional dysregulation for all of the reasons noted above. Nonetheless, it has been my clinical experience and the experience of others that the symptoms of RSD/ED can be significantly relieved with clonidine and guanfacine in about 60% of adolescents and adults. To me, this observation strongly indicates that RSD is neurological, not due to a lack of skills. Skills do not come in pill form.

There currently exists no formal research on using alpha agonist medications to treat symptoms of RSD or ED in patients with ADHD.