Rejection Sensitive Dysphoria in ADHD & autism

Rejection Sensitive Dysphoria (RSD) is characterized by strong emotional reactions to real or perceived rejection. These reactions have been described as “immense emotional pain from real or perceived failure to meet others’ expectations.”^[1]The result is immense emotional pain from perceived failure to meet one’s own or others’ expectations, Bedrossian (2021) Reactions can be internalized, like feelings of low self-esteem and self-criticism, or they can be externalized, like responding to someone with anger or bursting into tears.

Common RSD characteristics

RSD is not an official diagnosis recognized by the DSM, which means there are no specific diagnostic criteria.^[2]American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA (American Psychiatric Association, 2013) Because it’s not an official diagnosis, there also isn’t a lot of research about it. Nevertheless, clinicians and individuals who experience RSD often describe the following characteristics:

• You are often described as “too sensitive”
• You often perceive criticism or feedback as rejection
• And you may respond to feedback with anger or emotional outbursts
• You have low self-esteem/self-worth
• You are a “people pleaser”
• You constantly replay social situations in your head so you can figure out what you did “wrong”
• You avoid getting close to people altogether
• You often fear disappointing others
• You have a fear of making mistakes
• You avoid situations where you are likely to make mistakes (e.g., trying a new activity)
• You feel embarrassment or shame when given feedback
• You fear being judged by others even when doing everyday activities

If you have lived experience with RSD, what are some characteristics that you identify with?

RSD & ADHD

RSD is commonly recognized as a trait of ADHD even though it is not officially listed in the diagnostic criteria. Dr. William Dodson is a prominent ADHD clinician and the first person to use the term RSD. He says in a recent article that excluding RSD from the official diagnostic criteria for ADHD is frustrating because it is evidence that these criteria were developed to identify observable stereotypical presentations of ADHD in children, but they do not capture internalized emotional and cognitive traits, especially in adults.^[3]New Insights Into Rejection Sensitive Dysphoria (Dodson, 2023) | ADDitude

The lack of recognition in the DSM is even more frustrating given that there have been many findings over the years that highlight how ADHDers tend to experience stronger emotional reactions than non ADHDers.^[4]Emotional lability, comorbidity and impairment in adults with attention-deficit hyperactivity disorder (Skirrow & Asherson, 2013)^[5]Understanding deficient emotional self-regulation in adults with attention deficit hyperactivity disorder: a controlled study (Surman et al., 2013)

In Europe, the diagnostic criteria for ADHD recently recognized emotional dysregulation as a common trait.^[6]Updated European Consensus Statement on diagnosis and treatment of adult ADHD (Kooij et al., 2019) Since RSD relates to emotion regulation, it would fall under this category.

What leads to RSD in ADHD?

Conditioned rejection

ADHDers have more experiences of real rejection than neurotypicals. This starts early on in childhood, where ADHDers experience higher rates of rejection at school from peers and teachers.^[7]ADHD symptoms and the teacher–student relationship: a systematic literature review (Ewe, 2019)^[8]Peer Rejection and Perceived Quality of Relations With Schoolmates Among Children With ADHD (Grygiel et al., 2014)^[9]Peer Functioning in Children With ADHD (Hoza, 2007) This also includes higher rates of bullying compared to peers.^[10]Peer victimization in children with Attention-Deficit/Hyperactivity Disorder (Wiener & Mak, 2008)

It is likely that the very real bullying and rejection from peers were traumatic. Thus, it makes sense that we would learn coping mechanisms for dealing with rejection. For example, people pleasing can be a ‘fawn’ trauma coping mechanism. Emotional outbursts can be a ‘fight’ trauma coping mechanism. And avoiding social interactions can be a ‘flight’ trauma coping mechanism.

Therefore, due to experiencing rejection often in childhood, ADHDers learn to become hyperaware of any potential rejection scenarios. However, what makes RSD distinct from a typical trauma response is that the RSD emotional reaction is disproportionate to the situation.

Emotional regulation

Research has found that ADHDers often experience emotions more strongly than neurotypicals.^[11]Attention-Deficit Hyperactivity Disorder and the Dysregulation of Emotion Generation and Emotional Expression (Blader, 2021) This is often also associated with having more trouble regulating emotions. We may feel the fear and the rejection so strongly that it can be very distressing, painful, and difficult to manage. This can look like becoming completely consumed and overwhelmed by feelings of shame and inadequacy when your friend cancels a coffee date even if logically you are able to recognize that the cancellation was because they were sick, not because you did something wrong.

In addition, the higher levels of impulsivity typically seen in ADHDers can exacerbate RSD. When we respond impulsively, we may respond to strong emotions by immediately assuming rejection is actually happening. However, if given the time to reflect, we may recognize that the rejection was a feeling but not a reality.

In sum, RSD is a product of having to cope with a lifetime of real rejection experiences AND a nervous system that is wired to experience emotions very strongly. Both of these experiences are common in individuals with ADHD.

RSD & justice sensitivity

One less talked about feature of RSD is justice sensitivity. Since we are more attuned to rejection and criticism, we are also more attuned to injustice toward victims.^[12]The Kind Nature Behind the Unsocial Semblance: ADHD and Justice Sensitivity—A Pilot Study (Schäfer & Kraneburg, 2012) One study showed that ADHDers with RSD traits are more likely to recognize injustice, feel injustice intensely, and show stronger responses to witnessing injustice.^[13]Justice and rejection sensitivity in children and adolescents with ADHD symptoms (Bondü & Esser, 2015)

It sounds like while there can be a lot of distress associated with RSD, I can imagine how this might make us excellent advocates and activists!

Differentiating RSD from other conditions

The term RSD is typically used to refer to emotional dysregulation in ADHD, but the traits associated with RSD are common in other conditions. There appears to be such a high degree of overlap that many many ADHDers may have previously received a misdiagnosis.

Here are some ways RSD can appear like other conditions, and how to differentiate between them:

PTSD

Because RSD develops as a conditioned response to experiencing real rejection, many of the coping mechanisms relate to the fight/flight/fawn/freeze responses often associated with PTSD. Moreover, individuals with ADHD also experience higher levels of childhood trauma than the general population.^[14]A Review of ADHD and Childhood Trauma: Treatment Challenges and Clinical Guidance (Boodoo et al., 2022) Identifying RSD in this case involves isolating what triggers the emotional reaction. RSD is always triggered by a fear of rejection. Therefore, if the underlying cause of strong emotional reactions is the fear of rejection, RSD is likely.

Social anxiety

Often, social anxiety is associated with a wide range of social fears. In contrast, RSD is specific to rejection. Also, strong emotions that arise in social anxiety can appear when an individual is anticipating a social interaction. In RSD, strong emotions are more commonly a reaction to something that has occurred (though we still may engage in active avoidance). Finally, in social anxiety, the level of anxiety can fluctuate depending on the person you are interacting with or the type of interaction. If you have RSD, you will likely be just as triggered by someone you have a strong relationship with—like a close friend or partner—as you would by someone you just met. The perceived rejection is not dependent on the strength of the relationship.

Borderline Personality Disorder (BPD)

Differentiating between BPD and RSD comes down to recognizing the distinct core belief in each case. Someone with RSD is specifically worried about being rejected. In BPD, individuals are focused on abandonment. Another differentiating factor is that an emotional response in RSD is always triggered by a specific event, like getting feedback at work. An emotional response in BPD may be a more generalized pattern of behaviour as opposed to being closely tied to a trigger.

Depression

Many of the characteristics of RSD, such as low self-worth and social withdrawal, can look like depression. There is also a correlation between rejection sensitivity and depressive symptoms.^[15]A Longitudinal Rejection Sensitivity Model of Depression and Aggression: Unique Roles of Anxiety, Anger, Blame, Withdrawal and Retribution (Zimmer-Gembeck et al., 2016) Nonetheless, the most significant difference between RSD and depression is that depression is a more stable state whereas RSD is triggered by a situation.^[16]New Insights Into Rejection Sensitive Dysphoria (Dodson, 2023) For example, someone with depression may engage in negative self-talk consistently for months, while someone with RSD may engage in negative self-talk as a response to a social interaction, but after a few hours, the feelings will dissipate.

Differentiation based on length of onset and duration can also be applied to other conditions such as bipolar disorder.^[17]How to Distinguish ADHD’s Rejection Sensitive Dysphoria (RSD) from Bipolar Disorder (Dodson, 2023)

How autism influences RSD

There currently isn’t any research specifically looking at RSD and autism. However, since 50-70% of autistics also have ADHD,^[18]ASD and ADHD Comorbidity: What Are We Talking About? (Hours et al., 2022) it’s likely that many autistics also experience RSD. Here are some ways that autistic traits may exacerbate RSD:

Higher levels of conditioned rejection

Just like in ADHD, autistics experience a lot of bullying and rejection in childhood and adulthood. These experiences may compound the need to be hyperaware of rejection.

The impact of these rejection experiences are amplified by a lack of understanding about certain social interactions and a difficulty navigating many neurotypical social norms. This also includes differences in nonverbal communication and a difficulty interpreting neurotypical social cues. By not understanding, the only ways to avoid real rejection is to adopt RSD qualities such as people-pleasing.

Interoception difficulties

Many autistics struggle with emotional regulation due to alexithymia and poor interoception. We may not be able to accurately identify what we are feeling. For example, in response to someone canceling plans, we may not be able to recognize the difference between feeling sad and disappointed versus rejected. We may also struggle to identify what others are feeling. For example, our friend may make a facial expression signaling feeling surprised, but we may assume it means they are mad, and therefore about to reject us.

Autistic support for RSD

It is important to recognize and validate how debilitating RSD can be. The emotional dysregulation is very distressing and painful and can have negative impacts on our mental health. For example, one study found that individuals who reported more rejection sensitivity also experienced more depressive symptoms.^[19]A Longitudinal Rejection Sensitivity Model of Depression and Aggression: Unique Roles of Anxiety, Anger, Blame, Withdrawal and Retribution (Zimmer-Gembeck et al., 2016)

If you experience RSD, you may find it helpful to identify what triggers your strong emotions. What specific situations lead you to perceive or experience rejection? This way you can hopefully recognize when you find yourself in a triggering situation and apply any coping skills you’ve learned more quickly and effectively.

It’s also important to seek understanding in confusing social situations. It might be helpful to ask for clarification when you sense feelings of rejection. Perhaps with more information, you can identify the other person’s intentions more accurately.

And finally, don’t forget about your own needs! If you find yourself people-pleasing, you may forego asking for what you need to avoid rejection. Here’s a reminder that your needs matter too.

How has RSD impacted your well-being? Have you found strategies that help you?