Rejection Sensitive Dysphoria and ADHD
Rejection sensitive dysphoria or RSD for short, is an innate feature of attention deficit hyperactivity disorder. Its resonating and surprisingly descriptive title is one that most people with ADHD can self-identify with. Dysphoria is the Greek word for “too difficult to bear”. Essentially, Rejection Sensitive Dysphoria is the real or perceived rejection, criticism, or failure felt by the recipient. More often than not, it is an exaggerated emotional response relative to the incident. It could also be a conditioned response to certain triggers from the past. It has been described as an “emotional sunburn”, which is an insightful description. After a sunburn, the slightest touch can feel like agony. Although readily acknowledged in clinical settings as a tangible manifestation of emotional dysregulation, RSD is not an official diagnosable symptom of a variety of mood disorders, autism, and ADHD.
Consequences of Untreated ADHD
Pay attention! Sit still! You’re not listening! I’ve already explained this to you! Calm down! For a child growing up with ADHD, constant and consistent reprimanding of their symptoms is commonplace. On average, kids with attention deficit hyperactivity disorder will receive an estimated 20,000 more negative interactions than neurotypical children during their school years. The predictable consequence is a child with high levels of anxiety and low levels of self-esteem and self-worth. If these children don’t get diagnosed, they often grow up to become adults who are underequipped to manage their emotions in healthy ways.
These oft-repeated phrases are usually accompanied with a frustrated and flustered adult delivering the lines, and a deep-seated resentment in the child, full of self-doubt. These kids tend to grow up having honed their protective armour which can further exacerbate their condition. This armour is extremely thin and only serves as a false barrier to critique.
The hypersensitivity of someone with ADHD is caused by the emotional dysregulation that is inherent to all those who deal with this condition. Although this subject is well studied, emotional dysregulation is not currently included in the diagnostic criteria of the DSM-5 for adults. This is a detriment to the treatment of ADHD, because emotional dysregulation is a major barrier to living a balanced life.
70% of adults with ADHD and 80% of children with ADHD experience emotional dysregulation. In a small case study done by ADDitude using computational methods on children with ADHD, found that “30% of children fit a profile strongly characterized by irritability and anger. These children have very high levels of anger and low levels of rebound back to baseline.”
How Dare You Ruin My Mood?
The immediate shift in mood in the face of criticism, rejection, or failure is very real and intense, oftentimes described in terms of physical discomfort or pain. To understand this, one must first take a peek at the brain. In the anterior cingulate cortex of the brain or ACC, physical and emotional pain have connections in this region. So, when people experience severe emotional pain it can present as physical pain also.
Juggling the cascade of social damage caused by many of the symptoms of ADHD, pile on top of that RSD and you’ve got yourself a highly anxious, angry, and/or withdrawn individual.
RSD can occur in comorbid conditions as well, which is one of the reasons it is often mistaken for rapid cycling bipolar, other mood disorders, or social anxiety.
High Anger RSD vs. High Anxiety RSD
Cycling back to the armour that most lifelong ADHD people develop over time, there are a number of ways this armour is used and broken.
High Anger RSD
- Significant outbursts of hostility and frustration
- Strong urges to release anger and lash out or get revenge
- Aggressive behavior, either directed at self or others
High Anxiety RSD
- Avoiding situations where there’s the possibility of rejection
- Withdrawal from others to avoid rejection
- Rumination and preservation
- Perfectionism, limiting the possibility of failure
Long Term Effects and Mitigation Techniques
RSD in people with ADHD often report that highly effective mood awareness methods like dialectical behavior therapy (DBT), a derivative of cognitive behavior therapy (CBT) are often not as effective as with other emotionally dysregulated symptoms. This may be due to the extremely fast and vehement onset of RSD that makes it more difficult to manage.
Although RSD is intense, luckily it is short lived. Despite its ephemeral nature, it is reportedly one of the most difficult ADHD symptoms to manage. Bearing that in mind, there are ways to help mitigate the intensity of episodes. Explicit communication is an effective way to help others understand the potential for overreaction and misunderstanding. Therapy can help to recognize when RSD is triggered and help manage exposure. Mindfulness can aid in reflection and refrain, noticing when your thoughts are full of cognitive distortions based on past situations can help to depersonalize.
Karalunas, S. L., Gustafsson, H. C., Fair, D., Musser, E. D., & Nigg, J. T. (2019). Do we need an irritable subtype of ADHD? Replication and extension of a promising temperament profile approach to ADHD subtyping. Psychological Assessment, 31(2), 236–247. https://doi.org/10.1037/pas0000664