In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is rejection sensitive dysphoria.
You may have heard of rejection sensitive dysphoria (RSD), perhaps in the context of ADHD (attention deficit/hyperactivity disorder). I was going into writing this post thinking that it was a well-established thing, and I ended up being rather surprised by what I found.
Rejection sensitive dysphoria isn’t a psychiatric diagnosis. It’s not in the DSM-5 diagnostic criteria for ADHD, although it is mentioned as an associated feature that supports making the diagnosis. The ICD-11 diagnostic system describes emotional dysregulation as being common in ADHD, but again, it’s not part of the diagnostic criteria. One diagnosis where rejection sensitivity does show up up is the DSM-5 criteria for major depressive episode with atypical features, which includes a longstanding pattern of interpersonal rejection sensitivity as a possible symptom.
The earliest scholarly mention of rejection sensitive dysphoria that I came across was in a 1982 paper on atypical depression in the journal JAMA Psychiatry, although Donald Klein had earlier called this hysteroid dysphoria back in the 1970s. There were some papers on RSD when I did a Google Scholar search, but not many. There’s a lot of research on rejection sensitivity, but not on the more specific term rejection sensitive dysphoria.
The Dr. Dodson show – part I
Psychiatrist Dr. William Dodson seems to be one of the more prominent voices talking about RSD. Some sources, including Metro UK, incorrectly credit him with coining the term. The Metro said he came up with it in 2017, but linked to a 2016 article by him posted on the CHADD (Children and Adults with ADHD) website, although I’m not sure if they’re the original publisher.
Anyway, in that article, he writes that RSD can be triggered in people with ADHD when they’ve been rejected, teased, or criticized, disappointed people who are important to them, or stopped approving of themselves because they didn’t meet their own standards/goals. He adds, “If this emotional response is internalized, it looks like an instantaneous but triggered major depression.” This presentation may lead to misdiagnosis as conditions like borderline personality disorder, rapid cycling bipolar disorder, or social anxiety disorder.
He says that 1/3 of adolescents and adults with ADHD report RSD as being the element of their ADHD that causes the most impairment, although it’s not clear where that figure came from. He explains that “since RSD is genetic and neurological, psychotherapies have been found to have little benefit.” However, he suggested that the alpha-2 adrenergic blocking medications clonidine and guanfacine can be helpful for some people, as can the monoamine oxidase inhibitor (MAOI) antidepressant tranylcypromine. Taking MAOIs requires being on a low-tyramine diet, but he minimized this, saying “people who eat a balanced diet in moderation usually do not have to make any changes.” That struck me as somewhat irresponsible.
The Dr. Dodson show – part II
In a 2022 article in ADDitude Magazine, Dr. Dodson refers again to that 1/3 figure again and relates it to his adult patients with ADHD. He repeats the idea of instantaneous mood episode if the feelings are internalized, and says this can include suicidal ideation; if the feelings are externalized, this can lead to intense rage. These episodes typically last under 2 hours. In this article, he mentions that in his clinical experience, therapies like CBT (cognitive behavioural therapy) and DBT (dialectical behaviour therapy) don’t help with RSD, so presumably he was also referring to his own experience in the 2016 article as well.
In terms of observable behaviours due to RSD, Dr. Dodson identifies:
- abrupt emotional outbursts
- withdrawal from social situations
- avoidance of situations where failure or criticism is likely to occur
- relationship difficulties, including responding defensively
People with RSD may also experience negative self-talk, thoughts of self-harm, low self-esteem, and rumination.
ADHD diagnostic criteria
Dr. Dodson writes that the “DSM-V” (which is actually the “DSM-5”) diagnostic criteria for ADHD “intentionally avoid symptoms associated with emotion, thinking styles, relationships, sleeping, etc. because these features are hard to quantify.” Um, has he looked at the criteria for other diagnoses that include exactly those things? That’s a weird thing to say.
He writes that the idea of rejection sensitive dysphoria being linked to ADHD has received a cool reception from many clinicians and researchers, adding, “Many professionals did not fully grasp that the emotional component of ADHD had always been there but intentionally not pursued.” Ooh, bring on the cover-up drama! He offers some reasons why RSD may never be included in the diagnostic criteria, including this reason that struck me as making no sense: “Even when RSD/[emotional dysregulation] is present, it can’t be measured, and therefore, can’t get published in research.” Emotional dysregulation is a core element of borderline personality disorder, and there don’t seem to be any issues researching that.
European Union consensus statement
Dr. Dodson argues that rejection sensitive dysphoria or emotional dysregulation should be included as a diagnostic criterion for ADHD. His ADDitude article refers to the 2018 Updated European Consensus Statement on Diagnosis and Treatment of Adult ADHD, saying that it lists emotional dysregulation as “one of the six fundamental features used to diagnose ADHD in the European Union.” Not exactly, though. The consensus statement says, “Although emotional dysregulation may dominate the clinical presentation, it is not a criterion for classifying individuals as it lacks specificity, occurring in many other mental health conditions.”
The consensus statement further describes emotional dysregulation in ADHD as poor self-regulation of emotions like irritability, frustration, and anger, along with low frustration tolerance, emotional impulsivity, and rapid changes in mood. It adds, “Whether the type of emotional instability seen in ADHD is qualitatively different to that seen in other chronic conditions such as borderline personality disorder or post-traumatic stress remains unclear.”
What does this mean?
All of this seems to mean that Dr. Dodson decided to run with an idea and quite a few people jumped on the bandwagon. And maybe I’m just cynical, but I can’t help but wonder if there’s any sort of secondary gain associated with said bandwagon. There doesn’t seem to be any real question that emotional dysregulation is a common issue in people with ADHD, given that it’s mentioned in both the DSM and ICD, but whether rejection sensitive dysphoria is a specific, discrete thing that is distinct from other things doesn’t seem to have been clearly established yet.
Another issue that I see is that many (or even most) of us like to self-label. I highly doubt that anyone likes rejection, although some people handle it better than others. For anyone with low self-esteem or a sense of self-worth that’s highly dependent on external sources, rejection is likely to feel really shitty. In that case, self-labelling with rejection sensitive dysphoria may seem appropriate, but it’s not necessarily the same issue as the emotional dysregulation that tends to occur in ADHD.
Had you heard of RSD before? Did any of this surprise you?
The Psychology Corner has an overview of terms covered in the What Is… series, along with a collection of scientifically validated psychological tests.
Ashley L. Peterson
BScPharm BSN MPN
Ashley is a former mental health nurse and pharmacist and the author of four books.
I tend to be quite mindful of people’s agendas, and as you put it, secondary gain. I don’t know enough about adhd to comment on that tho. I know with a lot of books, the gain seems to deal with selling books. And sometimes, doing so at all costs.
That selling agenda is definitely off-putting.
Your blog on this reminds me of 9 out of 10 people on twitter.
Most tweet their hallucinations at someone doing the real work using one hand while the other hand is doing something “else”.
I am someone who has been diagnosed as suffering from the textbook definition of this, and it’s debilitating. All we want are answers and treatments. And his article was the only competent definition I could find. My Doc is highly respected and well known in the DC Metro area and recalled RSD from the early 80’s. He and I put in the work to get to this point to say “bingo”.
Patients are Guinea Pigs, what the med community doesn’t know is up for grabs.
As a sufferer, had this been it’s own condition, we could have easily gone down the list 25 years ago and said bingo and dove head first in. But no one sees it for what it is.
How many conditions are mis medicated as it is? How many are trial and error as it is?
My son has ADHD. I would say two of the four trouble him some: we were discussing yesterday that he finds social situations and conversations hard. Cues and the like. He practices in my head. I’m often amazed at how close anxiety and ADHD are. They’re like flip sides of the same coin.
I’ve heard of RSD. It came up during discussions about my PTSD with my psychiatrist.
I remember a blogging friend of mine who has ADHD saying that it looks like almost any other mental illness if you catch it at the right moment.
That’s unfortunate.
I had never heard of the term before. Thank you
😊
I’ve never heard of RSD, but I definitely have ADHD and now I’m wondering if that plays a role in it in any significant way…seems like it might 🤷🏻♀️
I always kind of assumed the rejection sensitivity stemmed from trauma and PTSD though
That seems like an unsurprising consequence of trauma.
I’ve heard of RSD. It sounded like something I experience. I was once also loosely diagnosed with ADHD, but at the time I thought the Dr just wanted to get rid of some more Ritalin. Weird. Thanks for sharing!
Hmm, that’s strange.
yeah!
Had you heard of RSD before? Did any of this surprise you?
I had never heard of this before and it was fascinating (to me) reading about it. I’ve only ever heard “sensitive” used in the context of someone who does NOT understand emotional trauma stating something about another person..as in “Oh you’re so touchy (sensitive)” or “He’s really sensitive about that issue.” It did not surprise me, but the tie to ADHD was a revelation. But I’m not a doctor nor psychiatric care worker and I don’t know half as much as I think I do either. I know I’ve been labeled as ‘sensitive” for most of my adult life. I’ve done some hard work to adjust my perspective that way, and try to remember whatever is upsetting me (99.5% of the time) is none of my business and other people’s stupidity (as I see it) or crass behavior are beyond my control. It’s helped a little bit to lessen my ‘sensitivity.’ But there’s no link to ADHD for my particular situation. It boggles my mind a little bit to have the two linked, which I did mention above. Very interesting post Ashley, thanks!
I tend to be emotionally sensitive too, and in my case I think it’s just part of my personality.
Very interesting!
🙂
I had never heard of it, while I do live with adhd. But I Googled it and I do recognize myself in some of the examples, with reacting out of proportion because I can’t regulate my feelings towards the (little) things that happened. Thanks for this insight. Even though it’s hard to find anything conclusive on it. As you mentioned in your post. 😊
😊
Sounds similar to BPD type thing… borderlines typically struggle to regulate their own emotions especially rejection. But then so can those who struggle with ptsd too.
Often reacting to things out of proportion to event.
I’ve not heard of this either…
I find with a lot of disorders, there are sub-divisions to the disorders, and then almost like these bolt-ons that you can have if that makes sense..
Basically everyone is unique and although a disorder will effect many in similar ways, no one person will be the same.
I think people like to put us in a box with a label. But some of us don’t fit in any box.
People are also not their disorders.
I agree, and labels work better for cardboard boxes than people.
For RSD to be in effect, does it generally apply to anyone the person encounters or can it be specific to one relationship? I realize I sometimes react out of proportion to what my husband says but I have a thicker skin when it comes to others. I had never heard of RSD before this blog post. Thanks so much for all you do to help remove stigma from mental health challenges, friend.
I didn’t come across anything that mentioned it only applying in specific circumstances, but it seems reasonable in general that feeling rejected by someone close would likely have a greater impact than being rejected by someone else.
That’s what I thought but wasn’t sure. Thanks! Hope you are having a good day.
💕
I’m very sensitive to criticism and feel it’s a person’s attack. It bothers !e and I take it to heart. I can’t mix I never did at school . I feel different to others . I have himself ester ad no confidence. Partners have been cruel to me and abusive . I can’t handle it. I tend to hide away. I have a problem with image and trying to look my best. . No one knows the pain and trauma I! Going through. I struggled with responses and couldn’t rust anyone. I would go through partners like mooned business yet I didn’t truly love them . Why I don’t know can anyone help !e on that .
I’m so sorry you’re having to deal with all of that.
I’ve never heard of this before. Thanks for sharing
I think I may have this!
Rejection is definitely not an easy thing to deal with.
Yeah…
Thank you, Ashley, for this article. Your openly reflective style of writing, along with your extensive research, is admirable and enjoyable to read. Linking RSD with ADHD, as though ADHD has the RSD market “cornered”, seems to leave too much doubt about both conditions, especially without appropriate research. RSD does not appear to be exclusive to any one diagnosis in the DSM-5. It occurs in many situations and for multiple people. It is likely safe to say that RSD can be “triggered” in those who have been “rejected, teased, criticized”, or those feeling they have “disappointed people who are important to them…” no matter whether they have ADHD or any other mental health issue….in fact, those who do not have a diagnosis of a mental “disorder” can likely be triggered by those same thoughts or actions. It does not seem, yet, as though RSD is proven to be “genetic and neurological”. Therefore, it would seem premature to state that “psychotherapies have been found to have little benefit”. Perhaps, some clinicians have discovered their particular approach is unable to reach the desired effect, yet that doesn’t equate to psychotherapies being ineffectual. With the apparent lack of research studies in this area of mental health, it is difficult to state facts about what does and does not “work” with RSD treatment. As for MAOI’s, these are known to be significantly cautioned and require a great deal of forethought on the part of the medical doctor prescribing them, as well as considerable monitoring throughout their use with all patients. If, as was said, psychotherapy is ineffectual, and the “answer” is to turn to medications, what happens to the patient that is “too sensitive” to tolerate medications for mental health conditions? Emotional instability is not uncommon in chronic mental health conditions. Not all patients can tolerate medications. Those who cannot tolerate medications need another avenue.
Thank you for questioning and reporting on an important current topic of interest.