Rejection Sensitive Dysphoria (RSD) is a term from Dr. William Dodson, a renowned expert in ADHD, that describes someone’s intense feelings that occur due to perceived or actual rejection or failure. The person has both intense emotional pain, and often a sense of physical pain as well… pain that isn’t quite physical, but it feels like it is.
While a neurotypical person is prone to feeling unpleasant due to rejection or failure, RSD is a much more intense reaction. Dysphoria comes from the Greek word dusphoria/dusphoros, meaning ‘hard to bear.’ Feelings from RSD may prompt the person to make substantial changes to their behavior or life. They may be even have suicidal ideation or make a suicide attempt as a result of the feelings.
Dodson believes that RSD is very common in people with ADHD. He believes that up to 99% of people with ADHD have RSD at some point in their lives. While he coined the term in the 1990s, he initially identified it as atypical depression in the 1960s.
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This blog is for educational purposes only. This information is best case scenario, at least within the scope of my knowledge and experience at the time I write the post. Not only does everyone have different approaches to parenting and life- and my way may not be your cup of tea, but also- I am not perfect, nor do I want anyone to imagine that I am. Despite being a therapist and having a whole host of really cool techniques for all the mental health related things, I am constantly learning and trying to do better.
I’m hoping that this blog can help you. When we share what works for us, we can help others develop their own toolkit for improving their mental health.
RSD isn’t a Formally Recognized Symptom of ADHD
It’s important to understand that RSD isn’t a diagnostic criteria for ADHD. Many practitioners haven’t heard of it or understand what it might look like. As a result, someone who is experiencing RSD may get diagnosed with a Major Depressive Disorder because the psychologist, psychiatrist, and/or therapist doesn’t understand why the intensive emotional response occurred. They see a person who is depressed or suicidal, and don’t see that there was a very specific cause. Or perhaps they see that, but still decide to treat the depression as the most significant issue (similar to the physical medicine field, we want to treat the heart attack before addressing dietary changes and exercise to improve our blood pressure).
To be honest, I’m not sure exactly where psychology is drawing the line in terms of this diagnosis: do we diagnose ADHD and acknowledge the RSD symptoms and treat the RSD? Or is it more important to treat the depressive symptoms that the person is experiencing due to the RSD? As a therapist, I don’t really need an answer to that: I teach coping mechanisms and we talk about what is happening. With psychiatry, however, it’s an interesting question because there are different medications to address mood disorders, depression, RSD, and ADHD. And the psychiatrists need to prioritize which medications to start with when they’re tackling multiple symptoms that need to be treated because starting three medications at once makes it difficult to identify side effects and what is working/not working.
The main problem is that if RSD occurs due to errors that occur from someone’s ADHD not being well controlled/treated, treating the ADHD properly may prevent future episodes of RSD induced depressive episodes.
It’s even helpful to just be aware of RSD and be able to recognize it when it shows up… this might look like “Whoops, that was an intense emotional reaction to that situation- that’s just my RSD, I need to recognize that I may not be reacting in a way that’s healthy for my mental health. Let me put some coping mechanisms into place. Let me use my ‘it’s okay to make mistakes’ affirmation.”
As an additional note- while RSD is something common in people with ADHD, it isn’t an issue exclusive to people with ADHD.
Symptoms of RSD
Keep in mind that all symptoms are compared to what a neurotypical person would feel… if you experience these symptoms at the same level as the ‘normal’ population, you’re probably not experiencing RSD. If you’re more sensitive than a same age peer, it MIGHT be RSD.
To qualify as RSD, these responses must be IN RESPONSE to perceived criticism, rejection, or failure.
- Physical Response to Perceived Rejection/Failure: Heart racing, chest pain, stomach pain, etc.
- Intense feelings of sadness, anger, or worthlessness
- Avoiding situations or conversations where you may fail, be criticized, or be rejected: i.e. not bothering to try out for the higher level sports team, even if you’re qualified, because you might not get selected and you fear how you’ll feel if you don’t make the cut.
- Low Self-Esteem and Negative Self Task
- Belief that you aren’t lovable or are dysfunctional in some way.
- Extreme defensiveness and/or anger if someone gives you feedback that isn’t 100% positive.
- Hypervigilance: Constantly scanning and analyzing social cues, looking for signs of potential rejection.
- Isolating yourself from others or avoiding social situations to lower risk of rejection.
- Frequent mood changes due to fluctuations in others’ real or perceived feelings towards you.
You’re Too Sensitive: Or Not
People who experience RSD have often been called ‘too sensitive’ throughout their lives.
And it’s no surprise that individuals with ADHD may develop RSD. When researchers have studied the difference between ADHD children and neurotypical children, they found that by age 10, ADHD children hear 20,000 more negative messages and critiques than their peers without ADHD. This is 5 additional messages per day.
A lot of these messages are due to behaviors that are very difficult for ADHD children to control, particularly without medication, therapy, or education about coping mechanisms. Many of us who go undiagnosed end up developing coping mechanisms over time, but it is a LIFE LONG learning process if no one educates us.
It makes sense that we might be a bit more sensitive.
For those who experience RSD and experience a lot of rejection without some balancing support, they may eventually begin to dissociate as a coping mechanisms for rejection/failure. This may look like a person APPEARS as if they aren’t sensitive at ALL. This may look like a person who doesn’t even bother trying.
Examples of RSD
Sam goes to his first party. At the party, he begins to talk to a person that he finds attractive and they excuse themselves to talk with a friend or to go get a drink. He believes that they walked off because they hate him. As a result, he gets a drink and quietly sits in the corner at the party the rest of the night to avoid further rejection. He avoids parties or talking to potential partners in the future to avoid being rejected. His thoughts may include, “I don’t know why I bother, everyone hates me.” “I can’t do anything right.” “I am ugly/stupid/etc.”
Sarah was distracted and didn’t read a parking sign correctly. As a result, she ended up getting towed. Initially she thought that her car had been stolen and she was very worried. When she called the police, they asked if it was possible that she had been towed. She checked and found out that due to misreading the sign, she now owes a substantial fee to retrieve her car. When she goes to retrieve the car, the tow company accuses her of illegally parking on purpose and the employee gives her a hard time. She goes into a major depressive episode, with suicidal ideation, due to being so upset with herself for making a mistake and also due to feeling like everyone thinks she intentionally broke the law. While the fine may be difficult for her financially, the bulk of her depression is related to the mistake- not the financial stress. Her thoughts may include, “I am so stupid!” “Everyone hates me and thinks I’m an idiot.”
Sally’s boss schedules a meeting to talk to her for Friday. It’s Monday. She assumes that she is about to be fired or written up, despite no indication that she’s done anything wrong, and despite the fact that the meeting clearly isn’t an emergency meeting. She panics and starts applying for other jobs, just in case she’s about to lose her job. She calls her parents to see if she can move back in with them once she’s fired. She has extreme anxiety about the meeting and tries to think through any potential mistake that she might have made in the past two weeks. She may walk into that meeting fully prepared and expecting to be fired. She may even have a speech and be angry about them firing her when she’s worked so hard at the company. When the meeting actually occurs, her manager offers her a promotion and raise. She now needs to shift her mood from anger, fear, and/or sadness to something resembling gratitude for the opportunity.
Stella started kindergarten this year and her math teacher has been really positive about her work. As a result, she works harder at math and tries to get perfect grades so she can receive more positive reinforcement. Her reading teacher is kind, but has been concerned that she is a little behind peers on picking up letter sounds. When her teacher suggests Stella join a specialized reading group, Stella yells I CAN’T DO ANYTHING RIGHT! I AM NEVER GOING TO READ! I HATE READING! She no longer wants to go to school (or reading class), and often refuses to start her reading homework. If she’s given a standardize/multiple choice test in the subject, she doesn’t bother to try to answer the questions and just checks off answers randomly.
Stan wants to get As on every assignment, and he gets angry when he doesn’t get the grades that he wants- even when an assignment was supposed to be challenging. He is afraid that if he doesn’t get good grades, he won’t have value or be loved by others. When he gets a B on a test, he feels intense anger and/or sadness. He feels like he failed and that he’s stupid. Even though he studied hard for the test and did his best, he tells himself that he will study harder next time.
Recognition Responsive Euphoria (RRE)
Dr. Hallowell, one of the authors of ADHD 2.0, pegged a different term that is the opposite of RSD: Recognition Responsive Euphoria (RRE). While people with ADHD experience extreme lows from perceived criticism, failure, or rejection, we also have extreme highs when we feel like we’ve done something well or receive praise.
We REALLY like positive reinforcement: I’m not talking about meaningless trinkets, I’m talking about others expressing true gratitude, pride, or positivity in the things that we do.
When we feel like we’ve done a good job or received praise, we glow. It’s truly one of the best things about being ADHD. Even when I’m really, really sad, completing a simple, but satisfying task can boost my mood substantially.
Mood boosting activities may include:
- Doing that task you’ve put off for a long time
- Completing a craft or DIY project
- Rearranging your furniture
- Ace-ing an exam.
It’s interesting because although I didn’t know about RSD or RRE earlier in my life, I can see where I have specifically sought out the “RRE feel goods” when I was having a tough time throughout my life. This might look like getting a new hair cut or changing my hair color, taking up a new hobby, or trying to hang around with people who are very positive and reinforcing.
Medication
There is psychiatric medication that is used to combat RSD, but not every psychiatrist is knowledgeable about ADHD, RSD, or the most recent information about medication for RSD. These are psychiatric medications for other disorders that sometimes help people with RSD as well. Apparently there are 2 or 3 medications that are used and usually people only respond to one or the other.
I find that treating ADHD symptoms, particularly if they’re causing your RSD, is also helpful. In most cases, stimulants are the go-to most consistently effective option for ADHD. Stimulants can help us focus a bit better and make fewer mistakes.
Unfortunately, stimulants don’t work all day soooooo…. you may still have some “moments” at 7pm when they’ve worn off. Sometimes your psychiatrist can offer some options for those situations.
But not all RSD issues are caused by ADHD fails. Having a partner leave you for someone else or getting fired from a job despite excellent performance could still potentially trigger RSD.
Here is some information about how to decide if medication is the right choice for your psychiatric symptoms.
Coping Mechanisms for RSD
I think there are some solid coping mechanisms that can help with RSD. These are some of the ones that I find helpful and that I try to teach in therapy sessions. It’s important to practice these skills WHEN YOU ARE FEELING GOOD instead of waiting until an emergency. You don’t want to learn CPR when you see a person having a heart attack. You want to learn and practice it in advance.
Not all of these ideas work for everyone. Print the list and cross off what you hate… highlight the ones you love. Everyone’s a bit different.
- Affirmations: Use affirmations that reinforce to yourself that you’re allowed to make mistakes and be a human. I like to set passwords as affirmations as a way to force myself to use them.
- Hang out with people who make you feel good!
- Ask for positive reinforcement: tell people what you need if necessary. For example, if I’ve worked on a project that I’m proud of, but know isn’t perfect, I will say, “TELL ME HOW AWESOME THIS IS!” or “ISN’T IT AWESOME!?” rather than ask someone for feedback. I have too many people in my life who will give honest feedback and there are times when that is DEFINITELY NOT HELPFUL. I may even say, “Do not… I REPEAT… DO NOT… give me negative feedback.”
- Acknowledge that it’s normal to not be perfect.
- Ask yourself what advice you’d give a friend who experienced the same thing. Are you harder on yourself than you’d be on your friend?
- Don’t spend too long talking about your mistakes/the rejection: while it’s beneficial to try to apologize for mistakes or deal with rejection to some degree, we don’t want to spend too long thinking and talking about it because I think we tend to get stuck there. This can cause us to spiral into thinking about all of the other rejections and failures in our life.
- If you MUST process the mistake, FOCUS ON ACTIONABLE STEPS to improve or make changes or genuinely apologize- not on berating yourself.
- You’ll need to evaluate what helps or doesn’t help YOU. Ie. Traditional journaling is NOT good or healthy for me because of the two issues above. It’s too focused on the things that are bothering me- and unlike a person without RSD, I’m not leaving those things behind on the paper. Writing about them is exacerbating the issue.
- Make a fun, easy change: rearrange your bedroom furniture, organize a small space in your home, dye your hair, or get a hair cut.
- Understand what prompts your RRE to kick in: do those things when you’re hit with RSD symptoms to trigger some feel good feelings!
- Acknowledge that you make mistakes and so do other people. Your RSD MIGHT be a product of or exacerbated by someone else’s mistake. It’s okay for both of you to make mistakes. We need to allow others to make mistakes in order to accept our own.
- Reality check your perceptions: Are you reading the situation correctly or are you assuming what someone else is thinking? Are you assuming you need to change for that person’s benefit?
For example, I worked for someone once who was pretty blunt and rarely gave positive feedback. If he didn’t say something negative, you were doing a phenomenal job. So in order to combat RSD, I needed to remember that everyone has a different personality and deals with people differently. I had to change my expectations for HIS personality.
Likewise, we don’t know what the face someone is making really means. We can think we do. We may even be accurate. But we have no way to fact check that- EVEN IF WE ARE CORRECT, there is NO BENEFIT to assuming we are right. We are just causing ourselves undue anxiety over something that a neurotypical person will ignore. This sensitivity is a useful skill in some cases- perfect for reading and responding to animal body language, getting us out of dangerous situations, etc. But fixating on someone’s small facial expression during a conversation and not letting that go is unnecessary and can cause significant social anxiety. Even if they do have a response to something we say or do, everyone’s responses are a result of their very individual and specific view of the world. Maybe you said something that triggered them because you reminded them of their mom who they have a difficult relationship with. They may not be aware of this either. Some people don’t mesh well due to baggage they have carried with them throughout life. Maybe with therapy, they’d be a great friend/mom/partner/etc., but that’s not where they are RIGHT NOW. You can’t change that- it’s not your responsibility.
Here is a more concrete example. As a person who is openly neurodivergent, I trigger a lot of other people who mask. My neurodivergence (and being a therapist, my openness about discussing good mental health) can make people very uncomfortable. Not everyone can handle me in their life- and that’s okay. I’m here to model what it looks like to be okay with who I am. I can be confident about who I am and set the stage for others to achieve this level of comfort. If I try to mask and fit the mold in order to make “Susan” like me, I’m doing a disservice to myself and those whose lives I could improve by just being me. Also, I don’t have the time, energy, or ability to be anyone, but myself. But I’ve tried masking and acting neurotypical in the past- it wasn’t a worthwhile endevour. - Do NOT tackle tasks that are difficult or frustrating in the moment. This is NOT the time to work on your taxes if you’re bad at math. You SHOULD NOT set yourself up for failure in these RSD moments. If you think something is going to be easy and it ends up being too hard that day, switch to something else.
- Meditate and practice deep breathing/mindfulness.
- Watch a tv show or movie that makes you feel good.
- Use humor to deal with your mistakes, if this works for you. I have made some EXTREMELY silly errors in my life due to the inattentive, impulsive, and hyperactive symptoms of ADHD and I tend to make jokes about those errors now. I make up stories about scars (“oh that’s from a shark bite”). We will even sing silly songs about the mistakes or near misses (this is probably a bit of stimming on my end). Yesterday I nearly put a fork in the microwave and my 12 year old started singing “Dumb ways to die” under his breath at me. We all laughed. While I could have gotten upset at myself for making a silly mistake that might have set the house on fire, most mistakes that we make are not really life changing.
- Talk to your psychiatrist about if medication for RSD would be a good fit for you.
A martial artist that I really like, Jhoon Rhee, says that the key to happiness is to repeat this mantra every day:
“I am wise because I learn something new every day. I am humanly perfect because I never make mistakes knowingly. I like myself because I always take action to make good things happen. I am happy because I always choose to be happy.”
Jhoon Rhee
I love the piece about mistakes because people with ADHD do not intend to make the mistakes that we do and yet… we make them. It happens. People frequently tell us that we must have done it on purpose, but we KNOW when it was a mistake and it’s frustrating to have others accuse you of doing it on purpose. As someone with ADHD, I have experienced the intense pain of knowing that it was a genuine mistake and having others blame me for doing something intentionally. It’s really hard.
Sensitivity isn’t All Bad
With any symptom, it is not all bad news. I love being around other sensitive people because I find they tend to have a lot of empathy for others and they tend to try to make sure they aren’t being hurtful or harmful themselves. They’re less likely to unintentionally (or intentionally) take advantage of others. They’re a bit more aware of their surroundings and what’s going on around them.
This quality can be useful for a lot of jobs, particularly if you can separate yourself from being triggered by others’ reactions to you. Animal trainers need to be aware of animal body language. Therapists need to be aware of human body language. I think being an investigator would be interesting because we tend to be pretty good at reading people (as long as we don’t get overconfident).
I think in most jobs, it’s helpful to be aware of how others respond to your ideas or behavior so you can evaluate what they like or dislike about say, a presentation, then tailor the presentation better for that person next time. “Ah my boss really perked up when I started talking profits, but he got bored/angry when I mentioned the social benefits of this project and how it will help others… I may need to save that part of the presentation for so-and-so who WILL care.”
It’s just important to be aware that not all people have that same sensitivity. We need to make sure we don’t end up being taken advantage of due to this skill. We also need to make sure that we manage our RSD… we cannot manage other people’s reactions to us, but we CAN manage our feelings of sadness, anger and frustration.
Learning More about RSD
Rejection Sensitive Dysphoria: