The Third Pillar of ADHD: Rejection Sensitive Dysphoria

I’ve hinted at this third pillar for some time now. I know you may be tired of me calling out ADHDers as “sensitive” in more scientific terms than you can imagine. Rejection sensitive dysphoria is a big one, though, that requires specific attention both because of how overlooked it is as a symptom of ADHD, and the immense pain it causes ADHDers and their loved ones.

Nobody likes rejection, right? Breakups, job interviews, bullying …you will never find a person that says, “Oh man I LOVE rejection. When someone lets me know that they hate who I am and what I do, I’m like, I FEEL SO ALIVE.” But just like ADHD amplifies our emotions and our senses, it also makes us experience this already-unpleasant sensation in a unique way. Almost 100% of people with ADHD suffer from rejection sensitive dysphoria (RSD), yet very few people have found the words to accurately describe it. RSD is an extreme (dysphoria means “difficult to bear”) emotional reaction to the perception of rejection, failure, or criticism – regardless of the circumstantial reality.

Everyone I’ve talked to has articulated RSD as something intense and debilitating – either physical or emotional pain that makes them feel small and vulnerable.

“It’s like someone is stabbing me in the chest with a white hot iron.” “Rejection makes me feel like I’m a kid who lost his parents in the mall.” “Failure is so painful I would do anything to prevent it.” “It’s like my body is aching and splintering into a million pieces.” This blog post describes RSD as an “emotional sunburn,” which I love – because it makes every seemingly harmless touch feel like an assault.

RSD is perhaps such a pervasive and integral part of ADHD that it slips under the radar of the symptoms we look for; remember, this is a HUGE reason ADHD is misdiagnosed as a mood disorder such as depression or bipolar. It’s also hard to spot due to the shame it evokes in us – which, as we know, inevitably leads to secrecy. RSD – and the avoidance of it – shapes our daily lives so dramatically that it can easily meld into our very identities.

From AdditudeMag.com. Click here to download.

So if all ADHDers experience RSD, and it’s so difficult to identify, how could you possibly know if someone is suffering from this? Glad you asked. As you see on the above infographic, ADHDers tend to respond to rejection and/or failure – or the perception of rejection and/or failure – in one or both of these ways:

  1. Please everyone. There is a very good reason why so many people with ADHD become comedians, or actors, or advocates, or entertainers/performers: they’re very accustomed to anticipating and fulfilling others’ needs in order to survive. Maybe this looks like the class clown, or the peacekeeper in your family, or codependency (if I can just make sure no one else close to me feels pain, then I won’t feel pain either), or perfectionism. Maybe this response seems counterintuitive, because people pleasing inevitably leads to chaos and drama. But as long as that chaos isn’t rejection, it is worth it. One of the things I’ve learned as a therapist is how this outcome of RSD does not always look like making people happy, but instead could look like someone trying to intervene in rejection by whatever means necessary. For example, I knew a kid who had some difficulties with behavior in school, so her mom was in frequent contact with her teacher to monitor her progress. At the end of the day when mom came to pick her up and she stopped to talk with the teacher, the kid ran over and started screaming, crying, tantruming…Master Distracter. Her efforts ultimately drew even more negative attention to herself, but it prevented the conversation – and suspected criticism of her – from continuing.
  2. Stop trying. This is my camp. I didn’t get my driver’s license until I was two months away from graduating high school, because I was so scared I would totally fail at it. (And I did! I failed the written test my first time!) This paralyzing fear of failure and rejection bled through so many areas of my life: I quit piano lessons when we started learning songs that required BOTH my hands to play them. I wanted to be an artist, but gave up completely when I went to an arts summer day camp and someone made fun of a puppet I made or some shit like that. I LOVED theatre, but I refused to audition for things outside of my tiny everyone-gets-a-role community theatre just in case I wouldn’t get cast. Another nearly-universal ADHD experience that ties into this is procrastination. Now, as we know, RSD isn’t the only thing that can lead to procrastination; urgency is one of those things that kicks our nervous system into gear, and the ADHD brain also can’t accurately perceive time (a fun thing known as time blindness). But imagine how unthinkable it would be to walk across a rickety swinging bridge if one wrong step – that you are pretty likely to take because, let’s be honest, balance isn’t your strongest ability – would lead to a plummet towards your death? Yeah, no thanks. But wait, you need to cross that bridge to move forward in your life and achieve any kind of success or fulfillment and oh also that cliff you’re standing on is literally eroding before your eyes. Now imagine that is everything. Everything always feels like life or death. You would avoid crossing that bridge as long as you possibly can, because it’s scary and besides, maybe if you wait long enough you’ll find another way across the canyon, like a monorail or a helicopter.

Rejection sensitive dysphoria understandably impacts our ability to make and keep friends – or any relationship at all, in fact. When you are close with someone, there is always a chance they might reject you. And if you are terrified of that vulnerability, your relationships will reflect that. The more intimate the relationship, the more likely RSD is to show up – like this post about how RSD plays a role in the writer’s marriage. You can see how the above reactions could easily apply to friendships: someone may overcompensate for their fear of rejection by constantly seeking out people to charm so as to never be alone, or someone may lean more toward introversion and isolation in order to avoid the possibility that people won’t like them.

The sad news is that there is no straightforward answer to treating RSD. There are things that can help, like medications listed in the infographic above, but there is no way to eradicate it. In my experience as a mental health clinician who also has ADHD, what we can do is build coping skills that may not put out the fire but will contain or shrink it to prevent burning down the town.

We’ve gone over the ways ADHDers try to prevent rejection/failure. But how do they respond to it when it happens? Obviously every person is different, but reactions can be grouped into internalizing behavior and externalizing behavior.

People often feel a bit better after discovering that their experience has a name. And once we uncover the type of behavior RSD triggers, we can look at how to manage them. Internalized reactions tend to affect women more often, and can look like depression, withdrawal – even suicidal ideation. Coping skills for these symptoms might include:

  • mindfulness and grounding exercises
  • creating a safety plan or crisis card with resources for suicidality or emotional escalation
  • DBT (Dialectical Behavior Therapy) distress tolerance skills to wait out the feeling

For externalized reactions, this typically looks like a burst of rage directed at whoever or whatever caused the perceived rejection/failure. Like that one time I destroyed my computer monitor because it was loading too slowly. I’m not going to tell you when that happened because it’s embarrassing. Something else mentioned in that handy infographic is that 50% of people given court-mandated anger management have previously undiagnosed ADHD. Wow! And that’s not even touching on the unbelievably high percentage of ADHDers in the prison population. So coping skills for externalized symptoms might include everything already listed above, but also incorporate ones more tailored to impulsive behavior or angry retaliation:

  • regular exercise
  • strengthening boundaries – i.e., I know where I stop and you start, so your actions/words don’t define me
  • channeling impulsive energy into more constructive outlets

How do you respond to rejection sensitive dysphoria? Have you discovered any tips on how to deal with it?

That concludes our series on the Three Pillars of ADHD: interest-based nervous system, emotional hyperarousal, and rejection sensitive dysphoria! Do you have a topic or question you would like me to cover next? Drop a comment below or shoot me a message.

Message me | theadhdmanual@gmail.com | Comment below ↓↓

19 thoughts on “The Third Pillar of ADHD: Rejection Sensitive Dysphoria

  1. Holy shit.
    I think this is the most profound life-changing thing about my mental health I’ve ever read on the internet.

    I’m in my early 40’s. I got my ADHD Dx earlier this year, when I felt I was in danger of losing the first real tech job I’ve ever had / the first real chance at a foot in the door to an actual career. I’d scored a 33 on the ACT when I was 15, and beyond a college scholarship, I felt like a failure because my degree was worthless and I couldn’t figure out how to get any sort of professional job. I sucked at customer service because I couldn’t (still can’t) deal with people yelling at me, so I couldn’t hold any kind of entry-level job for long.

    The irony of the fact that I suspected I had ADHD in college, but never pursued help, because back then, everything I found on the internet said that it was mostly in boys, and that people grew out of it as they reached adulthood. I was so afraid of being labeled as a hypochondriac or drug abuser, or being told ‘it’s all in your head, go see a therapist’.

    I used to think that my inability to deal with rejection or criticism was because my mom yelled at me as a child any time I messed up even a little bit. Or at least it felt like it. And the only attention I really got from my dad was when I screwed up big-time.

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  2. Story of my life. Can’t tell you how much it’s cost me. I’m also a female who wasn’t diagnosed until my mid 30s. I dropped out of college 3 times. Series of low-end jobs, never a career. No friends to speak of. I got married and I agonized over the fact that I wasn’t going to have bridesmaids by default. I didn’t have anyone to ask!

    There’s also so many hobbies I’d love to try but my closet is full of things I gave up on as soon as I discovered I wasn’t immediately talented. Painting, jewelry making, crochet…I get so anxious that anyone might see how much I suck. I have to be perfect 100% of the time or no one will like me. Stupid thoughts but they’re always there. My therapist says I need to address this deep-seated sense of shame I feel about everything and I’m trying but the feelings just overwhelm me sometimes.

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  3. This article, and the previous discussions, have helped me tremendously. Its helped me understand that although those feelings or thoughts are intrusive and painful that theres a reason I feel them and it’s not something distinctly wrong with me.

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  4. I just wanted to thank you for this. I suffer from the ‘Stop Trying’ camp, too. I’ve lived with criticism all my life so it stops me in my tracks anymore and I feel like giving up and crawling into a hole. I recently discovered my ADHD these past few months and so reading this really helped me to understand myself better. Now I know why I’m affected so badly by even constructive criticism.

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  5. Thankyou so much for this post. I 100% relate to this post and always had the feeling no one really understood , only maybe my family a bit – also because they knew how intense I reacted on situations .
    Doctors/ specialists often kind of ignored it when I came out with the question how to deal with this and said it’s just normal; then continued their program.
    Best help I found in ( ofcourse living, and) modern buddhistic meditation and life approach. However the RSD still holds me back in so many things and I feel somewhat deeply socially isolated.

    What I wanted to actually ask in my respond: when will you continu your word about time blindness? 🙂
    (I found a sport/ hobby in which time blindness isn’t of concerns, the moment I execute it :D)

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  6. You really need to share sources of legitimate research for the things you are stating as fact (but are actually your opinions). “100% of people with ADHD have RSD” uhh you’re going to need to source such a bold statement. This is not at all backed by research and psychology.

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    1. Hi there Amelia. Thank you for your diligence! I agree with you, and I put a lot of care into my research because I want to do my best to deliver accurate information. Perhaps you missed the link I provided within the text you’re referring to; it is to this article https://www.additudemag.com/symptoms-of-add-hyperarousal-rejection-sensitivity/ written by Dr. William Dodson. In it, he says “98-99% of adolescents and adults with ADHD acknowledge experiencing RSD.” So that is where I got this statistic. I have not reached out to him to see which study he is referring to, but if you do, please let me know! Thanks for commenting! 🙂

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  7. I can tell from your article that nearly all 👥 diagnosed w/ADHD have RSD. What I would like to know however, is it possible for someone who does not have ADHD to have RSD?

    I’m curious a/b this b/c a lot of the symptoms and anecdotal recollections that you mentioned sound similar to experiences that I have had, however I’m certain I don’t have ADHD. I do have lots of health issues including chronic pain from my shoulders all the way down to my hips.

    I am on medication that is very sedative and makes me feel like life is passing me by. I’d be the 1st to admit that the frustration of it all sometimes gets the best of me. These circumstances could account for what I’m interpreting as possible RSD symptoms. Hence, my thinking it was worth asking the question.

    As a former teacher having taught every grade from kindergarten through 12th, including all Three RS as well as a few others b/4 settling in the math department @ a gifted magnate school, I’ve encountered quite a few students with ADD or ADHD over the years. I also have a brother with ADHD.

    Although it sometimes seemed to me like ADHD is over-diagnosed in the school system, I very much sympathized w/the students that I could tell were really struggling w/this myriad of symptoms. Looking back, I recognize some of the symptoms and experiences as well as the coping tools of RSD mentioned above in some of my former students.

    To tell you the truth, these were some of my favorite students. Some of them are friends w/my sons and I still see them to this day, even though it’s going on 15 years since I taught them! They we’re in my son’s wedding and he’ll probably be in their weddings. Their friendships are solid and will probably last a lifetime.

    Why were these students among my favorites you might ask. B/c they worked hard! And even though they had their problems, they didn’t use them as crutches; they did their best to be successful in my class (Algebra I) in spite of their problems. In my 📘, that’s a good work ethic, and that’s what makes a good student, and that’s what makes one of my students become one of my favorite students! But, don’t tell them that.

    I very much enjoyed your informative article. I learned a lot even though I kind of feel like I already knew some of it, but you put a name to something I not only sort of recognize in myself, but also in some of my former students which, even though I’m no longer teaching due to my health issues, is nice to be able to finally put a name to.

    Thank you for whatever further information you can provide on the occurrence of RSD in 👥 w/o ADHD.

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    1. Hi Stacey, thanks for sharing your experience. And thank you so much for your service as a teacher! The research seems pretty split on whether or not RSD is a separate disorder, and whether it’s unique to ADHD. The DSM doesn’t define it as a disorder by itself. I certainly think most of the time, it’s associated with ADHD. But you will very rarely hear me say that something is impossible. Heightened sensitivity to rejection can be a characteristic of several conditions, like PTSD, bipolar, and even depression. But RSD is different in that the flare-up is relatively short-lived compared to other disorders. In my opinion, ASD (Autism Spectrum Disorder) is most likely to have high crossover with RSD…but I also think ADHD could be considered part of the autism spectrum, so I think that’s connected. If you find more information on this question, I’d love to hear it!

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  8. I find this very interesting. I have a now three-year-old preemie (born at 27 weeks) who I feel may have ADHD. One personality characteristic that has recently emerged is his profound embarrassment in certain settings. When he feels as though he has been “put on the spot” about something, he absolutely loses it. Not like, “throwing a tantrum” but more like quiet, ragged sobs of sheer humiliation.

    Examples:

    We recently went to Boo at the Zoo. Knowing about his quirks, I tried to prepare him do he knew what to expect. First stop to get candy and the person looked at him expectantly….complete melt down.

    First day of soccer class (super excited about it!) he played and warmed up. We got in the circle to do organized stretches, and the coach looked at him and said, “Arms up, you have to reach your arms up.” Very kindly. Total meltdown.

    Ninja class, trying to get him to do the first jump activity, literally he imploded on himself at the mere thought of trying. Even though he very much wanted to.

    He is not shy in general, socially. He struggles to maintain any activity more than a few minutes at a time.

    I’m just wondering how I can help him at such a young age.

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    1. First things first, those activities sound awesome. You are the Coolest Parent.
      Obviously I know very little about you and your son, but I’d say ADHD is certainly a possibility, given the examples mentioned and the fact that premature birth does increase the likelihood of ADHD. Three is not too young for a diagnosis, but with kids I recommend always starting with their pediatrician. They could check him out for other health conditions that might be affecting him, like hearing/vision/etc, and also advise on whether or not it’s better to try medication now (typically methylphenidate) or wait. Autism spectrum disorder also tends to become noticeable at this age, and there is considerable overlap between the two disorders.
      Behavioral treatments for people with ADHD aren’t really effective, at least not for very long or across multiple settings. However, you absolutely can – and should – help your little ADHDer as much as possible.
      I started writing my suggestions and it got wayyyy too long, so I’m going to post it in its own article. Keep an eye out! And thank you for sharing your story! I’m positive many will relate.

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      1. Thank you for your response! I am just now getting around to reading it. My son has been in early intervention programs since birth, simply because of his low birth weight and prematurity. No vision/hearing issues (in fact his hearing is better than any human being I’ve ever met). He does not sleep well. He never has which I’m sure you know is another preemie/sensory thing. He had tonsils/adenoids removed which improved sleep and got him talking at 2.

        He was screened for an IEP with the school system and the PT, OT, Speech and child psychologist all agreed he did not need an IEP but I did let the psychologist know that we may come see her again some day.

        He THRIVES in a structured/routine environment (many kids do). He has to know what to expect or he becomes overwhelmed and the situation consumes him, even if it’s something he loves.

        I read your most recent post and 10000% agree about keeping him active. He seems so much more at ease when we do some sort of outside play. Unfortunately it’s now winter so we can’t get out as much.

        Anyway, I just wanted to thank you for your reply and let you know I appreciated your feedback!

        Liked by 1 person

  9. I’m ADHD that causes anxiety and depression, and I never new about this. I’ve wondered if I’m bypolar, borderline, something because I could not explain this right here. I didn’t truly know how to articulate any of this until I read this articke.
    I’m 45 and can not maintain a job for more than 2 years, have never had a long term romantic relationship, get so overwhelmed with not being able to do things to my standards that I just give up, and I tend to break things.
    Thank you for opening my eyes to this, hopefully this will help me make progress.

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  10. I was diagnosed late with ADHD (inattentive type), but there seems to be a wave of adults just now being diagnosed that has put it into a different perspective since I was still only 14 and have now lived and learned with my diagnosis for almost 20 years. I also seem to have ridden the initial wave of understanding that no one just “grows out of” ADHD, so it’s quite jarring and saddening to see it come as such a surprise to so many, even (especially) among my friends who were there when I was diagnosed and with whom I spent hours discussing symptoms and strategies and things my therapist said and whom are just now receiving diagnoses of their own well into their 30s and 40s. Either way, I would actually put myself into both camps: either I overcommit to projects and events to try and make everyone happy, or I “lose” my homework and get an F, never turning it in to avoid the possibility that I might fail on my own merits.

    What IS fascinating is how, even though I’ve been immersed in it for so long, there still seems to be so much about myself and all things ADHD I don’t know, because this article was truly a revelation for me. While I haven’t experienced anything quite as extreme as the woman in the ADDitude article, I definitely struggle with criticism of any kind and it definitely impacts my relationships and, yeah, it definitely starts fights. I’ve been in a new position at work as a repair technician for 8 months now, and it has been a hell of a struggle because every mistake is potentially very serious, expensive, or life-threatening, so my anxiety has been through the roof because of it. Sometimes it’s been so bad I had to retreat to the bathroom to cry and pull myself together – definitely not something I remember doing when criticized by the manager of the old pizza place where I used to wait tables in college. I was starting to wonder if there was something wrong, and I was “getting worse” somehow, but I can see now that this job just pits me against the worst aspects of my own RSD. I can even see how the combined heightened anxiety and stress may have led to overlooking details or forgetting steps in a process more than usual, or if not, feeling very much like I am. It really is extremely comforting to have the connection drawn and to understand what’s going on.

    I would love to see an article on the overlap between ASD and ADHD. Have you seen the one on “spectrum” from the Aspergian? It was very informative, very clear about the common misconception about what a spectrum is, and gave me a new understanding of why people have said ADHD may fall under the umbrella.

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  11. My son is 15 and has been Dx with ADHD since he was 7 on top of being Dx with dyslexia at the age of 9. To say he has struggled in school is an understatement. Things have got better with help for his “learning disabilities” as school likes to put it. But with out some type of strenuous activity (sports in his case) then things get crazy around my house. But with sports comes being told that you aren’t good enough for that position or you’re doing that wrong! When that happens he shuts down!! Wants to quit, gives all the way up. It takes everything I let know that it’s ok these things will only make you better at this sport but he has only heard “I’m a failure”. Sometimes my little pep talks work other times it’s depression. Since he’s in high school he plays HS football and that was a great time in our home. Then it was time to tryout for the HS Basketball team ( this gave me more anxiety then I can remember having). He didn’t make it. We are on week 3 and he’s lost. He sleeps right after school, hygiene has went down, school is suffering, attitude is worse, and he has let me know that he isn’t ever touching a basketball ever again. Only 2 kids from the football team made The basketball team. All football players had late tryouts since the season was still going which means the basketball coach already had his team together. He’s only a freshman but he doesn’t understand this, that he still has time. The depression is real in my house right now. I just recently joined a group on Facebook regarding ADHD and stumbled upon this. You have shed light on this for me. Everything makes a little more since for me to help my son. I read him everything I learn so he can try to process what’s going on in his own head also. This seems to help him a little.. Thank you for helping a mom who feels helpless so much of the time….

    Liked by 1 person

  12. So many overlapping symptoms with physical misdiagnoses on top…

    I’ve given up trying to get any more ‘help’

    I’ve got at most another 20 years left then the apparently impossible task of ‘holistically’ seeing me as a whole person not a set of broken damaged Blue Peter cobbled back together with cornflake packets and double sided sticky tape will be done and dusted.

    Deteriorating every year, I get a bit better by June and whoosh September arrives and the deterioration speeds up again.

    Broken systems everywhere.

    I have 2 very good human reasons to battle on but Oh Goddess I’m in smithereens.

    Like

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About Abby Minor, LMFT, ADHD-CCSP

I am a marriage and family therapist based in Seattle, WA. I also have ADHD! And I love learning more about it, by myself and with my clients. Join me as I create an ADHD Owner's Manual! (she/her)