Rejection Sensitive Dysphoria (RSD): Definition, Symptoms, & Treatment

What Is Rejection Sensitive Dysphoria (RSD)?

Rejection sensitive dysphoria (RSD) is a condition characterized by an extreme sensitivity to perceived rejection, judgment, or criticism from others. People with RSD often experience intense emotional responses to situations where they feel rejected, contributing to feelings of shame, humiliation, and sadness.

While common to neurodivergent conditions like ADHD and autism, anyone can experience RSD. Over time, RSD can significantly impact self-esteem, relationships, and overall well-being.

RSD Vs. Rejection Sensitivity

Many people use RSD and rejection sensitivity interchangeably, but these are two distinct experiences. Rejection sensitivity refers to a general sensitivity to rejection, while RSD is a more severe form of sensitivity that can lead to debilitating emotional responses. Even perceived failure or criticism can trigger RSD. In contrast, rejection sensitivity is often specific to interpersonal relationships.

RSD Vs. Emotional Dysregulation

Emotional dysregulation refers to a broad category of emotional difficulties found in RSD and other conditions, such as borderline personality disorder and bipolar disorder. While RSD refers specifically to the emotional response to rejection and criticism, emotional dysregulation refers to difficulty regulating emotions, mood swings, and impulsivity.

Rejection Sensitive Dysphoria Symptoms

RSD symptoms include an intense fear of rejection or criticism and hypersensitivity to perceived rejection. Individuals with RSD may also use avoidance behaviors to limit potential triggers, such as withdrawing from social situations or not pursuing opportunities. Other signs of rejection sensitive dysphoria can include low self-esteem, poor relationship quality, and emotional dysregulation.

Symptoms of rejection sensitive dysphoria can include:

• Being easily embarrassed
• Heightened fear of failure
• Unrealistically high expectations for self
• Feeling helpless or hopeless
• Needing constant external approval or validation (i.e., being an approval addict)
• Becoming aggressive or confrontational in new situations
• Feeling anxious around new people
• Avoiding social settings
• Becoming spiteful or vindictive after being rejected

Understanding ADHD & Rejection Sensitive Dysphoria

People with ADHD are at an elevated risk for RSD. Because ADHD affects emotional regulation, events like teasing, rejection, or disappointing others can trigger an exaggerated reaction.² The pain often feels automatic and consuming, leaving many people avoidant of necessary social, occupational, and personal risks.

The presence of rejection sensitivity in individuals with ADHD can further complicate their already impaired executive functions. RSD in ADHD can contribute to difficulties in social interactions, as individuals may be hypervigilant for potential rejection. They may interpret neutral or ambiguous social cues as signs of dissatisfaction, which can further perpetuate their symptoms.

Simultaneously addressing ADHD and rejection sensitivity is crucial for maintaining mental health and overall functioning. Treatment may involve therapeutic interventions to improve emotional regulation and challenge distorted perceptions of rejection.

Effects of Rejection Sensitive Dysphoria

RSD symptoms can be intense and consuming for both the individual and their loved ones. Some people with RSD might avoid social settings or situations altogether to reduce the risk of rejection. Other times, they may become upset and angry when faced with criticism. These behaviors can ultimately lead to relationship strain, depression, and poor self-image.

Impacts of rejection sensitive dysphoria may include:

• People-pleasing tendencies: Many people with RSD attempt to control their behavior via people-pleasing tendencies. They hope they can avoid the risk of rejection by going along with what others say, do, or want. However, people-pleasing requires immense energy and self-control, which can exacerbate anxiety.³
• Chronic procrastination: Chronic procrastination is a common consequence of rejection sensitive dysphoria, as individuals fearing rejection or failure may avoid tasks or responsibilities.
• Avoidance behaviors: Avoidance behaviors can be prevalent in individuals with rejection sensitive dysphoria as they try to prevent potential rejection or criticism.
• Perfectionism: Perfectionism often arises as a coping mechanism for individuals with RSD, as they strive for flawlessness to avoid rejection from making mistakes.
• Thoughts of self-harm: Self-harm can manifest as a result of the intense emotional distress and feelings of shame associated with RSD.
• Depression: Depression can coexist with RSD because constant fears of rejection can lead to persistent feelings of sadness and hopelessness.
• Aggression: Aggression can also be a response to the heightened emotions experienced with rejection, with individuals struggling to regulate their emotions and reacting defensively to perceived rejections or criticism.
• Low self-esteem: Low self-esteem is a frequent consequence of RSD, as individuals may internalize the fear of being unworthy and struggle with negative self-talk.
• Anxiety: Anxiety is a prominent feature of RSD, with individuals living in fear of potential rejection and experiencing overwhelming worry about being judged or criticized.
• Relationship problems: Individuals with rejection sensitive dysphoria may experience relationship problems due to potential overreactions to perceived slights or criticisms from loved ones. These issues can lead to interpersonal conflicts, misunderstandings, and strained relationships.

What Causes Rejection Sensitive Dysphoria?

Experts have not identified a single variable that causes RSD. Instead, multiple risk factors can increase the likelihood of experiencing the condition. Those with histories of trauma, frequent rejection, and other mental health conditions may be more prone to symptoms. However, environmental factors also play a role, and not everyone with a predisposition will develop RSD.

Possible causes of rejection sensitive dysphoria include:

• Childhood trauma: First, research shows that a history of early childhood neglect or abandonment issues can undoubtedly affect personality development. Feelings of self-devaluation and inadequacy can emerge and persist into adulthood if a child doesn’t feel adequately loved by their caregiver.⁵
• Experiencing rejection: Repeated experiences of rejection (breakups, divorce, friendship issues, getting fired from a job) can trigger RSD. Over time, a person may internalize the idea they are somehow doomed, possibly leading to an unfortunate self-fulfilling prophecy.
• Mental health conditions: Some people with untreated mental health issues may feel like something is profoundly wrong with them, and this distorted belief may perpetuate problems with rejection.
• Genetic factors: Some experts suggest genetic factors play a role in the development of rejection sensitive dysphoria, as having relatives with the condition increases the risk of RSD.
• Brain differences: Neuroimaging studies reveal alterations in brain regions involved in emotional processing and regulation. Specifically, individuals with RSD have shown heightened activity in the amygdala and anterior cingulate cortex, which are regions involved in emotional responses to social stimuli.

Rejection Sensitive Dysphoria & Co-Occurring Conditions

Rejection sensitive dysphoria can occur independently or alongside other mental health conditions. RSD is frequently associated with ADHD, and these intense emotional reactions and fears of rejection can exacerbate symptoms of ADHD. However, RSD is not exclusive to ADHD, and anyone can experience symptoms.

Conditions associated with RSD may include:

• ADHD: RSD frequently affects individuals with ADHD, with estimates suggesting a high co-occurrence.³
• Anxiety disorders: RSD can overlap with and contribute to anxiety disorders, including generalized anxiety disorder, social anxiety disorder, and separation anxiety disorder.^{3, 4}
• Depression: RSD often co-occurs with depression, as both conditions involve negative self-perception, low self-esteem, and emotional dysregulation.⁴
• Borderline personality disorder (BPD): BPD and RSD share similarities in emotional dysregulation, reactive responses to perceived rejection, and difficulties in interpersonal relationships.⁴
• Autism spectrum disorders: Although not universally observed, RSD traits are common in autistic people.⁴

How Is RSD Diagnosed?

Diagnosing rejection sensitive dysphoria involves a comprehensive assessment by a mental health professional. A specific diagnostic test for RSD does not exist, but self-reported symptoms, clinical interviews, and observations can provide insight into the disorder.

During the diagnostic process, a mental health professional may explore the individual’s history of emotional reactivity, sensitivity to criticism, and experiences of perceived rejection. They may also assess for the presence of co-occurring conditions like ADHD that frequently overlap with RSD.

Because RSD is a symptom and not a distinct mental health condition, the DSM-5 does not provide specific diagnostic criteria. However, some clinicians may use RSD as an explanatory framework for understanding and addressing intense emotional responses to rejection.

Rejection Sensitive Dysphoria Treatment

Proper RSD treatment begins with an appropriate medical evaluation. A qualified healthcare professional can determine how to treat RSD based on individual needs, underlying conditions, and presenting symptoms. While RSD has no cure, successful treatment tends to be multifaceted, including a combination of therapy, medication, and lifestyle changes.

Therapy

Therapy can be highly beneficial when treating RSD. For example, cognitive behavioral therapy (CBT) helps individuals identify and reframe negative beliefs into healthier, realistic thoughts. Similarly, this therapy focuses on increasing positive behavioral strategies for managing triggers and responding to difficult stimuli.

In addition, dialectical-behavior therapy (DBT) focuses on improving emotional regulation and interpersonal skills. Individuals can learn tolerance skills to reduce reactivity to adverse events. Both DBT and CBT can be valuable when assessing how to treat rejection sensitive dysphoria.

Choosing a therapist, counselor, or psychologist can take time, but focus on finding a provider who understands the emotional struggles associated with rejection. A therapist may not advertise a specialty in RSD, but those with a focus on social anxiety disorder, depression, or ADHD can be helpful.

Medication

The FDA has not approved specific medications for RSD. However, some individuals receiving treatment for rejection sensitive dysphoria may benefit from medications for conditions like ADHD, bipolar disorder, or depression. These can help reduce emotional reactivity and feelings of sensitivity to inadvertently decrease the impact of RSD.

All medications have their risks and benefits. Similarly, they each have various side effects and potential interactions. If you believe you might have RSD, consult with your primary care physician (PCP) or psychiatrist for a medication evaluation.

How Long Does Rejection Sensitive Dysphoria Last?

The duration of rejection sensitive dysphoria can vary from person to person. Available research is limited, but some individuals may experience reduced RSD symptoms with age as their brains develop.³ However, RSD can persist into adulthood and require ongoing management and support.

How to Deal With Rejection Sensitive Dysphoria

Healthy lifestyle changes can reduce the impact of RSD and associated symptoms. For example, mindfulness can help you feel more “in control” of your thoughts and reactions, while meditation can provide relief when overwhelmed or upset. Likewise, ensure you take care of your physical and emotional well-being by eating a healthy diet, exercising regularly, following a consistent sleep schedule, and spending time with positive social support.

Below are tips for how to deal with RSD:

• Practice self-acceptance: Embrace and accept yourself, including your strengths and weaknesses. Recognize that everyone faces rejection at some point.
• Build your self-confidence: Engage in activities that boost your self-esteem and self-worth. Focus on your accomplishments and positive qualities.
• Develop resilience: Cultivate resilience to help bounce back from perceived rejection. Learn strategies to manage setbacks and develop a growth mindset.
• Seek social support: Surround yourself with understanding and supportive individuals who appreciate and validate your emotions. Share your struggles with trusted friends, or consider joining support groups.
• Practice emotional regulation techniques: Explore deep breathing exercises, mindfulness, or meditation to help manage and regulate intense emotional responses.
• Challenge negative thoughts: Identify negative thought patterns associated with rejection and practice reframing them. Replace distorted thoughts with more realistic and positive perspectives.
• Set realistic expectations: Remember, not every interaction will result in acceptance. Set realistic expectations for yourself and others, and be compassionate toward yourself.
• Engage in self-care: Prioritize self-care activities that promote relaxation, stress reduction, and overall well-being. These techniques could include exercise, exploring hobbies, spending time in nature, or engaging in creative outlets.
• Seek therapy: Consider seeking support from a mental health professional who can provide guidance, support, and evidence-based strategies to manage RSD.