Rejection Sensitive Dysphoria (RSD) & ADHD: Understanding the Connection

What Is Rejection Sensitive Dysphoria (RSD)?

Rejection sensitivity dysphoria is an intense emotional reaction to actual or perceived rejection, disapproval, or criticism. It can look like anger, resentment, sadness, hurt, and a lack of understanding around why you feel the way you do. This can impact someone’s life in many ways, including social anxiety, difficulty attaching to others, lack of trust in people’s intentions, low self-esteem, and depression. There is no formal diagnosis for RSD, as it is more of a symptom of a diagnosis than a diagnosis itself. RSD can be seen most often associated with attention deficit hyperactivity disorder (ADHD), Generalized Anxiety, Major Depression, borderline personality disorder, autism, and bipolar disorder.¹

RSD symptoms can present as mild, moderate, or severe, depending on the situation and context of the rejection. Some RSD symptoms can resemble mood disorders, anxiety disorders, and even personality disorders.

Common symptoms of RSD include:

• Fear of failure
• Low self-esteem
• A chronic fear of rejection
• Catastrophizing small rejections
• High expectations of oneself
• Avoidance of social situations
• Perfectionism
• Seeking validation
• Aggression in social situations
• Feelings of hopelessness or helplessness
• Increased anxiety in new social situations
• Malicious and vindictive responses to rejection

What Is ADHD?

Attention-Deficit Hyperactivity Disorder (ADHD) is a reduced ability to focus on anything deemed “unimportant” or interesting. ADHD can impact a person’s ability to function at home, school, work, or in relationships. The average age of onset of ADHD is between four and seven years. About one-third of those with childhood ADHD will continue to have this diagnosis into adulthood. ADHD is more commonly diagnosed in males than females; however, females often go undiagnosed until later in life.²

Symptoms of ADHD fall under three different categories: hyperactive/impulsive presentation, inattentive presentation, and combined presentation. These symptoms may overlap with symptoms of other conditions on the neurodiversity spectrum, including autism, dyslexia, dyspraxia, OCD, and Tourette’s syndrome.

Common symptoms of ADHD include:

• Difficulty starting or completing tasks
• Emotional dysregulation
• Mood swings
• Sensory sensitivities
• Difficulty with executive functioning
• Hyperfixation
• Limited energy for socializing
• Fidgeting
• Difficulty with patience
• Careless mistakes
• Difficulty listening when spoken to
• Difficulty organizing tasks

What Is the ADHD-RSD Connection?

RSD can be caused by a few different things, including early childhood abandonment or neglect, repeated experiences of rejection, and untreated mental health issues. Individuals diagnosed with ADHD are more likely to be deemed lazy, unproductive, a lost cause, difficult to manage, and failures in childhood. These experiences can result in parents disconnecting from meeting their children’s needs and professionals rejecting the individual’s ability to improve their symptoms. These rejections can add up over time. In addition, when ADHD begins to impact how a person functions in a relationship (romantic or friendship), it can lead to an increase in rejection.

Furthermore, RSD is viewed as a symptom of ADHD, not the other way around. This is because ADHD is a neurological disorder of the brain that can cause a disruption in one’s mood. RSD is a mood disruption directly resulting from how someone views the world. Our perception of the world can impact our reactions to rejection, criticism, and disapproval. Unfortunately, for those with ADHD, this increased sensitivity can lead to further complications, such as issues with maintaining employment, establishing stable housing, and substance abuse, among others.

People with RSD and ADHD may have a heightened risk of:

• Homelessness: Having multiple failed roommate or landlord situations results in difficulty finding housing. This can result from forgetting to pay rent, frequent disputes due to criticism, or anxiety that has developed out of fear of criticism and rejection.
• Unemployment: Having a big emotional response to constructive feedback or criticism in the workplace can result in job loss and difficulty finding new employment.
• Social withdrawal: The perception that you are unlikeable or that others will inevitably reject you can result in a lack of social interaction and fears about socializing.
• Emotional unavailability: Fears of rejection by others can result in not wanting to make deep connections in relationships. People with RSD will often reject someone before they can be rejected themselves.
• Suicidal ideation: Feeling hopeless or helpless about the situation can result in feeling as though there is no point in trying anymore and that everyone would be better off without you.
• Aggression: In an attempt to get others to understand and not reject you, you may become more aggressive in tone or physicality. Especially at the end of a relationship due to ADHD symptoms and RSD reactions.
• Substance use disorder: Finding ways to cope with the strong emotions associated with RSD can be difficult. Oftentimes, especially with ADHD comorbidity, self-medicating feels like the best option to calm the mind and the heart.

RSD & ADHD Diagnosis

To obtain an official ADHD diagnosis, it is important to seek appropriate testing. Any therapist, psychologist, or psychiatrist can provide a brief questionnaire to determine if ADHD symptomology is present. However, for a more in-depth perspective, seeking psychological testing from a qualified psychologist or psychiatrist would be the best place to start.

While there is no official test for RSD, seeking professional help from a therapist, psychologist, and psychiatrist that has a specialized approach to ADHD will be able to help you identify this as one of your symptoms.

Treatment for Comorbid ADHD & RSD

Seeking treatment for ADHD and RSD can be difficult but rewarding for those who suffer with disruptive symptoms. An excellent place to start would be to find a neurodiversity-affirming therapist, whether through a doctor referral or local resources. You can also search an online therapist directory.

Medications

There are several ADHD medication options available for treating comorbid ADHD and RSD. While there are some associated adverse side-effects, medications can help a person better manage their symptoms. Always ask your doctor before pursuing any kind of medication regime.

A medication regimen for treating comorbid ADHD and RSD may include:

• Antihypertensive: While initially developed to assist with high blood pressure, these medications have been found to be an effective alternative to a stimulant to treat ADHD. These help an individual maintain attention for longer. These medications, however, may increase suicidal ideation and behaviors in certain people, so it is important to speak with your doctor if you have struggled with this in the past.
• Stimulants: Stimulants help to increase dopamine and norepinephrine in the brain, which helps increase attention.³ These can be short-acting, intermediate, or extended-release options. These differ from non-stimulants because they are focused on the dopamine receptors in the brain, which can help us connect with tasks we would typically feel to be draining or uninteresting.
• Antidepressants: While antidepressants have effectively reduced ADHD and RSD symptoms, they are not an FDA-approved treatment. However, many providers may prescribe these in conjunction with stimulant medication to help with some of the other symptoms associated with ADHD and RSD. These medications include Bupropion, Imipramine, Desipramine, and modafinil.

Therapy for ADHD & RSD

Therapeutic methods for treating RSD with ADHD focus on identifying the ADHD symptoms that may be causing the RSD, as well as teaching emotion regulation skills to help manage the RSD.

Therapeutic options for comorbid ADHD and RSD include:

• Cognitive behavioral therapy (CBT): CBT can be a helpful treatment for ADHD and RSD because CBT focuses on our thoughts, feelings, and behaviors. CBT can help you understand your perception of rejection, criticism, and disapproval how it makes you feel and how it impacts your responses to others.
• Family therapy: Family therapy can be helpful as a treatment for ADHD and RSD to help the individual struggling communicate with their family about their experience. This can help open the conversation and reduce the feelings of criticism, rejection, and disapproval, in addition to the individual working on themselves.
• Acceptance and commitment therapy (ACT): ACT can be helpful in the treatment of ADHD and RSD because it focuses on mindfulness and behavioral change while also paying attention to what our own needs are. This can help the individual struggling to accept their reality and develop strategies to improve their overall well-being one day at a time.
• Dialectical behavior therapy (DBT): DBT can be used to treat the emotion dysregulation associated with ADHD and RSD. DBT is a skills-based model that incorporates mindfulness and CBT. It can help those struggling with intense emotions find effective ways to think before they act/respond.
• Eye movement desensitization and reprocessing therapy (EMDR): EMDR can be used as a way to reduce the anxiety associated with ADHD and RSD. EMDR is a short-term treatment that helps target the brain’s processing system and to change the emotional intensity of the brain’s response to certain situations.

How to Cope With Comorbid RSD & ADHD

When trying to work through RSD and ADHD symptoms, it is important to develop healthy coping mechanisms. In addition to seeking treatment, some of the most helpful coping methods include journaling, mindfulness, exercise, and creativity.

Here are some self-coping skills to try:

• Try Self-soothing: Self-soothing is a way to improve our emotional state without the assistance of others. This can be helpful as we often isolate and withdraw from others when we struggle. Self-soothing can include progressive muscle relaxation, meditation, counting down from 5, mindfulness, and the square breathing technique (breathe in for four seconds, hold for four seconds, breathe out for four seconds, and hold for four seconds).
• Practice emotional self-care: Emotional self-care can include talking to a friend, setting boundaries with distressing friends/family, paying attention to what it is that you need, and following through.
• Journal: Journaling for your mental health is a way to connect with your emotions and process them in a safe way. Journaling can help with rumination, perseveration, and feeling stuck in a problem.
• Get Creative: Creativity helps us process our emotions differently than talking. This can include art, music, dance, and cooking.
• Exercise: This does not have to be intensive exercise. However, finding 15-30 minutes a day to move your body in a way that feels good to you can increase serotonin and dopamine levels in your brain.

Final Thoughts

RSD and ADHD can present challenges that impact our home, work, school, or personal lives. While it may feel you are overreacting, dramatic, or unlovable, that is not the case. Finding help, leaning into your resources, and learning healthy coping skills can make all the difference in your experience.