ADHD & Rejection Sensitive Dysphoria: What the current research tells us (or doesn’t) about RSD.
Written by Jillian Enright, CYW, BA Psych.
Why are some people with ADHD so sensitive? We’re extra.
There are a number of possible reasons for people with ADHD experiencing emotions more intensely than others. People with ADHD often experience emotional lability (Sobanski et al., 2010), emotional impulsivity (Barkley, 2015), and negative intent attribution (Andrade et al., 2011).
There has been a lot of discussion about Rejection Sensitivity Dysphoria in the ADHD community over the past few years. The detailed descriptions of what RSD feels and looks like resonates with so many people who also have ADHD. There are very strong arguments for the connection between ADHD and RSD, unfortunately, the research has not yet caught up with people’s lived experiences (as usual).
What is Rejection Sensitivity Dysphoria (RSD)?
Dr. William Dodson describes RSD as severe physical and emotional pain suffered when people encounter real or perceived rejection, criticism, or teasing.
McDonald et al. (2010) defined rejection sensitivity as the tendency to anxiously or angrily expect rejection.
At present, there are very few (as in none) peer-reviewed studies explicitly linking RSD and ADHD, or even evidence supporting the existence of RSD.
Dr. Dodson is a psychiatrist who has retired from active patient care who has since become a speaker, consultant, and writer on adult ADHD medicine.
While he has extensive experience in treating ADHD, and his RSD theory has been warmly welcomed by many in the ADHD community, it has not yet been accepted by the medical community as a formal diagnosis.
One recent study concluded that youth with ADHD exhibited enhanced sensitivity to peer rejection, as well as reduced responding to peer acceptance (Babinski et al., 2019).
Isn’t that is a normal reaction to constant criticism, critique, and actual rejection?
What Connects ADHD and RSD?
The strongest links I have found between ADHD and RSD are the emotional impulsivity and lability mentioned above, in particular, negative intent attribution. This is the tendency to make distorted judgments about others’ behaviours, in particular, to misconstrue behaviour with positive or neutral intent as negative or hostile (Andrade et al., 2011).
If we perceive the neutral or positive behaviour of others towards us to have negative intent, it would make sense that we would be more likely to fear and assume rejection, whether we are actually being rejected or not.
People with ADHD are also impulsive, not just in our actions, but in our thoughts and feelings as well. As Dr. Barkley explained, “those with ADHD will be as impulsive with their primary emotions as they are with their behavioural responses” (Barkley, 2015).
If our thoughts and emotions come fast and furious, before we have a chance to contemplate various possibilities and consider our responses, it follows that we would be more apt to jump to conclusions.
Impulsivity, combined with a propensity for negative attribution bias, makes us particularly vulnerable to rejection sensitivity. Lucky us.
If the shoe fits…
Repeated negative feedback from others could understandably make some people with ADHD more sensitive to perceived rejection and criticism (Bondü & Esser, 2015).
If a significant number of our social interactions involve criticism or rejection (Jellinek, 2010), it certainly stands to reason that we would anticipate and perceive rejection more often than others.
People with ADHD often suffer from low self-esteem, children and adolescents (Mazzone et al., 2013), and adults as well (Cook et al., 2014).
Low self-concept and self-worth would predispose us to think and assuming the worst about ourselves and about how others perceive and treat us.
Unfortunately, children with ADHD are indeed more likely to be rejected by their peers. In a 2007 study, Dr. Hoza found that 52% of 7–9 year old children with ADHD fell in the rejected category (Hoza, 2007).
Children with ADHD are also more vulnerable to bullying and victimization (Wiener & Mak, 2009), and some adults with ADHD describe childhood experiences of rejection and bullying by peers (Barkley, 2015).
As Dr. Barkley surmises, these effects can shape our self-evaluation and relationships. Many adults with ADHD also describe a history of low-level social anxiety as a result of repeatedly missing social cues due to inattention, or gaffes due to impulsivity (Barkley, 2015).
Well, if that doesn’t paint a rosy picture, I also wrote a story about surviving years of severe and relentless bullyingthroughout most of my school years. Suffice it to say, we folks with ADHD have many reasons to fear, anticipate, and expect rejection more than neurotypicals.
RSD or CPTSD?
I recently read an amazing piece by Jesse Meadows, entitled Is It Rejection Sensitive Dysphoria or Complex Trauma?
In that article, Jesse explains how RSD is really just CPTSD with victim-blaming — Okay, it’s way more nuanced than that, but I’ll let you read their work because they wrote it much better than I could.
I’ll just leave this here:
”What is RSD but an acceptance of the neurotypical belief that we are not enough?… Your intense pain is valid and justified. It’s real, and there is a reason for it… Trying your entire life to fit into a world not designed for you is traumatic.” — Jesse Meadows
But wait… there’s more! People with ADHD also have difficulty with mental flexibility, often referred to in the literature as “set shifting” (Halleland 2012), which stems from executive functioning deficits (Barkley, 2015).
This presents two different challenges. First, we have difficulty considering various possibilities when attributing motive to someone’s behaviour. Second, because of our cognitive rigidity, we can get stuck. Once we have an idea or thought in mind, or are experiencing an emotional response, it is much more difficult for us to shift our mind.
These intense emotional experiences can also lead back to impulsive behaviour. I can remember many times in my youth where feelings were so overwhelming that I would engage in impulsive behaviour as a way of attempting to escape the emotions. This can lead to a very negative cycle of rejection, hurt feelings, (over)reaction, and maladaptive coping strategies.
Although research into the treatment of RSD and its symptoms is scarce, there is research describing the links between ADHD and CPTSD (Sprafkin et al., 2007).
In fact, researchers have been saying for years — more than a decade — that clinicians must consider co-morbid PTSD when assessing and treating ADHD, and that treating one helps ameliorate symptoms of the other (Ford & Connor, 2009).
Dr. Dodson recommends guanfacine and clonidine to treat RSD. These are non-stimulant medications, initially developed to treat high blood pressure, but commonly used to treat ADHD as part of adjunct therapy, or on their own for people who do not tolerate or respond well to stimulants.
In my personal experience, these medications do not work well for my son or myself as we already have low blood pressure. I have found, however, that as our ADHD and anxiety are well managed with other treatments, our RSD symptoms have also improved.
Interestingly, some medications used to treat ADHD and anxiety have also been found effective for treating symptoms of PTSD (Jeffreys et al., 2012).
Awareness is an important starting point for addressing mental health challenges. If I am constantly pulling our hair out wondering, “Why do I do this to myself?!” with no understanding or insight, there isn’t much I can do to ameliorate my situation.
When I have a deeper knowledge and understanding of what I’m up against, then I can explore my options and find what works best for me.
“To pathologize a very human response to all this trauma with a label like Rejection Sensitive Dysphoria is yet another way the medical system attempts to call us disordered while evading any social criticism.” — Jesse Meadows
Adler, L. A., Kunz, M., Chua, H. C., Rotrosen, J., & Resnick, S. G. (2004). Attention-Deficit/Hyperactivity Disorder in adult patients with Posttraumatic stress disorder (PTSD): Is ADHD a vulnerability factor? Journal of Attention Disorders, 8(1), 11–16. https://doi.org/10.1177/108705470400800102
Andrade, B. F., Waschbusch, D. A., Doucet, A., King, S., MacKinnon, M., McGrath, P. J., Stewart, S. H., & Corkum, P. (2012). Social Information Processing of Positive and Negative Hypothetical Events in Children With ADHD and Conduct Problems and Controls. Journal of Attention Disorders, 16(6), 491–504. https://doi.org/10.1177/1087054711401346
Babinski, D.E., Kujawa, A., Kessel, E.M. et al. (2019). Sensitivity to Peer Feedback in Young Adolescents with Symptoms of ADHD: Examination of Neurophysiological and Self-Report Measures. Journal of Abnormal Child Psychology, 47, 605–617. https://doi.org/10.1007/s10802-018-0470-2
Barkley, Russell A. (2015). Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis & Treatment. The Guilford Press.
Bondü, Rebecca & Esser, Günter. (2015). Justice and rejection sensitivity in children and adolescents with ADHD symptoms. European Child & Adolescent Psychiatry, 24, 185–198.
Cook, J., Knight, E., Hume, I. et al. (2014). The self-esteem of adults diagnosed with attention-deficit/hyperactivity disorder (ADHD): a systematic review of the literature. ADHD Attention Deficit Hyperactive Disorders, 6, 249–268. https://doi.org/10.1007/s12402-014-0133-2
Ford, J.D., Connor, D.F. (2009). ADHD and posttraumatic stress disorder. Current Attention Disorders Reports 1, 60–66. https://doi.org/10.1007/s12618-009-0009-0
Halleland, Helene Barone; Haavik, Jan; Lundervold, Astri J. (2012). Set-Shifting in Adults with ADHD. Journal of the International Neuropsychological Society, 18(4), 728–37.
Hoza, B. (2007). Peer Functioning in Children With ADHD, Journal of Pediatric Psychology, 32(6), 655–663. https://doi.org/10.1093/jpepsy/jsm024
Jeffreys, M., Capehart, B., & Friedman, M. (2012). Pharmacotherapy for posttraumatic stress disorder: Review with clinical applications. Journal of rehabilitation research and development. 49(5), 703–16. https://doi.org/10.1682/JRRD.2011.09.0183
Jellinek, M. (2010). Don’t Let ADHD Crush Children’s Self-Esteem. Clinical Psychiatry News. https://mdedge.com/psychiatry/article/23971/pediatrics/dont-let-adhd-crush-childrens-self-esteem.
Mazzone, L., Postorino, V., Reale, L., Guarnera, M., Mannino, V., Armado, M., Fatta, L., De Peppo, L., & Vicari, S. (2013). Self-esteem evaluation in children and adolescents suffering from ADHD. Clinical Practice and Epidemiology in Mental Health, 9, 96–102.
McDonald, K.L., Bowker, J.C., Rubin, K.H. et al. (2010). Interactions Between Rejection Sensitivity and Supportive Relationships in the Prediction of Adolescents’ Internalizing Difficulties. Journal of Youth and Adolescence 39, 563–574. https://doi.org/10.1007/s10964-010-9519-4
Sobanski, E., Banaschewski, T., Asherson, P., Buitelaar, J., Chen, W., Franke, B…. Faraone, S.V. (2010). Emotional lability in children and adolescents with attention deficit/hyperactivity disorder (ADHD): clinical correlates and familial prevalence. Journal of Child Psychology and Psychiatry, 51, 915–923. https://doi.org/10.1111/j.1469-7610.2010.02217
Sprafkin, J., Gadow, K. D., Weiss, M. D., Schneider, J., & Nolan, E. E. (2007). Psychiatric Comorbidity in ADHD Symptom Subtypes in Clinic and Community Adults. Journal of Attention Disorders, 11(2), 114–124. https://doi.org/10.1177/1087054707299402
Wiener, J., Mak, M. (2009). Peer victimization in children with Attention-Deficit/Hyperactivity Disorder. Psychology in the Schools, 46(2), 116–131.