If you’ve heard the comment, “You're so sensitive!” as an accusation a few too many times in your life, consider this question, posed by Dr. William Dodson: Throughout your entire life, have you always been much more sensitive (compared to other people) to rejection, criticism, teasing, or even your own perception that you have failed or fallen short?
If you answered no, lucky you! Read no further!
However, if you read that question and answered, YES (or it reminds you of someone you love), read on!
Dr. Dodson asks that question to help determine if someone may have rejection sensitive dysphoria (RSD). RSD is not a diagnosis on its own but is thought to be a trait experienced by some people with ADHD. RSD is a triggered, wordless emotional pain that occurs after a real or perceived loss of approval, love, or respect. This is not typical rejection sensitivity but is a profound physiological reaction to perceived judgment or criticism. As Dr. Dodson explains, this is an overwhelming emotional experience that feels unbearable and that is extremely hard for people to describe.
Here are some common questions about RSD:
What are the triggers for an RSD episode?
RSD triggers include any perception of criticism or judgment, and people with RSD can perceive criticism or judgment very easily, including in neutral comments, teasing, or negative feedback (even when well-intentioned). They can also be triggered by a sense of falling short of other people’s expectations (real or imagined) or their own high standards for themselves. I suspect that RSDers can even have a strong reaction to episodes of not receiving positive feedback when they hoped for or expected it, and also when others in their life do well and they feel that, by comparison, they don’t measure up.
What is the experience of RSD?
There are two parts to the RSD experience. First, there is the painful initial response to the trigger. People who have RSD often find it hard to describe this intense experience, but many liken it to physical pain, like feeling wounded, their heart pounding, a whooshing sound in their ears, being lightheaded, or feeling like they might just explode from the pain. These bodily reactions suggest that they are experiencing an altered physiological state, similar to being in fight or flight.
While this state comes on instantly, with no warning at all, it sometimes takes hours to subside. This is the second part of the experience: People with RSD can get stuck in a ruminative loop, unable to snap out of it, no matter how badly they want to. During this time, the RSDer can come across as irritable, angry, and/or withdrawn. Any attempts to get them to move on are typically unsuccessful and can escalate their already intense reaction (and if you can easily talk them out of this, then it’s likely not RSD).
Dr. Dodson has explained that there is a profound loneliness to this part of the experience, “as if I’ve been cast outside the realm of other people, completely isolated.” He adds, “It is as if their participation in the world around them just grinds to a halt until the episode has run its course.” When RSDers are in this state (which, again, sometimes lasts for hours), it’s extremely difficult for them to communicate about what they are experiencing and almost impossible for others to connect with them.
Once the RSDer is triggered, they feel almost powerless to stop either part of the experience. Once triggered, they often spend significant energy trying to look as if nothing is going on. Afterwards they may feel mortified and/or remorseful.
What are the long-term consequences of having RSD?
There are both social and emotional consequences to having RSD. During an RSD episode, the individual often behaves in ways that can be quite off-putting to others. They may be verbally aggressive, they may burst into tears, and/or they may completely shut down and become unreachable and uncommunicative. Other people don’t (and really can’t) understand why this normally reasonable person suddenly (and seemingly for no reason) refuses to engage or communicate. People regularly see them as too sensitive, over-reactive, and unable to just get over it. If this happens repeatedly over time, relationships are strained and — ironically — often end with rejection. Thus, there can be a pattern of repeated social rejection over time.
(It is also important to note that there is an impact on the parents, partners, and friends of people with RSD, as they are constantly on alert to avoid triggering an episode and can also feel confusion or resentment about how they are sometimes treated.)
Emotionally, RSD episodes are experienced as “unbearably painful,” and over time, these individuals often experience chronic invalidation and embarrassment, which are then internalized as shame and self-blame. They can become socially anxious (for good reason, as interaction after interaction goes horribly awry. They may become hypervigilant to criticism or rejection — noticing it more — and their self-esteem can suffer as well.
Between the emotional pain and the social fallout, living with RSD can be one of the most severely challenging and impairing aspects of ADHD, even more than inattention or poor impulse control.
What diagnoses are relevant to or may be confused with RSD?
ADHD: As noted above, RSD is thought to be a trait of ADHD, though not all ADHDers experience it.
Autism: I have seen some people with RSD have such significant and persistent social problems that they can appear to be autistic. Some of them may actually be autistic, in addition to their ADHD, but many are not. The overlap with autism may include difficulty coping with interpersonal conflict, difficulty maintaining relationships, periods of withdrawal, and social anxiety. Common features may also include inflexibility, particularly when they are in an RSD episode, and sensory hyper-responsivity (which is common in ADHDers). However, a non-autistic RSDer is not expected to experience confusion or overwhelm in regard to social interactions (outside of RSD episodes), difficulty reading nonverbal cues, repetitive/idiosyncratic behavior, a high need for sameness, literal interpretation of language, or restricted interests. While they may experience sensory hyper-responsivity, in my experience they are less likely to experience unusual sensory craving.
Depression: Some RSDers also appear to be depressed. As with autism, these can (and often do) co-occur. Areas of overlap may include irritability, sadness, withdrawal, and having a negative interpretation of events. However, RSD is different from a mood disorder in that it is episodic in nature. In between episodes, the RSDer can experience a positive mood, enjoy preferred activities, eat and sleep well, etc. They may only experience significant irritability and withdrawal during RSD episodes, in response to specific RSD triggers. In contrast, people who are depressed generally experience their symptoms fairly consistently over time, and not necessarily in response to specific triggers. Additionally, with a mood disorder, mood shifts (positive or negative) tend to be gradual over time (weeks to months), while RSD mood shifts tend to be very rapid (seconds at the onset of an episode and hours for it to resolve).
Borderline personality disorder: I agree with Dr. Dodson’s observation that some people with RSD will be misunderstood as borderline, and it’s also possible that being RSD can contribute to development of this personality disorder, which is characterized in part by interpersonal sensitivity.
Is there research about RSD?
RSD is very hard to research for a few reasons. First, it comes and goes seemingly without warning, so it is challenging to make it happen on demand in order to study it. Second, RSDers tend to hide their reactions from others, because there is so much shame around being “overly sensitive.” Even when they do try to describe it, people with RSD find the experience extremely challenging to put into words. RSD reactions are likely often perceived by others as part of ADHD emotional dysregulation, which they are, but once they are lumped in with other types of strong emotions, RSD episodes become harder to research. Finally, it could be challenging to measure either the initial RSD reaction or the follow-up period of irritability/withdrawal, making it hard to research.
Is there a positive side to RSD?
While RSD can be painfully hard to live with, Dr. Ned Hallowell, a well-known ADHD expert, observes that, like all aspects of ADHD, RSD also has a positive side, namely, that these individuals can thrive on recognition and encouragement. Dr. Hallowell refers to this as recognition responsive euphoria (RRE). He points out that people with RSD have strong responses to rejection but have equally strong responses to recognition and encouragement. He also notes that they are resilient (because they have to be). Additionally, my friend and colleague, Dr. Sarah Wayland, has theorized that RSDers can make very good friends, because they are highly sensitive to the reactions of others and genuinely want to make others feel good.
How do people try to cope with RSD?
RSD is present from birth, so it affects a child throughout their development and ultimately can affect the way they interact with others. For instance, some people with RSD become very anxious and highly conflict avoidant people pleasers. Others simply give up, stop trying, and remain withdrawn, never fully leaning into their lives for fear of rejection or failure. Still others become highly perfectionistic super-producers, striving to make themselves above judgment or reproach.
What are recommendations for someone who has RSD?
RSD is a physiological response, which suggests that medication may be at least as helpful as therapy, if not more so. I have not found any research on this, but Dr. Dodson has observed that alpha agonists such as guanfacine or clonidine can be quite helpful for about 60% of people with RSD. This is not surprising, as these medications are commonly prescribed for ADHD, and RSD is an aspect of emotional dysregulation in ADHDers. Dr. Dodson has stated that RSDers describe the experience of taking an alpha agonist medication as one of “putting on emotional armor.” Dr. Dodson has also found that MAOIs can be tremendously effective in about 85% of people with RSD. However, MAOIs (which were the original antidepressants, before the advent of Prozac) require significant dietary restrictions and regular lab work, so they are not great options for everyone.
In addition to considering medication, it can be helpful to:
Name it to tame it. Naming something is extremely powerful. When we name something, we put it outside of ourselves which makes it easier to stop blaming and shaming ourselves. Start by explaining RSD to the individual, so they understand that their nervous system has a physiological reaction (and not that they have a character defect). This alone can be life changing.
Educate others. Provide education about RSD to everyone who lives with, works with, loves, or otherwise supports the individual. This includes parents, siblings, partners, teachers, and healthcare professionals, to name a few. Depending on the RSDers’ age, they should consider self-disclosing to friends and others who may observe an episode (or otherwise be affected).
Befriend your nervous system. I love this phrase by author Deb Dana. Befriending your nervous system includes understanding your body’s reactions and also nurturing your nervous system to help it learn how to come back to “rest and digest” after an episode. It is incredibly important to find ways to experience “rest and digest,” such as movement (any movement that feels good to you), being in nature, co-regulating with other mammals (human or otherwise), listening to music, or meditating.
Engage in psychotherapy. CBT and DBT techniques may not be helpful to stop an RSD episode, because these episodes happen instantaneously - way too quickly to change one’s thinking in the moment (which is why I encourage a focus on the body more than thoughts at those times – more on that below). However, therapy can help one learn about, understand, and process this experience, and it can be a safe place to work through any related shame, grief, and other reactions. Finally, a therapist may be able to help determine who should be aware of the RSD, how to tell them, etc.
Surround yourself with positive people. Talk to the important people in your life and ask them to limit their teasing, negative feedback, or other remarks that trigger you. Let them know that you respond far better to encouragement than discouragement. If there is someone in your life who consistently triggers you, either limit your interactions with them (if possible) or seek help with the relationship.
Suggestions for when you are triggered:
Focus on the body. This is not easy, but it is possible. Strive to become aware of what it feels like in your body when you are triggered. Focusing on your body can buy you some time (even if only a few seconds) before you respond. Try to do a body scan. How fast is your heart rate? Your breathing? Is your jaw clenched? Your shoulders? Does your face feel flushed? Are you shaking? Dizzy? Remember, this is a physiological reaction, so you will feel it in your body. This will be far easier to do if you practice when you are not having an RSD reaction, even by doing one quick body scan at random times every day. Once you have scanned your body, you will be more able to be aware when you are in an RSD episode.
Stop. Once you know you are in an episode, if at all possible, STOP. Don’t let one word come out of your mouth. Do not text or email or call anyone involved in the situation. This is easier to do if you keep your focus on your body - Take a deep breath, open and close your hands, wiggle your shoulders – whatever you need to do to keep your attention on your body. This will help you get out of your head, even if only for a few seconds, which may be long enough to limit your external reaction.
Disengage. Do not engage when you are in this state! You know from past experience that it won’t end well. If possible, disengage from the situation until you have recovered. Find a reason to politely leave the situation if you can. Because the RSD episode can last for hours, you are likely to be highly irritable and you don’t want to say or do something you’ll later regret.
Disengaging from the loop. After being triggered, the episode needs to run its course, which likely includes being stuck in a negative thought loop. Your negative thoughts and emotions may be directed towards others or towards yourself. Either way, this is an unpleasant and unproductive state. To get out of this loop, you might try physically moving to a different location (even a different room in the same house, but ideally an entirely different location). It can also help to call someone you trust, engage in a favorite activity, play music, watch a TV show, or play a video game. Distraction can be incredibly helpful, as well as anything that calms down your nervous system, such as cuddling a pet, taking a walk, or being in nature.
Consider the trigger. After your nervous system has recovered from the episode, consider the triggering comment and determine if there is useful information there, either in the comment itself or in your interpretation of it. It may be most helpful to do this with someone you trust, such as a partner or a therapist.
Treat yourself with compassion. It may be helpful to separate your character from your behavior. Making a mistake, saying something you regret, being criticized, etc. are not the same as being a bad person. Treat yourself with the same compassion you would show to someone you love. You didn’t ask to have RSD and are doing the best you can!
If you are a family member of someone with RSD, it can be helpful to:
Limit teasing and any unnecessary negative feedback. When you do need to give feedback, choose your timing and your words very carefully. It can help to “sandwich” negative comments in between genuine positive ones.
Provide recognition and encouragement. As noted by Dr. Hallowell, RSDers are highly motivated by and responsive to recognition and encouragement from others.
Don’t take it personally. Recognize when your RSDer is in an episode, and don’t take their comments or their withdrawal personally.
Don’t bang your head against a wall. Some things just won’t work, so don’t waste your energy – and risk your relationship – by trying them. These include using threats, logic, rewards, punishment, or shame.
Try gentle humor. Sometimes, gentle cajoling, or a gentle invitation to return, in the context of a trusting relationship, can ease someone out of an RSD episode.
Provide unconditional love. Do not try to “toughen up” the RSDer in your life by repeatedly exposing them to teasing or criticism. Instead, accept them as they are. Remember, the individual does not choose to have RSD. It is a painful way to move through the world. Just like you, they are doing the best they can.
Podcasts
Taking Control: the ADHD Podcast, episode #405. Episode title: Rejection Sensitive Dysphoria: Dr. William Dodson Brings New Insight to Emotional Regulation.
Tilt Parenting, episode #310. Episode title: A Conversation with Dr. Norrine Russell about Rejection Sensitive Dysphoria (RSD) and ADHD.
ADHD Experts Podcast, episode #278. Episode title: The Flip Side of Rejection Sensitive Dysphoria: Tapping into ADHD Energy & Motivation with Edward Hallowell, M.D., and John J. Ratey, M.D.,
The Neurodivergent Nurse Podcast, February 26, 2021. Episode title: Six Reminders for Rejection Sensitive Dysphoria.
Attention Talk Radio, episode #215. Episode title: ADHD, Rejection Sensitive Dysphoria, and the Pink Elephant Paradox with Dr. Sharon Saline.
ADHD Focus, May 24, 2021. Episode title: Rejection Sensitivity [sic] Dysphoria in ADHD with Bill Dodson.
Online resources
