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Most people automatically associate ADHD with hyperactivity, inattention, and impulsivity — all easily observed from the outside. However, for those who experience this disorder one of the most challenging aspects is invisible to the onlooker — a severe reaction to rejection.

The debilitating experience of rejection sensitive dysphoria

Nobody likes being rejected or falling short of expectations, but for those with ADHD, the response to these situations can be extreme.

Common to ADHD patients, rejection sensitive dysphoria (RSD) is intense sensitivity and emotional pain triggered by the perception — not necessarily the reality — of being rejected, teased, or criticized by those who are important to you.

Also triggered by a sense of falling short of one’s own standards or of others’ expectations, RSD is the most debilitating aspect for 30 percent of people with ADHD.

People with ADHD aren’t weak or “too sensitive” — their brains actually perceive these situations as more painful than others do, and their emotional response hurts them much more than for those without the condition. Some even experience it as physical pain in the region of the chest.

When coping with RSD, a person may internalize or externalize their reaction — and sometimes both:

Internalized RSD can manifest as a major mood disorder, with sudden shifts from feeling fine to feeling intensely sad, even to the point of suicidal ideation. Often misdiagnosed as rapid cycling bipolar disorder, this aspect of RSD is frequently missed by healthcare practitioners.

Externalized RSD may look like a flash of rage at the person or situation at the source of the pain. Possibly related, half of the people assigned court-ordered anger-management treatment have previously unrecognized ADHD.

Those who suffer from RSD tend to anticipate rejection and cope in one or both of these ways:

• Becoming antisocial to avoid the expected rejection. Even the slight possibility of falling short in front of others is too painful and risky to consider. Meanwhile, these smart, capable people give up on social life, applying for jobs, or public engagements because of the fear. This social withdrawal can look like social phobia, which is a serious fear of being embarrassed in public, but they are not the same thing.
• Becoming an avid people-pleaser in an attempt to prevent the situations that cause so much pain. They scan those they interact with to try to determine what will make them happy, then become that person in an effort to be accepted. Some do this at the expense of their true personality. Others cope by becoming overachievers, but the search for perfection is never satisfied, leading to more effort at achievement.

While RSD episodes are intense and don’t last very long, recovery can take some time.

Perceptions and self-fulfilling prophesies

RSD can affect relationships with friends, family, and romantic partners. The ongoing perception that you’re being rejected can turn into a self-fulfilling prophecy.

Perception is the key word: Someone with RSD might feel they are being rejected or criticized, but the situation may not really exist.

This is also known as a self-fulfilling prophecy: An individual believes something is true, acts as if it was true, anticipates a particular outcome, and this expectation changes their emotional behavior.

As a result, they set themselves up to receive the feedback they expect, which only reinforces the belief.

Do I have RSD?

Some RSD symptoms are shared with other mental health conditions leading it to be confused with:

• Bipolar disorder
• Depression
• Social phobia
• Borderline personality disorder
• Post-traumatic stress disorder (PTSD)
• Obsessive-compulsive disorder (OCD)

Because RSD can look like other disorders, it’s important to get a proper diagnosis so you can get treatment and learn the right coping skills. If you have ADHD and experience any of these symptoms, see your mental health provider:

• Feel easily embarrassed in social situations.
• Feel instant rage or have an emotional outburst when you think someone has teased, criticized, or rejected you.
• Feel anxious in social settings.
• Set overly-high standards for yourself that you often can’t meet.
• Have low self-esteem.
• Avoid social situations.
• Feel like a failure because you haven’t lived up to your own or others’ expectations.
• Think about hurting yourself.
• Constantly feel under pressure.
• Avoid trying new things due to fear of failure.
• In a constant state of panic in your relationships.
• Unbearable anxiety.
• Often feel depressed and alone.
• Feel constantly rejected by friends, family, or your partner.
• Generally good at hiding your sensitivities.

How do I manage rejection sensitivity?

Aside from getting a diagnosis, the following can help you cope with RSD:

Stay ahead of your emotions. If you feel an episode coming, try to process your emotions rationally. Realize your sense of perfectionism and let it go. Remember that what you perceive as the cause of the rejection may not actually exist.

Seek counseling. A mental health counselor can help you learn how to cope with the extreme reactions common to RSD. However, counseling isn’t considered the first treatment option, because the fast reactions caused by RSD are in the moment and they overwhelm the mind.

Reduce your stress factors. Stress over-taxes your nervous and endocrine systems, making it harder for you to cope with situations where your RSD may flare up. In functional neurology we can help create a comprehensive diet and lifestyle plan to reduce and manage your stress level.

There are two possible medication options for RSD:

Alpha-agonist medications. Originally designed as blood pressure medications, guanfacine and clonidine can help. While only 30 percent of people experience relief from either medication alone, 60 percent experience better benefits when both are used.

Successfully treated patients report feeling at peace, as if they have “emotional armor,” plus having fewer thoughts at one time.

Monoamine oxidase inhibitors (MAOI) used off-label (for a condition other than that for which it has been officially approved). Effective for both the emotional and attention/impulsivity components of ADHD, this is the traditional treatment of choice.

MAOIs are FDA-approved for mood and anxiety disorders, but patients must avoid the following:

• Foods that are aged instead of cooked
• First-line ADHD stimulants
• All antidepressant medications
• OTC cold, sinus, and hay fever medications
• OTC cough remedies
• Some forms of anesthesia

If you experience RSD, remember you aren’t alone: it is experienced by a surprising 98 to 99 percent of adolescents and adults with ADHD and 1 in 3 say it’s the hardest part of living with the condition.

For some people, just knowing that RSD is a common part of ADHD brings comfort. It’s not your fault, you are not damaged, and there are ways you can improve your reactions to these painful situations to live a full and healthy life.

In functional neurology we have a variety of non-pharmaceutical brain rehabilitation techniques customized to your unique neurology that can help you better manage your ADHD, RSD, and other related symptoms. Ask our office for more advice.