Rejection Sensitive Dysphoria in ADHD: Meaning, Symptoms, and Treatment

Rejection sensitive dysphoria is something that many people with ADHD and autism experience which involves a strong feeling of emotional pain being inflicted on someone after they feel like they have been rejected or criticised. It can, however, also be experienced by the general population and those who don’t have ADHD or autism. In this blog, we will look at the symptoms, definition and treatment strategies for rejection sensitive dysphoria. A comprehensive and very interesting research paper to read on this topic is called ‘Rejection Sensitivity Dysphoria in Attention-Deficit/Hyperactivity Disorder: A Case Series’ Dodson et al. (2024). We refer to this paper in this blog.

Rejection sensitive dysphoria in ADHD symptoms

Rejection sensitive dysphoria is nicely and comprehensively defined by Dodson et al. (2024) when they said it starts with “perceived rejection, demonstrating rejection sensitivity, that progresses into a nearly instantaneous dysphoric mood, which causes significant distress and impairment”. It is a phenomenon commonly experienced by those with ADHD whereby perceived rejection can become detrimental to their mental health. Their study found that it may be triggered by a perceived ‘rejection’ that others don’t even notice, and that it may be triggered by teasing, criticism, or rejection. They also noted that a key feature of RSD is that the shift in mood after experiencing this rejection is instantaneous, not gradual.

Everyone who experiences rejection sensitive dysphoria has a unique experience of it, and how it affects them. However, here are a few common symptoms that they are likely to feel:

• Feeling of instant isolation upon the perceived rejection.

• Extreme mental pain, and can sometimes be felt in the body. This pain has been reported as being very difficult to describe.

• Inability to supress emotions upon feeling rejected.

• Actively avoiding rejection from others, doing whatever they can to not be rejected by people. This may include becoming perfectionists, so that there is very little to criticise.

• Feeling embarrassed about how they felt and acted when they were in the episode after it is over.

Rejection sensitive dysphoria causes

One reason why many people with ADHD experience rejection sensitive dysphoria is because of the emotional dysregulation associated with ADHD. Someone who has emotional dysregulation often struggles to manage their emotions and responses. It commonly applies to more intense emotions, whereby a person can’t rationalise or tone down a strong emotion, and therefore they feel it in a large intensity. It is commonly described as emotions going from 0-100 very quickly and taking a while to come back down. This makes sense why people with ADHD who experience emotional dysregulation, have difficulties managing feelings of rejection – and why their ability to manage and tone down that feeling (based on if it is significant) is impaired. It can cause people to spiral upon feeling rejected, which is what rejection sensitive dysphoria is.

This is further reinforced by the fact that from childhood, people with ADHD may have displayed atypical limbic system development (Connaughton et al., 2023). One of the limbic system’s primary functions is emotion and feelings processing. This atypical development of an area of the brain vital for forming emotions in those with ADHD provides reasoning of why they respond so emotionally differently when faced with rejection, from someone without rejection sensitive dysphoria.

For the same reasons as those above, people with autism are much more likely to experience rejection sensitive dysphoria. They too often struggle with emotion dysregulation which can alter the way they respond to certain stimuli.

Furthermore, rejection sensitive dysphoria can also be found in people who don’t have ADHD or autism. It can occur in people who are a part of marginalised communities in today’s societies, or just people who receive a larger than average amount of criticism regularly. For example, someone from the LGBTQ+ community who has faced not being accepted, or someone who struggles in school and constantly gets negative feedback. Having received this form of rejection can make people much more sensitive to rejection in the future, thus developing into rejection sensitive dysphoria. This could also apply to those with ADHD and/or autism, as another reason why they are more likely to experience this as it has been researched that they receive more criticism in comparison to those who don’t have ADHD or autism. The study by Beaton et al. (2022) researched this and focused on those with ADHD, they also found that they actively avoided criticism which ties into the symptoms we discussed earlier.

Treatment for Rejection sensitive dysphoria

As we have discussed, one of the major reasons behind why rejection sensitive dysphoria occurs is due to the person’s difficulties effectively managing and regulating their emotions – in this case, rejection. Therefore the treatments we focus on in this part will be looking at how to overcome this.

Managing your impulsivity

Impulsivity is a quick and initial reaction to a stimulus. Upon perceiving rejection, someone’s impulsive nature may kick in and cause their brain to spiral without intervention of rationality which would otherwise force them to rethink the real significance and likelihood of this ‘rejection’. This impulsivity happens subconsciously and is not regulated and can cause them to behave in a certain way depending on how it immediately makes them feel. Managing this impulsivity gives your brain a second to rethink and re-evaluate if you are interpreting the situation correctly, without impulsively acting and ruminating based on your initial feelings. You can do this by purposely and consciously taking a pause upon feeling rejected or criticised. Don’t act on anything, instead, notice what you are feeling in your body and notice what thoughts are running through your mind. You can use any strategy to give yourself this pause before acting, such as breathing and counting to 10, or writing a note on your phone about how you're feeling. With a moment's pause to reflect, you can begin to assess the situation - was that really a rejection you faced, or have you misinterpreted it? What is a constructive way forwards? Will you be concerned about this in an hour, or a day, or a week or a month? Is it something that needs action? From here, you can make a plan without acting on impulse.

Mindfulness

People who face emotion dysregulation often go from 0 to 100 when faced with a situation that involves rejection. In order to slow down your brain when it comes to emotional reactions, try out mindfulness techniques, which involves paying attention to our body and our thoughts without judgement. For example, pay attention to where you feel the emotional pain in your body - where exactly is it? What does it feel like? How would you describe it - is it hot, cold, tense, heavy, light, big or small? What would you name it? What thoughts does it come with, and what sort of story are the thoughts telling? Mindfulness helps us to 'zoom out' of difficult thoughts and feelings, to notice them without judgement or reaction. This can be a powerful shift from them taking over in the moment. It does take practice and patience, so exploring ways to practice mindfulness is recommended.

Relaxation Techniques

When we experience strong emotions, our brain goes into fight/flight/freeze mode and essentially gears our body up for action, as if there's a tiger at the door. Rejection or criticism becomes a modern day tiger-like threat in rejection sensitive dysphoria. Relaxation techniques such as relaxed breathing whenever you get the chance, or in the situation you are feeling rejected, can be very helpful to reverse this. Square breathing is an effective technique to do this, and it involves breathing in for 4 seconds, holding it for 4 seconds, breathing out for 4 seconds, then holding that for 4 seconds. This helps to engage your parasympathetic nervous system which takes you out of the fight-or-flight mode that feeling rejected or criticised may put you in, and gives you the headspace to reinterpret the stimuli.

Therapy

If these techniques are not eliminating your tendency to be significantly affected by a sense of rejection, it is definitely worth seeking therapy. There are well researched and very effective forms of therapy out there for you to try, such as cognitive behavioural therapy, which aim to tackle the root cause of your mental health concern (such as rejection sensitive dysphoria). Through rewiring your patterns of thinking, feeling and behaving, therapy will help you think in a different way in about rejection all together. This means that in any new situation, you will be fully equipped to handle rejection or criticism yourself and will not fall into the negative spiral that you would have before.

In this blog, we have introduced the key themes of rejection sensitivity dysphoria. This includes what it is, the symptoms, the potential causes, and how to treat it. For more information on other aspects of ADHD, autism, anxiety and more, check out our other blogs!

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