New Insights Into Rejection Sensitive Dysphoria

What Is Rejection Sensitive Dysphoria?

Rejection sensitive dysphoria is not a formal diagnosis, but rather one of the most common and disruptive manifestations of emotional dysregulation — a common but under-researched and oft-misunderstood symptom of ADHD, particularly in adults. Rejection sensitive dysphoria is a brain-based symptom that is likely an innate feature of ADHD. Though the experience of rejection sensitive dysphoria can be painful and even traumatic, RSD is not thought to be caused by trauma.

Dysphoria is the Greek word meaning unbearable; its use emphasizes the severe physical and emotional pain suffered by people with RSD when they encounter real or perceived rejection, criticism, or teasing. The emotional intensity of RSD is described by my patients as a wound. The response is well beyond all proportion to the nature of the event that triggered it.

One-third of my adult patients report that RSD was the most impairing aspect of their personal experience of ADHD, in part because they never found any effective ways to manage or cope with the pain.

What Triggers Rejection Sensitive Dysphoria?

Sometimes called hysteroid dysphoria in Europe, rejection sensitive dysphoria is characterized by intense mood shifts triggered by a distinct episode, typically one of the following:

• rejection (the real or perceived withdrawal of love, approval, or respect)
• teasing
• criticism, no matter how constructive
• persistent self-criticism or negative self-talk prompted by a real or perceived failure

The new mood sweeps in immediately and it matches the individual’s perception of the trigger. If these triggered emotions are internalized, the person can instantaneously appear as if they have a full Major Mood Disorder syndrome complete with suicidal thinking. If the feelings are externalized, they are commonly expressed as a rage at the person or situation that wounded them so severely. The moods return to normal very quickly so that a person with ADHD can have multiple episodes of mood dysregulation in a single day.

[Self-Test: Rejection Sensitive Dysphoria in Adults]

Many people with RSD say it’s always been a part of their lives, however some report growing significantly more sensitive in adolescence.

What Are the Outward Signs of Rejection Sensitive Dysphoria?

Individuals suffering from rejection sensitive dysphoria may exhibit the following behaviors:

• Sudden emotional outbursts following real or perceived criticism or rejection
• Withdrawal from social situations
• Negative self-talk and thoughts of self-harm
• Avoidance of social settings in which they might fail or be criticized (for this reason, RSD is often hard to distinguish from Social Anxiety Disorder)
• Low self-esteem and poor self-perception
• Constant harsh and negative self-talk that leads them to become “their own worst enemy”
• Rumination and perseveration
• Relationship problems, especially feeling constantly attacked and responding defensively

What Does Rejection Sensitive Dysphoria Feel Like?

The excruciating pain of RSD is often beyond description. Patients describe the intensity of RSD as “awful,” “terrible,” “catastrophic,” or “devastating,” but they cannot verbalize the quality of the emotional experience.

[Watch This: The Emotional Dysregulation of ADHD]

No one likes to be rejected, criticized, or to be seen as a failure. It is unpleasant, so people avoid those situations if they can. RSD is distinguished by its extreme, unbearable intensity, which sets it apart from normal emotional responses familiar to people who are neurotypical.

This intense pain is often experienced as a physical “wound;” the patient feels as if they were stabbed or punched in the chest. Commonly, people will hunch over, grimace, and clutch their chests when they describe their RSD experience.

How Is Rejection Sensitive Dysphoria Different from a Mood Disorder?

RSD is characterized by intense but short-lived emotional pain triggered by a distinct event of real or perceived rejection, criticism, or teasing. Mood disorders, on the other hand, are characterized by the following:

In other words, the moods of ADHD and RSD are normal in every way except their intensity.

Is Rejection Sensitive Dysphoria a Symptom of ADHD?

Rejection sensitive dysphoria is not included in the DSM-5 for attention deficit hyperactivity disorder (ADHD or ADD); it is not a formal symptom of ADHD in the United States, however emotional dysregulation is one of the six fundamental features used to diagnose ADHD in the European Union.

It’s widely understood that the diagnostic criteria for ADHD in the DSM-5 only fit well with elementary school age children (6-12) and have never been validated in a group of people over the age of 16.¹ They are based on only observational or behavioral criteria that can be seen and counted. The traditional diagnostic criteria intentionally avoid symptoms associated with emotion, thinking styles, relationships, sleeping, etc. because these features are hard to quantify. For clinicians who work with later adolescents and adults, the DSM-V criteria are almost useless because they ignore so much which is vital to understanding how people with an ADHD nervous system experience their lives.

When people started writing and researching the concepts of RSD and emotional dysregulation about 5 years ago, this new awareness of the emotional component of ADHD was enthusiastically accepted by patients and their families because they matched their life experiences so exactly. The reception from clinicians and many researchers, however, was decidedly cool. Many professionals did not fully grasp that the emotional component of ADHD had always been there but intentionally not pursued. It appeared to them that the concept had no real and historical basis. What’s more, there was very little published research just 5 years ago and most studies came from the European Union, which used the term emotional dysregulation (ED), not RSD.²

These obstacles to recognizing RSD/ED as a major and defining characteristic of adult ADHD and to using medications to offer some relief from the disruptions and pain of this feature of ADHD are being rapidly addressed. There has been a rapid increase in available research in a very short period of time.³ The redefinition of adult ADHD in the EU — adding emotional self-regulation as a fundamental part of the criteria for the diagnosis of ADHD — has furher assured that RSD/ED is really “a thing” that cannot be ignored any longer.

Still, there are at least three reasons why emotional dysregulation or RSD may never be included in the diagnostic criteria for ADHD, no matter how prevalent:

1. RSD/ED are not always present. It comes in triggered episodes.
2. People with RSD/ED are usually ashamed of their over-reactions and hide them so that they will not be further embarrassed and thought of as mentally or emotionally unstable
3. Even when RSD/ED is present, it can’t be measured, and, therefore, can’t get published in research.

As a consequence, emotional dysregulation was consciously excluded from the diagnostic criteria for ADHD and effectively forgotten for many years. Over the last decade, researchers have developed several new ways of looking at ADHD through the lifecycle. By the end of 2019, this re-evaluation of the very fundamental aspects of ADHD led the European Union to issue its 10-year update of the Consensus Guidelines on Adult ADHD⁴, which redefined adolescent and adult ADHD to include difficulty with emotional regulation as one of only six fundamental features in the ADHD syndrome:

1. inattention and hyperfocus
2. impulsivity
3. hyperactivity
4. emotional dysregulation
5. excessive mind wandering
6. behavioral self-regulation (which they equated with executive function deficits)

Although the EU has chosen the more inclusive term of emotional dysregulation (ED) instead of RSD, the concepts are fundamentally the same. Emotional dysregulation is described as:

“The type of emotional dysregulation seen in ADHD has been characterized as deficient self-regulation of emotional symptoms such as irritability, frustration and anger and low frustration tolerance, temper outbursts, emotional impulsivity, and mood lability.⁵ Emotional dysregulation in ADHD is different from episodic symptoms such as marked sustained irritability occurring within the context of altered mood states, such as an episode of extreme sadness or mania. In ADHD, emotional symptoms tend to reflect short-lived exaggerated changes, often in response to daily events, with rapid return to baseline within a few hours”.⁶

Is Rejection Sensitive Dysphoria a New Concept?

Rejection sensitive dysphoria and emotional dysregulation are old concepts associated with ADHD that are gaining new exposure in research and clinical settings. Dr. Paul Wender, who spent four decades conducting the pioneering studies on ADHD beginning in the 1960s, was the first to recognize emotional dysregulation as a persistent, prevalent, and highly impairing component of what we now call ADHD.

The most recent contribution to this new thinking about the mood regulation component of ADHD comes from Dr. Fred Reimherr, one of the founding fathers of ADHD who established the current childhood criteria for ADHD along with Wender more than 50 years ago (the original criteria for what we now call ADHD were originally called the Wender-Reimherr Criteria). His recent replication⁷ of his study of the validity of each diagnostic criterion has led him to now conceptualize ADHD as being divided into only two subtypes: the well-known inattentive type and an emotional dysregulation type.

This is a huge change in thinking. A feature of ADHD that was ignored for 50 years now is rapidly becoming one of the defining features of the syndrome in both the European Union and North America.

In 2019, Faraone published “Emotional dysregulation in attention deficit hyperactivity disorder – implications for clinical recognition and interventions” in the Journal of Child Psychology and Psychiatry.⁸ It states that there is “solid theoretical rational” for emotional impulsivity and deficient emotional self-regulation “as core symptoms of ADHD.”

How is Rejection Sensitive Dysphoria Treated?

Although the alpha agonist medications, guanfacine and clonidine, have been FDA-approved for the treatment of ADHD for decades, they were not directly associated with the terms of rejection sensitivity and emotional dysregulation for all of the reasons noted above. Nonetheless, it has been my clinical experience and the experience of others that the symptoms of RSD/ED can be significantly relieved with clonidine and guanfacine in about 60% of adolescents and adults. To me, this observation strongly indicates that RSD is neurological and not something that is due to a lack of skills. Skills do not come in pill form.

There currently exists no formal research on using alpha agonist medications to treat symptoms of RSD or ED on patients with ADHD.

If a patient benefits from an alpha agonist medication, they describe the new experience as one of “putting on emotional armor.” They still see the same things happening that would have emotionally devastated them last week, but now on medication they just watch these triggers fly past them “without being wounded.” Often people report that, with time, they come to realize that this armor is not needed after all “because I came to see that the arrows I was protected from were not arrows to begin with.” They are very clear, however, that they would never have developed this emotional control unless they had had some initial protection from the pain of RSD.

If a patient does not benefit from medication, they have little control over an episode of RSD once it begins. The incidents have to run their course. Some people with ADHD, however, report that getting interested in something new and fascinating can help to end an RSD episode more quickly than it would otherwise. In my clinical experience, neither coaching nor traditional psychological or behavioral therapies — like CBT or DBT — offer any prevention or relief from impairments. Nonetheless, many people report that it is very helpful for them to know that this highly disruptive experience is real, common, and shared by other people with ADHD. “It helps me to know what is happening to me and that it is ultimately going to end.”

Rejection Sensitive Dysphoria: Next Steps

• Read: ADHD, Women, and the Danger of Emotional Withdrawal
• Download: Understanding ADHD and Rejection Sensitive Dysphoria
• Understand: How to Distinguish ADHD’s Rejection Sensitive Dysphoria from Other Disorders

References

¹ Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder. AACAP Official Action. (2007). Journal of the American Academy of Child and Adolescent Psychiatry. 46 (7):894-921. This article is in the public domain and can be accessed at
http://www.aacap.org/galleries/PracticeParameters/JAACAP_ADHD_2007.pdf

² Kooij Sandra JJ, et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BioMedCentral – Psychiatry (2010), 10:67. Pages 1-24. http://www.biomedcentral.com/1471-244X/10/67

³ Graham J, Banaschewski T, Buitelaar J, Coghill D, Danckaerts M, Dittmann RW, et al. European guidelines on managing adverse effects of medication for ADHD. European Child and Adolescent Psychiatry (2011) 20:17–37. DOI 10.1007/s00787-010-0140-6

⁴ Kooij J.J.S., Bijlenga D, Salerno L, Jaeschke R, Bitter I, Balázs J, Thome J, Dom G, Kasper S, Nunes C, Filipe S.Stes. Mohr P, Leppämäki S, Casas M, Bobes J, Mccarthy JM, V.Richarte, Philipsen AK, et al. Updated European Consensus Statement on diagnosis and treatment of adult ADHD. (2019) European Psychiatry 56: 14–34. http://dx.doi.org/10.1016/j.eurpsy.2018.11.001

⁵ Skirrow C, Asherson P. Emotional lability, comorbidity and impairment in adults with attention-deficit hyperactivity disorder. Journal of Affective Disorders, (2013);147 (1-3):80–6. https://pubmed.ncbi.nlm.nih.gov/23218897/

⁶ Surman CB, Biederman J, Spencer T, Miller CA, McDermott KM, Faraone SV. Understanding deficient emotional self-regulation in adults with attention deficit hyperactivity disorder: a controlled study. Attention Deficit Hyperactivity Disorders2013;5(3):273–81. https://pubmed.ncbi.nlm.nih.gov/23413201/

⁷ Reimherr FW, Roesler M, Marchant BK, et al, Types of adult Attention Deficit/Hyperactivity Disorder: A Replication Analysis. (2020) Journal of Clinical Psychiatry 81 (2) e1-e7.

⁸ Faraone SV, Rostain A, Blader J, et al. Practitioner Review: Emotional dysregulation in attention deficit hyperactivity disorder – implications for clinical recognition and interventions. Journal of Child Psychology and Psychiatry (2019) 60(2): 133-150.

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