Rejection Sensitive Dysphoria: What You Need To Know
(Basically It's the Worst)
If you spend a decent amount of time online, particularly in the mental health or "self diagnosis" side of social media you've likely come across a term called Rejection sensitive dysphoria (RSD). This is something those of us who are neurodivergent, especially with ADHD, are prone to experiencing. RSD is an extreme emotional pain that's triggered when you believe you've been criticized or rejected by someone important in your life. It can also happen when you feel like you haven't met another's standards or expectations or when you fell short of an unrealistic goal or expectation you set for yourself. Most of the time this is something you perceive to be true and while there may be some truth to it, like you're having a disagreement with your partner about how you load the dishwasher, you perceive it to be much more critical than it actually is.
And while no one enjoys feeling like they're being criticized or rejected, or even failing to meet an expectation, people with RSD experience pain that can only be described as unbearable. An RSD episode is highly impairing to your daily life and restricts your ability to function. What is different about this kind of pain is it is internalized and an episode can come on so intensely they can look like a full blown mood disorder and for many, they include suicidal ideation. For those of us who experience this (yes, I have them!) they happen so quickly that you can go from feeling perfectly fine and normal to so intensely sad within minutes. If you are a clinician who has not experienced this for yourself you could diagnose this as a rapid cycling mood disorder based on presentation alone, which it isn't.
Why Does RSD Happen?
RSD is linked to differences in emotional regulation, particularly in people with ADHD. The brain’s sensitivity to social cues, combined with a strong desire for acceptance, makes rejection feel more painful than it might for others. Even when no actual rejection has occurred, a comment, a facial expression, or simply a delayed text response can feel devastating. Overall though, the medical community really isn't sure why it happens, they just know an overwhelming majority of adults with ADHD all report the same exact experience which is how this has come into existence. Research consistently and overwhelmingly links Rejection Sensitive Dysphoria and ADHD, with some researchers saying emotion dysregulation may be the core struggle within ADHD. Nearly all people with ADHD are thought to experience RSD. It is thought to most likely be attributed to how the frontal lobe of the ADHD brain works slightly differently and therefore processes social cues and regulates emotions differently than a non-ADHD brain. In addition to the brain's structure they also believe genetics may play a role because ADHD has such a high genetic link and RSD is linked to ADHD, but it's still unknown.
How Is RSD Diagnosed?
Unfortunately RSD isn’t a diagnosable medical condition just like "high functioning anxiety" isn't a diagnosis. Because of this there's little research and support around it. This is why I believe it's very important if you're neurodivergent to have a therapist or support professional who is also neurodivergent. America is behind the curve when it comes to recognizing emotional and mental health holistically and because of that those who do not fit into a diagnosis that can be found in the DSM-5 aren't left with many resources. Many of my clients who have experienced episodes of RSD their entire lives had no idea what it was and simply believed they were a totally unhinged and unstable person despite mounds of evidence to the contrary. It wasn't until we worked together long enough that I was able to pick up the pattern and educate them on RSD that they understood what was actually happening and we could plan for how to cope with these episodes moving forward. But if I didn't experience this myself, even as a very seasoned clinician this most likely would have been missed.
How RSD Shows Up in Everyday Life
• Self loathing
• Overanalyzing your behavior and how it was perceived
• Avoiding new opportunities or social activities for fear of failure or criticism
• Taking feedback personally even when it’s constructive
• Feeling deeply embarrassed or ashamed after a perceived social misstep or interaction
• Becoming defensive, isolating or shutting down in response to criticism
What Makes a RSD More Likely to Occur?
Not getting enough sleep
High levels of stress
Isolating from friends and family
Not engaging in your regular coping strategies
What is RSD Like?
I'm speaking from personal experience but if you ask anyone else who experiences this you will likely get a similar account. When it comes on the emotional tumble downward feels akin to living on top of a seacliff, going about your day to day life and generally feeling stable and well. You can't see it coming and every time this happens it seems like someone ran up and pushed you over. Before you realize what happened you're already tumbling down the side of the cliff, hitting every rock on the way down. The onset is alarmingly sudden and comes out of nowhere which to me is one of the most frustrating and maddening parts.
The experience is both physical and emotional. It starts in my chest and feels as if someone has collapsed it by stomping or stabbing it, taking my breath away. The physical pain is very real. I notice my body will literally hunch over and as if I'm guarding my chest or organs reflexively; it truly is the oddest thing. The pain travels upward, my throat tightens and the tears explode. The chest tightening continues and then nausea sets in. This happens on and off for hours. As a teenager I assumed I was overly sensitive and this was just another thing very wrong with me so I didn't share it with anyone. As I grew into adulthood this was a part of my emotional dysregulation and I chalked it up to something off with me and/or I assumed maybe other people went through this and just didn't talk about it.
I refer to these as "episodes" because after enough observation I've noticed they last on average from a few hours to a full day. The acute physical symptoms lessen in intensity after the first day and then depressive symptoms take over after that. Again this is my personal experience but anecdotally, this is a common depiction for most people who have RSD.
As the physical symptoms ease in intensity the emotional piece intensifies. The shame, self loathing, humiliation and criticizing takes over and sinks you into a depressive state. As a therapist this is where I think many clinicians who don't also experience this themselves understandably miss the mark on seeing what's happening because from the outside this absolutely looks like a major depressive episode. For the most part it checks all the boxes, including the scariest part which most of us don't want to talk about: suicidal ideation. The pain during one of these episodes is simply the worst but it is quite temporary.
What to Do When an RSD Episode Hits
Name it, tell yourself what's happening and know that you're in for a rocky few hours or possibly day
Tell someone who you trust and/or who is aware of this condition that you're having a hard time
Put yourself into what I call "low battery mode" until it passes
Nap, rest, downshift, cancel what you can from your day, etc.
Cry
Lean on your comforts and coping skills (i.e. cuddle your pets, go on a walk, watch your comfort show, listen to your favorite playlist, etc)
Journal or engage in a creative hobby that you like
Reach out to your therapist if you have one and let them know, particularly if you have suicidal ideation during an RSD episode
Continue to remind yourself this is an episode, it's temporary and it will pass
What Not to Do
Get on social media or post anything to social media
Drive if you can avoid it
Drink alcohol
Make any permanent or hard to undo decisions
Send heated texts or emails
Socialize if you don't have to
Break things or verbally lash out at others
Be around firearms
Continue to go back to the person who triggered you and ask for clarification or reassurance. This all will pass very soon and if you go back you will prolong this and it will make you feel even worse once you recover.
Are There Treatment Options?
Technically no, unfortunately. We do know that some SSRIs help because they block the reuptake of serotonin and that can help with emotional regulation. Treating and managing your ADHD also helps and both stimulants and non-stimulants may improve symptoms, but overall there is no medication prescribed for this. Knowing your triggers and taking care of yourself overall is the best treatment.
Knowing What This is MATTERS!
It's critical to know why this happens and to have a name for it. It's like a breath of fresh air to identify this and when it comes on, when you're pushed off the side of the cliff, you can recognize what's happening and buckle in for the ride instead of shaming yourself for feeling "unstable" or crazy. When you can educate your loved ones about what this is and how you experience it they can help you manage it and work through the aftermath. If you see yourself in these experiences please know that RSD is not a character flaw—it’s a neurological sensitivity. Many clients I work with don't talk about this because their "over-reactions" feel shameful and embarrassing, so their reflex is to hide it. But that only makes the RSD worse. With awareness and the right tools, you can lessen its impact and feel more in control of your emotional responses.
Here are some accounts of what this is like from ADDitude Magainze…
“The initial feeling is as if you’ve been punched in the head and are struggling to regain consciousness. You then deny that it is affecting you, but your brain goes blank, your body paralyzes and, as if by the force of a volcanic eruption, you plunge into an abyss of infernal pain and fear. That is only the beginning. Nothing derails the power of RSD.” – Anonymous
“Due to many real and perceived rejections in my life from friends, family and co-workers, I have become scared to start any new friendships or group activities. I no longer volunteer to do things at church as I struggle too much to remember to get the tasks done or to attend the meetings. My family helps me out by reminding me and forgiving me when I forget.” – Anonymous
“Any sidelong look or shared smirk between people in a group conversation feels like I’m being made fun of, and most corrective feedback feels like, ‘You are not good enough. This is how you have failed.’ I know intellectually that these worries are irrational, but the thought only occurs to me after I’ve already felt the emotional sting of perceived rejection. I feel like I’m walking on eggshells around new acquaintances because I’m constantly trying to figure out what they want.” – Anonymous
“It is humiliation, followed by self-berating, and I feel it as a nauseous anxiety in my stomach. I anticipate it all the time when I have to present ideas at work, and in social situations I tend not to express my thoughts or feelings.” – Wendy
“It feels like my heart drops into my stomach and I’m completely taken out of the moment.” – Anonymous
“When I am criticized for a simple mistake at work I become extremely emotional and cry. It has been so humiliating that I have quit jobs.” – Anonymous
“Every single time is like the very first time you got rejected as a child.” – Anonymous
“It’s a punch in the gut and a kick to the head while you are writhing on the ground. The parts of me that others miss I take care of by beating myself up for leaving myself vulnerable to them in the first place.” – Eric
Have you ever experienced this?
XO
Melissa
Thank you so much for writing about it. I definitely feel like this, but I also think my oldest son, who doesn't meet any of the classic markers for ADHD has it, to a tremendous degree. This is so well written Melissa, and puts the feeling into words so well.