Most people have a reasonably clear understanding of what ADHD is by now. We know it’s about more than little boys unable to stop bouncing in their seat so they can focus on schoolwork. We know it isn’t caused by poor parenting. We know there’s a genetic component, meaning if a parent has it, their child is more likely to have it.
ADHD manifests in a variety of ways — it often presents differently in girls and boys, and it has its positive aspects. My 15-year-old son has ADHD, and alongside it a fast-moving brain that, though it may not focus on prescribed tasks, can hyperfocus on really cool things at random, like solving Rubik’s cubes, learning about black holes, or teaching himself to play piano. Many people with ADHD, and their parents, will proudly tell you the list of accomplishments they’re pretty sure they wouldn’t have been able to achieve without ADHD.
One aspect of ADHD that’s only recently getting attention, though, is something called rejection sensitive dysphoria, or RSD. This is not a separate medical diagnosis — it is a specific set of symptoms that go hand-in-hand with ADHD.
What is Rejection Sensitive Dysphoria?
It’s not hard to guess what RSD is or why people with ADHD experience it. Its name — “rejection sensitive dysphoria” — says it all: A sense of dysphoria (intense discomfort) that arises from a sensitivity to rejection.
Years ago, I noticed that my son, who has ADHD, was being reprimanded and nagged many times more than his younger sister, who doesn’t have ADHD and also happens to be naturally compliant and a people pleaser. I noticed that my corrections of him, mainly when he was unmedicated, were unrelenting. I had become accustomed to constantly reprimanding him. I was trying so hard to “fix” his behavior and prepare him for “the real world” that I nearly missed what I was doing to him. I was hurting my child.
What does RSD look like?
Almost 100% of people with ADHD experience some form of RSD, which manifests as a strong reaction to a real or imagined rejection or slight. Just like ADHD, RSD doesn’t look the same for everyone.
For some people, RSD can look like an intense version of people-pleasing. Unlike my daughter, who can be an anxious perfectionist but who does not have ADHD, folks dealing with RSD may experience an intense desire to achieve perfection primarily because they are concerned about rejection.
They may fear that if they’re not good enough — if they can’t make straight A’s all the time, for example — then they will be liked less or rejected altogether by the people whose opinions matter to them. Eliza, a mom of three who lives in South Carolina, said she experienced this type of inward-turning RSD. Friends and family always told her to “stop being so sensitive” when she was younger. As an adult, she took an eagerly anticipated trip to meet work friends in a different state. She said it only took her four hours before a random comment left her certain that her coworkers hated her and thought she was “an idiot.” She later learned that this wasn’t the case at all, but in the moment she couldn’t convince herself. It had a huge impact on her ability to enjoy the trip — even though she never voiced her fears aloud.
For others, RSD can go in the opposite direction. It can manifest loudly or even violently. It can look like whining, “irrational” crying, flat-out rage, or like giving up — they may simply stop trying altogether. If a person with ADHD expresses their fear of rejection or acts “weird” as they attempt to manage their behaviors, it could even become a self-fulfilling prophecy. The person at whom the fear of rejection is directed ends up rejecting the sufferer after all.
That’s one reason why it’s important to be aware of this aspect of ADHD. That “quirky” behavior, that defiance, that outsized reaction you’re witnessing may have a good reason behind it. There is nothing wrong with people who have ADHD. Their brains work differently though, and we need to make space for that.
What RSD Isn’t
Because of how rapidly RSD can appear, and because it can appear so out of line with reality, RSD is frequently misdiagnosed as bipolar disorder, PTSD, OCD, depression, or even social phobia (intense fear of social interactions).
But RSD is none of these things. It’s part of ADHD, and it can come and go in varying degrees and appear differently for each person who has ADHD. One major difference between RSD and these other disorders is that RSD, though it can be intense, typically fades quickly (though the negative feeling can sometimes hang on for weeks or months, making a misdiagnosis even more likely).
When I look back over the years of learning to understand my son’s brain so I could better support him, I think with regret that it’s no wonder that most folks with ADHD experience RSD. People with ADHD already possess a nervous system that reacts more strongly to environmental stimuli. They tend to experience everything in a big way. And research has shown that by age 12, kids with ADHD receive up to 20,000 more negative messages about themselves than kids without ADHD. This is heartbreaking.
How To Avoid And Manage RSD
It took me years to get to a place where I understood how important it was for me to change my behavior even more than it was for my son to change his behavior. And in the intervening years, he heard a lot of criticism. He still hears more criticism than his sister, if I’m being honest, even though I’ve dramatically changed the way I interact with him since those early years. Thankfully, he’s well-adjusted and his self-esteem in a lot of ways is even better than a typical 15-year-old’s. He is confident and happy with who is.
Treatment is available for those who suffer from intense, repeated episodes of RSD. Doctors have found several medicines that can be used off-label to curb side effects (ask your doctor about these if you feel you or your child has reached this point). Traditional stimulant medications used to treat ADHD are often enough to curb incidents of RSD. That’s because when a person’s ADHD symptoms are managed, they’re less likely to receive that awful barrage of negative feedback from peers and adults. They’re also more likely to succeed at school or work and have an easier time relating to others when they’re not engaging in impulsive behaviors or inattention that can interfere in relationship-building. The latter has been true for my son.
We have learned so much about ADHD over the last few decades, and though ADHD has its good points, rejection sensitive dysphoria is one aspect of it that can be really frustrating. I hope learning about RSD can help people who may be suffering and not understand why, and I hope that those reading this who don’t have ADHD will find understanding that leads to compassion for those who do.