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  • Writer's pictureMelissa Shepard, MD

Rejection Sensitive Dysphoria: The link between ADHD and sensitivity to criticism.

Updated: Sep 19, 2023

Rejection Sensitive Dysphoria (RSD) refers to extreme sensitivity to perceived criticism or rejection.


RSD is not considered one of the diagnostic criteria for ADHD in the DSM-5. However, emotional dysregulation (a related term) is included as one of the six core features of ADHD according to EU diagnosis guidelines, and the link between ADHD and emotional difficulties has been well established. RSD is one of the ways that emotion dysregulation tends to show up in people with ADHD.


Research suggests that RSD is an underrecognized and important aspect of ADHD regardless of which diagnostic criteria or name we use for the symptoms. It can be a huge source of guilt, shame, and impairment for people with ADHD.




Why does RSD occur in ADHD?


We don't know for sure, but RSD in ADHD is probably the result of multiple factors.

ADHD is associated with impulse control difficulties and problems with self-regulation, which are essential factors in our ability to control emotions.


People with ADHD also tend to be more sensitive to any stimulation. This is part of the reason we get distracted so easily. Sights, sounds, and even bodily sensations may affect us more intensely than the average person, so they grab our attention more easily. Our sensitivity extends to our emotional world as well. We tend to feel our emotions (and the emotions of others) more intensely.


And finally, people with ADHD tend to face rejection and criticism more often than people who do not have ADHD. Especially during childhood, disruptive or challenging behaviors associated with symptoms of ADHD can elicit criticism from parents and teachers and rejection from peers. This can lead to decreased self-esteem and hypersensitivity to future rejection and criticism.


What does RSD look like?

People with RSD describe feeling extremely sensitive to perceived rejection or criticism.

Whenever someone with RSD thinks they are being rejected or criticized (even if there isn't any truth to that perception), they feel a rush of intense negative emotions like shame, anxiety, anger, and sadness. People with RSD may recognize that these emotional reactions are out of proportion, but they often feel powerless to control them.


These intense emotional reactions and fears of rejection or criticism may lead people with RSD to avoid social situations, engage in a lot of negative self-talk and self-criticism, have emotional outbursts, and respond to criticism defensively or passive-aggressively.

Because they are so scared to be rejected or criticized, those with RSD often become people-pleasers, constantly trying to pre-empt the disapproval of others. They may retreat and (reluctantly) avoid situations where they could face criticism or rejection. They may even subconsciously sabotage themselves so that they can have something to blame should they have to face criticism.


How can you tell the difference between RSD due to ADHD and other disorders?

It can be tough to distinguish RSD due to ADHD from other mental health issues. Many mental health conditions can overlap, and people with ADHD are at higher risk for mood and anxiety disorders that can look very similar to RSD. Here are some principles I use to tell these conditions apart:


First, someone with RSD due to ADHD will have other symptoms of ADHD, such as inattention, impulsivity, and hyperactivity (see my previous blog posts for more on these symptoms).


The timeline of symptoms is also important. ADHD is a neurodevelopmental disorder, meaning it is present throughout your life. Many other conditions that can produce RSD-like symptoms start later in life or may occur episodically. It's also important to note that the intense feelings that arise in RSD will usually happen only after a perceived criticism or rejection, and will resolve with hours to days. In contrast, the intense emotions that arise with anxious or depressive disorders may have no apparent trigger and tend to last for weeks, months, or even years.


RSD differs from anxiety disorders in that those with RSD don't tend to have as much "anticipatory anxiety," or anxiety that occurs before an event. Strong emotions like anxiety, anger, and shame tend to show up most intensely after someone with RSD feels rejected (not before). Those with anxiety disorders tend to be more preoccupied with their anxiety symptoms, whereas those with RSD tend to ruminate on the perceived criticism or rejection.


Borderline personality disorder (BPD) is another mental health condition commonly confused with RSD from ADHD. This is because a heightened sensitivity to rejection can also characterize BPD. Compared to those with ADHD, people with BPD are more likely to fear abandonment, have severe dissociative symptoms, engage in self-harm, and experience suicidal thoughts. Someone with BPD would also be less likely to have as much trouble with hyperactivity and inattention as someone with ADHD (although both can struggle with a lot of impulsivity).


Ultimately, though, it can be tricky to sort out these disorders, so it is always best to see a professional who can help you figure it out.






 


References and Further Reading:





Foxhall M, Hamilton-Giachritsis C, Button K. The link between rejection sensitivity and borderline personality disorder: A systematic review and meta-analysis. Br J Clin Psychol. 2019;58(3):289-326. doi:10.1111/bjc.12216


Shaw P, Stringaris A, Nigg J, Leibenluft E. Emotion dysregulation in attention deficit hyperactivity disorder. Am J Psychiatry. 2014;171(3):276-293. doi:10.1176/appi.ajp.2013.13070966


Surman, C.B.H., Biederman, J., Spencer, T. et al. Understanding deficient emotional self-regulation in adults with attention deficit hyperactivity disorder: a controlled study. ADHD Atten Def Hyp Disord. 5, 273–281 (2013). https://doi-org.proxy1.library.jhu.edu/10.1007/s12402-012-0100-8

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