Rejection Sensitive Dysphoria (RSD) and ADHD: Medications & Treatment

Rejection sensitive dysphoria (RSD) is the feeling of severe emotional pain from rejection, teasing and criticism. 

RSD is very common in people with neurodivergence, ADHD or having ADHD traits (also called VAST, Variable Attention Stimulus Trait), autism or being a highly sensitive person. Basically, Rejection Sensitive Dysphoria is part having more power feelings than others.

Having powerful feelings is amazing! We get very excited, even feeling euphoric about new ideas. This passion can lead us to pursue a project and our enthusiasm can be infectious.  

This feeling is the drive that pushes you to do things other people can only dream of.  We explore, we create, and we love deeply…..

But there is a flip side…

We can feel pain more deeply

Having a brain that is wired to respond powerfully to emotions, means that you may also experience rejection much more painfully. This is the flip side to the joy of euphoria.

Having these more powerful feelings associated with rejection and criticism is termed rejection sensitive dysphoria. Which is a very painful thing to experience.

This post will cover rejection sensitive dysphoria, how to manage it and cover the best treatment options (with references). And there are very good treatment options.

What is Rejection Sensitive Dysphoria?

Rejection sensitive dysphoria (RSD) is the term for experiencing severe emotional pain from rejection, teasing and criticism.  RSD can occur whether the rejection is real or is just perceived.  

This term was created by Dr. William Dodson, who has been an expert in adult ADHD for over 30 years. He discovered that when he asked, about 95% of his patients described experiencing the symptoms RSD but were often too ashamed to bring it up themselves.

While there is no current medical diagnosis for RSD, it is becoming more and more understood by the ADHD medical community. Rejection Sensitive Dysphoria is a subset of what is called Deficient Emotional Self-Regulation (DESR) although I prefer the term emotional hyperactivity.

Many also feel that the autistic brain experiences Rejection Sensitive Dysphoria and Deficient Emotional Self-Regulation too.

Woman with rejection sensitive dysphoria being comforted by her friend

Dysphoria is the Greek word for unbearable, which is exactly what sets RSD apart.  The feeling of rejection when someone has RSD is so strong that it can feel insufferable. It is not that the mood itself is unusual for the circumstances, it’s that the intensity of the emotion is so strong.

Essentially rejection sensitive dysphoria is a very raw and primitive pain.  People with RSD find that they cannot find the words to adequately describe how painful it is. Words like ‘traumatizing’, ‘catastrophic’ are commonly used. 

RSD – Rejection Sensitive Dysphoria

While this strong emotional pain of rejection has a specific name, some people have suggested that it is just a factor of having the type of mind that is highly sensitive to emotions. 

After all, rejection is one of the most painful things any human can experience.  Human beings evolved while living in cooperative societies, relying on social groups for safety and survival.

We are by our nature social beings, and our fundamental need to be accepted in our group is literally hardwired into our brains.  

Woman alone and upset

Having a strong need to be accepted was a mechanism for survival.  Before we lived in cities, we lived in small communities.

A human being living alone in the wild would not have been able to survive. Being ostracized from your community would have resulted in death.

Social acceptance was a life or death issue. So it makes sense that our brains are wired to feel rejection so strongly

And if the pain of rejection is the most painful emotion for anyone, it also makes sense that it would be unbearably painful for those who are more passionate emotionally.

What Triggers Rejection Sensitivity?

Rejection sensitive dysphoria is triggered by a specific episode, where someone feels rejection, either real or perceived. It can even be triggered just by thinking that you have been rejected.

The intense emotions of rejection sensitive dysphoria can be caused by:

  • Rejection, or the perception of rejection
  • Losing the respect of others
  • Feeling like no one likes you
  • Failing to live up to your own perfectionist standards
  • Feeling that you have disappointed people in your life
  • Being teased by others
  • Criticism

The difference between rejection sensitive dysphoria and depression is the quick onset and the intensity of the emotion.

RSD has a quick onset, specifically triggered by events and often has a quick resolution.  The mood experienced with RSD is similar to a normal mood, but it is much more intense.

What Does Rejection Sensitive Dysphoria Feel Like?

The emotions of rejection sensitive dysphoria come on suddenly when triggered. It is often described like a wave or a flooding of intense emotion

Rejection Sensitive Dysphoria may be internalized and may look like a person is depressed or anxious. Internalizing the emotions of RSD can manifest as:

  • Feelings of shame
  • Feelings of despair or hopelessness,
  • Intense mood shifts
  • Going over conversations in your head
  • Feeling anxious ahead of social outings
  • Withdrawing during social situations
  • Suicidal thoughts
Woman with internalized Rejection Sensitive Dysphoria

Or there may be externalized signs which can frightening or even dangerous to others. It may make a person look like a ‘basket case’. Externalizing can present as:

  • Outbursts of rage
  • Irrational anger
  • Meltdowns

How to Deal with Rejection Sensitive Dysphoria

Name it to tame it. The first step is to realize that you have RSD and are extra sensitive to rejection and criticism

There is nothing wrong with you, this is something hardwired into your brain.

This may not reduce the pain in the moment, but being aware will help you prepare for difficult encounters and help you manage your RSD. Knowing that there is a reason you have such difficulty can help you to be more gentle with yourself. 

Knowledge can help you to remember that painful feelings pass, even if it doesn’t feel like it at the moment.

Rejection Sensitive Dysphoria: Gain Conflict Skills

A therapist can help you gain skills to manage conversations that involve conflict. This will be particularly useful if this is not something that was modelled for you in your family. 

Since rejection sensitive dysphoria has a genetic predisposition, your upbringing may have involved a family where everyone avoided conflict. Growing up you were not taught normal skills in how to have difficult but respectful conversations.

Five people sitting in a circle for group support

If this sounds like your family, you may not even know what amount of conflict is normal in a relationship

Maybe you became the family mediator, constantly monitoring for conflict and putting out fires. This may have worked for everyone else. But it does not work so well for the mediator, as it involves putting everyone’s needs ahead of your own.

When you have RSD it is tempting to try to avoid any conflict, but this is not a long term strategy. Every relationship will have conflict, this is normal and it really is not possible to avoid it. Gaining skills will give you the confidence to confront an issue before it becomes overwhelming.

Rejection Sensitive Dysphoria: CBT or DBT

Our thoughts lead to feelings, and sometimes our thoughts can run away from us. A therapist can help you learn cognitive behaviour therapy (CBT) or dialectical behaviour therapy (DBT) skills.

These skills teach us to probe deeper into our thoughts and can help to deal with RSD.

A woman discussing a situation with her friend

You may still be knocked over by initial wave of emotion with RSD, but once that subsides these skills can help you ride the wave.

Consider what thoughts are causing these painful emotions. Take time to consider alternate possibilities for what you are finding hurtful.

Ask yourself ‘Is this really as catastrophic as it feels?‘.

Try to be curious about your feelings and what triggers them. This type of exercise not only helps in the moment but can reduce future occurrences as well.

Rejection Sensitive Dysphoria: Rest and Recharge Your Brain

Rejection Sensitive Dysphoria is a component of being dysregulated. There are many proven techniques to calm a dysregulated and overstimulated brain.

Sleep is incredibly important, so that needs to be prioritized.

But some simple Non-Sleep Deep Rest Protocols (as promoted by Dr. Andrew Huberman of the Huberman Lab) can really make a difference. 20 Minutes of Yoga Nidra, which is a calming body scan, or using self hypnosis can actually rewire your brain and help you deal with difficult emotions.

The Huberman Lab also covered science based supplements for brain health, which are shown to help with cognitive function, and might also help to manage RSD.

A woman lying down doing a NSDR Yoga Nidra protocol

Rejection Sensitive Dysphoria: Support and Advice

People with RSD often feel shame about their highly sensitive feelings. This can lead you to avoid others. It is important to seek out healthy connections with family and friends.

You are not alone in having these strong emotions. The advice of a trusted friend can offer insight and support.

Good friends or a counsellor can help you put things in perspective and support you through the pain.

A woman discussing rejection sensitive dysphoria with her therapist

By working through this experience you can make sure you have appropriate responses. You don’t want to lash out. It might feel good in the moment but it can cause you more pain later.

You also don’t want to become more people pleasing in an attempt to prevent future pain due to RSD. This may lead to your being accepted, but not on the terms you want.

Rejection Sensitive Dysphoria Medication: Pain Reliever?

Believe it or not, a simple pain reliever might actually help. Imaging of the brain has shown social rejection activates same regions in the brain involved in physical pain.

It turns out that a broken heart is not so different from a broken bone.

Based on this concept, a study in the journal Emotion showed that one tablet of acetaminophen (Tylenol) daily reduced the pain of social rejection.

Rejection Sensitive Dysphoria ADHD Medication

Dr. William Dodson, a widely respected expert in adult ADHD, has found that non stimulant medications helped the symptoms of RSD in many of his patients

He says many patients describe it this way:

Life changing, like putting on emotional armour!

Description of how guanfacine or clonidine helps RSD

They can still feel the painful emotions but they are not as wounding.

The two medications he has used are guanfacine and clonidine, alpha-agonists medications.

medication tablets for rejection sensitive dysphoria

Overall, he found that 60% of his patients responded to one of the medications!! 

In about 30% the first medication worked. For the 70% where it didn’t work, another 30% responded to the second options. He couldn’t really predict it ahead of time, he just had to try each one.

Some people have a response at first dose, but usually it takes a few days to tell if it works. You can read a transcript of Dr. Dodson discussing the treatment of RSD on an ADHD podcast here, speaking in a webinar here and many other places.

Using alpha-agonists for the treatment RSD is considered an ‘off label’ treatment. These are well known and safe medications that have been around for about 50 years.

They are FDA approved for treatment of ADHD in children. But getting approval for other indications is an expensive process, so it has not been done for adults.

If neither of these work, another option to treat RSD are Monoamine Oxidase Inhibitors (MAO medications). This is effective for 75% of people with RSD according to Dr. Dodson.

However MAO medications interact with a lot of other medications as well as certain foods, which requires diet restriction. The foods include aged cheese, meats, and fermented foods such as soy sauce or kombucha.

Rejection Sensitive Dysphoria ADHD Stimulant Medication

Emotional lability has been known to be a component of ADHD for decades, but was excluded from the DSM criteria. This exclusion has caused a lot of confusion, and likely misdiagnosis.

In Europe ’emotional dysregulation’ has been added a core feature of ADHD. There is an ongoing effort by experts to get emotions added to the DSM criteria for ADHD.

Artistic depiction of a woman with ADHD and emotional lability

If emotional lability is a core component of ADHD, it is likely that the medication that has the highest success rate in treating the other symptoms of ADHD, would also treat RSD (the most severe form of emotional lability). That medication would be stimulants.

And the weird thing is that because emotional symptoms fo ADHD is not in the DSM, doctors don’t know to ask if stimulants help emotional symptoms.

At follow-up they ask about distractedness or hyperactivity, even if it is actually ‘hyperactive emotions’ that is the worst symptom of your ADHD.

But a recent study looked at emotional dysregulation and treatment in adult patients with ADHD.

The author’s expert opinion is that emotional dysregulation is a very common and impairing problem in adult ADHD that can be treated with stimulants or atomoxetine.

Another interesting fact: stimulant medications can actually improve insomnia for some people with ADHD, and getting better sleep can help with managing RSD.

Dr Amen has a different way of classifying ADHD into 7 types, with one type ‘Limbic ADHD having a lot of emotional symptoms, and ‘Ring of Fire’ ADHD being the most intense type.

Rejection Sensitive Dysphoria: Seek Help if Needed

Certainly if you are interested in discussing if prescription medication, consult your physician. Medications can have side effects and your physician would be the best to decide if they are appropriate for you. 

Since RSD is often liked to ADHD, you may want to look at these medically validated assessment tools for adult ADHD, and read about the medical view of ADHD.

You may also want to seek help to sort out whether you are experiencing RSD or something more serious. If you are feeling self-harmful thoughts it is important to seek immediate help.

A woman seeing her physician for Rejection Sensitive Dysphoria

Rejection Sensitive Dysphoria: Self-Compassion

When you are someone who feels RSD, it is important to be compassionate with yourself. Accept that you will feel certain things in the moment. Be compassionate with yourself and your feelings.

If you have not done this already, write out a list of your best attributes. ADHD brains and VAST minds share a number very positive traits.

This will help you remember the complex and amazing person that you are. Everyone has difficult times, and this can help provide perspective.

Two friends enjoying a laugh

Rejection Sensitive Dysphoria: Summary

Rejection sensitive dysphoria is the name for the intense feeling of pain with rejection or criticism. It was originally developed to describe this symptom in adults with ADHD, but likely applies to adults with autism as well.

The emotional hyperactivity or lability of ADHD and autism has been overlooked for years. This is because the focus has been on externalizing symptoms (how we annoy others), not looking in at how people with neuroatypical brains experience and feel emotions.

Read more about this in how Dr. Dodson assesses an adult for ADHD.

Learning that what you are feeling is RSD is the first step to being able to understand and control it.

Managing and Treating RSD:

  • Understand RSD, what it is – Name it to Tame It!
  • Learn about your triggers
  • Realize that feelings, even when strong, will pass
  • Learn therapy techniques (CBT or DBT) to understand how emotions affect your thoughts
  • Rest and recharge your brain!
  • Learn conflict management skills
  • Get support and advice from trusted friends and family
  • Share to overcome shame (you are not alone!)
  • Pain medication (tylenol) may help
  • Guanfacine or clonidine can be ‘life changing’
  • Stimulant medications can help with emotional symptoms of ADHD
  • Seek immediate help if feeling self harm
  • Learn self-compassion skills
  • Realize that this is the other side of being able to get really excited and happy

Remember that ADHD/VAST minds feel things passionately, this isn’t a negative quality overall. It is part of our greatest strength.

Understanding and learning how to manage rejection sensitive dysphoria is a step to harnessing the full power of your ADHD/VAST mind.