Rejection Sensitive Dysphoria (RSD)

What is Rejection Sensitive Dysphoria (RSD)?

Rejection sensitive dysphoria (RSD) is characterized by extreme emotional pain associated with criticism, failure, or a perceived or real sense of rejection. While it is not yet a formal diagnosis, the term is gaining traction in the mental health world and is highly linked to people with attention-deficit/hyperactivity disorder (ADHD). 

In general, people want to be liked by others, and the fear of rejection is a real human fear. This fear is amplified in people with rejection sensitive dysphoria as they experience a downward spiral of emotions when they feel rejected by others, even if the rejection is a one-sided perception. They struggle to cope with perceived rejection or criticism from others, often engaging in prolonged rumination that prevents them from moving forward with their day.

In general, rejection sensitive dysphoria is characterized by the following:

• Intense emotional response (overwhelming shame, guilt, sadness, anger, etc.) to rejection or criticism.
• Having trouble differentiating between real and perceived rejection.
• Low self-esteem and trouble within interpersonal relationships.

One of the challenges of rejection-sensitive dysphoria is that the perceived rejection is often not actual rejection. Something as subtle as a change in someone’s tone or an unanswered text message can trigger an intense, interpretation-based emotional response.

In reality, the other person may have simply forgotten to check their phone or spoken curtly because they were stressed; circumstances that have nothing to do with rejecting someone. As a result, the emotional response is often disproportionate to the situation and reflects the perceived meaning of the interaction rather than what objectively occurred.

Common Symptoms and Signs Of RSD

Symptoms can widely range in people with RSD, as this disorder manifests in many different ways depending on how an individual processes their emotions and responds to perceived and real rejection.

Internalized RSD symptoms include the following:

• Overthinking and ruminating about the rejection and criticism
• Experiencing feelings of worthlessness, sadness, shame, and guilt
• Avoiding activities and responsibilities out of fear of rejection
• Self-isolating
• Having low self-esteem
• Engaging in “people pleasing” behaviors out of fear of being rejected

Externalized RSD symptoms include the following:

• Displaying sudden emotional outbursts
• Blaming others for fear of rejection
• Experiencing mood swings that go from anger to sadness
• Feeling rage and wanting to lash out because they think others are against them
• Having difficulty calming down after an outburst
• Having trouble with relationships due to emotional outbursts
• Having defensive and aggressive reactions to criticism and rejection

Physical symptoms can be seen in people who internalize and externalize their reactions and include the following:

• Headaches, neck and back tension, and gastrointestinal issues in reaction to emotional stress
• Fatigue and exhaustion due to emotional stress
• Problems with eating and sleeping
• Difficulty concentrating due to emotional stress

What Causes Rejection Sensitive Dysphoria?

Like many mental health conditions, there is not one specific cause for rejection sensitive dysphoria, but rather this condition is multifactorial, stemming from a combination of genetic, environmental, and neurological factors.

In people with RSD, it is believed that the brain has difficulty processing emotions due to an overactive amygdala, the brain’s emotional processing center. RSD is also strongly linked to an overactive hypothalamic-pituitary-adrenal (HPA) axis, which acts as your body’s central stress-response system. In people with RSD, the HPA is highly sensitive to stressors and overreacts to minor triggers, flooding the nervous system with the stress hormone cortisol.

Because RSD is closely linked with ADHD, and ADHD is highly hereditary, it is believed that genetics plays a role in the development of RSD.

Environmental factors, specifically adverse childhood experiences, can shape children’s emotional lability and their processing of stress and emotions as they enter adulthood.

Additional RSD risk factors include:

• Growing up with perfectionist standards
• Being bullied
• Experiencing extreme or continued rejection in childhood
• Having a dysfunctional attachment to parental figures

Is RSD A Recognized Medical Diagnosis in the DSM-5?

Although the Diagnostic and Statistical Manual of Disorders (DSM-5) does not recognize RSD, the DSM does recognize emotional dysregulation as an associated feature of ADHD.

Emotional dysregulation is seen in RSD when the brain cannot regulate or process emotional signals, leaving a person feeling overwhelmed and uncomfortable.

How is Rejection Sensitive Dysphoria Diagnosed?

RSD is not a recognized psychiatric or medical condition, and because of this, there are no formal diagnostic criteria.

Because of its emerging symptoms and the lack of diagnostic criteria, it may be mistaken for other disorders such as social anxiety disorder or borderline personality disorder. Professionals who are aware of this disorder are more likely to recognize it in people with ADHD who are experiencing intense emotions as a result of rejection or criticism.

Rejection Sensitivity Vs. Other Mental Health Conditions

Rejection sensitivity shares a lot of similarities with other mental health disorders. Individuals with RSD may be misdiagnosed with disorders such as social anxiety disorder, bipolar disorder, or borderline personality disorder. Although there is some overlap with these disorders, there are key differences that are important to distinguish.

RSD Vs. Social Anxiety Disorder

Social anxiety disorder is characterized by feelings of anxiety and stress before engaging in any type of social interaction, whether it be a small group of close friends, public speaking, or being in an elevator full of strangers.

People with social anxiety often experience excessive worry about embarrassing themselves or making a mistake in front of others. In anticipation of this anxiety, they may go to great lengths to avoid social situations altogether. These fears are typically most pronounced in interactions with strangers or acquaintances rather than with close friends or familiar individuals.

The emotional experience for someone with social anxiety disorder is marked by worry, anxiety, and perfectionism, and is centered around the anticipation of being around people and how these people will judge them.

People with RSD have intense guilt, anger, and shame that can manifest in physical symptoms that occur after a perceived or real event. The emotional anguish occurs after they have interacted with a person, often triggered by a tone of voice, text message, or facial expression that feels like rejection.

People with RSD feel even more shame when they feel these perceived threats from people close to them, rather than strangers, as feeling rejected by a loved one can trigger immense feelings of shame and guilt.

RSD Vs. Bipolar Disorder

Bipolar disorder is a mood disorder that is marked by feelings of depression and mania that occur regardless of life events. Manic episodes marked by periods of depressive episodes occur due to internal neurochemistry. In contrast, people with RSD experience emotional reactivity to external triggers.

Another main difference is the timing of symptoms. People with bipolar disorder may have symptoms of depression that last for weeks, marked by a brief period of mania or vice versa, whereas symptoms of RSD are very instantaneous and severe, but they dissipate quickly.

Both disorders are marked by emotional dysregulation, outbursts, irritability, isolation, and impulsive behaviors that are out of proportion to the perceived trigger.

RSD Vs. Borderline Personality Disorder (BPD)

Borderline personality disorder is characterized by a chronic, deeply ingrained fear of abandonment that leads to behaviors such as manipulation, self-harm, and any behaviors to prevent another person from leaving. People with borderline personality disorder have unstable identity patterns, regardless of whether triggers are present or absent, and experience chronic feelings of emptiness.

RSD is centered around outbursts and feelings of shame that are triggered by people and social cues, but once these triggers are gone, people with RSD have a stable sense of identity, and they quickly return to baseline.

Treatment Options for Managing RSD

Treatment options for rejection sensitivity dysphoria include psychotherapy approaches such as cognitive-behavioral therapy (CBT) and dialectical behavioral therapy (DBT).

CBT helps identify and challenge irrational thoughts related to RSD and reframes these unhealthy thought patterns into constructive, healthy perspectives and behaviors.

DBT helps to regulate emotions and interpersonal effectiveness.

Although there are no medications that are FDA-approved to treat RSD, medications have been shown to be helpful, especially if the person is also diagnosed with ADHD.

Medications that have been shown to improve symptoms of RSD include alpha-2 receptor agonists and stimulants. Alpha-2 receptor agonists such as clonidine and guanfacine work on neurons to help regulate emotional responses. Stimulants, such as Adderall or Ritalin, increase levels of neurotransmitters like dopamine and norepinephrine, which can help regulate intense emotions in response to perceived rejection.

Coping Strategies for Living with RSD

People living with RSD have a very difficult time navigating interpersonal relationships, especially romantic relationships and professional relationships in the workplace.

Fortunately, there are a few steps you can take to help navigate these scenarios while keeping a healthy mindset:

Recognize your triggers: Many situations that seem minor to others can trigger an intense emotional reaction in individuals with RSD. Common triggers may include a supervisor’s tone of voice, unanswered text messages from a partner, or constructive criticism from coworkers. Identifying your personal triggers is an important first step toward developing effective strategies to manage your emotional responses.

Ask clarifying questions: Innocent remarks can often be misinterpreted, leading to heightened emotions and feelings of rejection. Instead of trying to interpret what an email or text meant or what your co-worker or boyfriend said, ask specific questions so they can clarify what they mean. Usually, the intent is innocent, so asking specific questions can help prevent your emotions from spiraling.

Engage in self-regulation and mindfulness techniques: If you begin to feel triggered, you can take specific steps to try to dissipate these intense emotions.

• Take a breath or practice box breathing for 1 minute.
• Observe what you are feeling and take mental notes of your physical symptoms.
• Step away from the situation by going for a walk, listening to music, or doing whatever you can to pull back and see the big picture.
• Be kind to yourself.

Although rejection sensitive dysphoria can have a significant impact on daily life, it is treatable. If you think you may be experiencing its symptoms, reach out to a mental health professional or your healthcare provider. Early support and effective coping strategies can make a meaningful difference.