ADHD Awareness Month – A Look Into Rejection Sensitive Dysphoria (what?)

Katy examines something that is a serious problem (a cause of much unhappiness) in the ADHD community. Probably.

Take it away Katy!

LGF

The definition, science and controversy of Rejection Sensitive Dysphoria and ADHD

This is a long post so please feel free to scroll down to the headings that most interest you. You don’t need to read it all to understand each section.

Rejection sensitivity. It’s a hot button topic in online ADHD circles these days. Go to any ADHD forum or peer support page and you’re likely to find some mention of it, whether it’s a “does anybody else feel like this?” post or a link to an article about how common rejection sensitivity is for people with ADHD. However, it’s also a controversial topic with mixed scientific support.

“Huh? What’s rejection sensitivity?”

For the uninitiated, here’s a brief explanation of what rejection sensitivity is. Social rejection, the feeling that somebody has lost respect for you or that their opinion of you has gone down in some way, is unpleasant for anyone. But some people have a tougher time dealing with rejection than others. Rejection sensitive people are more likely to expect that others will reject them, interpret other people’s actions as rejection even if they’re not, and often have extreme emotional reactions to it. [1]

Here’s an example scenario. A rejection sensitive person sends a text asking their best friend if they want to hang out this weekend. 3 seconds after they hit send, they start convincing themselves that their friend will probably say no because they hate them, which there is no convincing proof of (expecting rejection). When their friend doesn’t respond for 5 entire minutes they are hit by a crushing despair that they are clearly hated by everyone and have no real friends (perceiving rejection, sometimes based on shaky evidence). While they are in the midst of crying and making plans to move to a remote deserted island where they can never be hurt again (intense emotional over-reaction to rejection), their phone buzzes. The friend responds “Sure I’d love to hang out, let’s do Saturday!”

If this is a common kind of experience for you then you might be rejection sensitive. I know I certainly have been. I’ve ruined friendships in the past by cutting people out of my life who I assumed hated me, despite no real evidence of that being the case and no need to react with such extremes. It’s even worse when the rejection is real. Folk with ADHD seem to experience these feelings an awful lot, leading some to argue it’s “an ADHD thing”.

“Wait – is this a symptom of ADHD?? Or just one of those things the internet says is a symptom of ADHD when it really isn’t?”

Yes and no. Until recent years this wasn’t nearly as much of a talking point. Enter American psychiatrist Dr William Dodson. In around 2017, Dodson wrote an article for ADDitude where he calls it “rejection sensitive dysphoria” (RSD) and claims it’s a core symptom of ADHD [2]. I’ve seen his articles about RSD linked in so many places. Since then Google searches for “RSD ADHD” have steadily increased as more and more people feel they can relate, want to find out more, and want help. Everywhere you look in online ADHD-land people are talking about their experiences of RSD.

Google search trends for “RSD ADHD”.

Dodson certainly appears to be right about the sheer amount of adults with ADHD who seem to be struggling with it. And having a label like RSD to unite under can be an amazing way to feel less alone with your struggles. At last, a name for the issues I’ve been having!

“Sounds great that people are finally talking about this. Surely there’s no way people on the internet or qualified clinicians could find a way to ruin it. Right..?”

Despite almost everyone and their dog saying that RSD is a huge part of their ADHD, the use of the term RSD does attract some criticism. For those like me who like to scroll down to the “controversies” section of Wikipedia pages, this is for you. Disclaimer: my previous points still stand – it’s incredibly useful as a way to find other people who’ve experienced similar things, and I’m in absolutely no position to say it isn’t real. Hell, RSD has been a horrible problem for me that I can imagine being related to my ADHD. But there are some things you should be aware of when using the term in regular conversation. Some of these criticisms are not entirely unwarranted.

Firstly, RSD appears nowhere in the diagnostic criteria for ADHD. Not in the DSM-5 or the ICD. The term RSD has pretty much no meaning in scientific research on ADHD. Even the broader concept of rejection sensitivity isn’t really a huge thing in ADHD research (probably because they’re too busy researching medications and behavioural therapies that can make us less of a burden on society, rather than treatments for things that primarily impact our quality of life and mental health, but that’s a rant for another day).

This all means that in many cases, if you walk into a psychiatrist appointment and talk about RSD then you may as well be telling the psychiatrist that you’re a Pisces. They won’t be likely to take it seriously as a core feature of ADHD. Well, unless the psychiatrist you’re seeing is William Dodson, who popularised it in the first place. In reality, when you use that term while talking to a doctor, their first thought often seems to be “wow, this person has read a lot of stuff online about ADHD that has no scientific backing. What else have they read?”

There is some reason to be sceptical about whether we can trust Dodson’s claims. After all, Dodson is a private clinician who claims he can help people with RSD in his clinic – in fact, he’s pretty much the only one who claims this so publicly. Always be cautious believing anyone who has a financial incentive to convince you about anything.

Some of the ADHD community is openly wary of RSD. One of the biggest ADHD forums, r/ADHD, has an automatic response message for anyone who mentions it. They urge caution and mention the lack of credible research, and even call it “popular science”.

Another criticism is that RSD is not unique to ADHD. That’s also partly true – rejection sensitivity can be found in the diagnostic criteria for other things like borderline personality disorder, social anxiety disorder, bulimia, substance abuse disorder etc. I won’t go too much into this argument here, other than to say I think the rejection sensitivity people with ADHD experiences is probably very different from the other kinds, and to note that misdiagnosis/comorbidity with those other disorders are fairly common.

“So what DOES the science say about rejection sensitivity and ADHD?”

Well, I’ve read quite a few peer-reviewed papers on it. Spoiler: the link is most definitely A Thing. None of it mentions RSD by name but refers to it more generally as rejection sensitivity. There is recent evidence that some ADHD specialists should probably be taking a little more seriously. Here’s a summary of some interesting psychological findings you might like to know.

Theories about different types of rejection sensitivity

Psychologists have come up with two main types of rejection sensitive reactions – anxious and angry. [3] Researchers recently suggested a third component of RS which is expectation, or the tendency to expect rejection before it’s actually happened. [4]

Initial findings from those studies suggest that expectation could be related to low self-esteem. Anxious-type reactions can make people socially withdrawn and depressed, whereas angry-type reactions can lead to conflict and even aggression. In other words, expecting rejection before it happens might be its own separate issue from the ways you emotionally react to it when it does happen.

The conceptual difference between components of rejection sensitivity is important – they might lead to different consequences, have different causes and require different treatments. This is a relatively early-days idea in the world of psychology and needs more research.

Evidence of teenagers with ADHD experiencing more rejection sensitivity than those without ADHD

A 2015 study with a respectable sample of 1,235 found that 10-19 year olds with ADHD had higher rejection sensitivity than non-ADHD controls. Anxious rejection emotions contributed to feelings of depression and low self-esteem, whereas angry rejection emotions contributed to conduct problems. [5]

Could this mean that some of the depression, low-self esteem and “bad behaviour” that’s often associated with ADHD is actually triggered by feelings of rejection sensitivity?

Rejection sensitivity as a part of emotional dysregulation in ADHD

A slightly smaller 2017 study with 161 participants found that “sensitivity to criticism” could be a core feature of the emotional dysregulation of ADHD, and the authors argue for emotional dysregulation in general to be included in future revisions of the DSM criteria for ADHD. [8] That’s backed up by a 2020 study, where young adults were more likely to be rejection sensitive if they also found it difficult to manage their emotions in general. [6] But it’s important to remember that everyone is different – some people with ADHD have difficulties with different emotions, e.g. excitement vs. sadness, and some people experience more emotional dysregulation than others. [7] So it can’t be claimed that rejection sensitivity is a universal ADHD experience.

Differences in the ADHD brain related to rejection sensitivity

Rejection sensitivity might be linked to neural differences in the ADHD brain. 10-15 year olds with ADHD symptoms may not only be more likely to experience rejection sensitivity, but there may be actual differences in the brain which cause it, according to a study published in 2019. [9] 391 participants, which is not too bad for a neurological study. A much smaller study in 2005 studied the brains of twenty one 8-12 year olds. The findings suggest that ADHD causes differences in the reward pathways in the brain, causing people with ADHD to be more emotionally sensitive to criticism and failure. [10] Small samples aren’t that uncommon in brain studies because they’re super expensive to run.

Evidence AGAINST a link between ADHD and rejection sensitivity

A 2007 study commonly cited by sceptics of RSD is that by Canu & Carlson. They found no differences in rejection sensitivity levels between college students with and without ADHD. [11] However, there are reasons to take these findings with a pinch of salt. Firstly, they only had 78 participants, only 25 as control. Secondly, they only studied men. Some researchers have found that girls/women with ADHD tend to be more likely to experience emotional dysregulation. [12] If rejection sensitivity could be considered part of emotional dysregulation [8], then isn’t it to be expected that fewer men with ADHD experience it?

Qualitative evidence

Although many psychologists (wrongly) take interview findings less seriously than surveys and correlations, researchers have noted adults with ADHD talking about their intense fears of failure and the anxiety it could cause – even when the researchers weren’t specifically asking about that. [13] My own qualitative research, unpublished as yet, found that women with ADHD could recall instances where their high sensitivity to rejection and failure caused them great social and emotional difficulties.

So what now? Is rejection sensitivity a symptom of ADHD or not? If there’s all this evidence then why aren’t doctors taking it seriously? Should I stop using the term RSD?”

I’m not here to police anyone’s language on this. I’ve laid out the basic arguments. I’m of the opinion that it’s a big part of the disorder that needs more attention. Please feel free to check any of the sources, you may even come to different conclusions than me. And it’s extremely likely that I’ve missed out some crucial research. After all, most of what I’ve read is about children and adolescents since that’s what my masters dissertation was about. But it really does seem like rejection sensitivity is a big contributor to many of the social and mental health problems that people with ADHD experience.

As for why it isn’t taken as seriously by doctors as it is by the ADHD community… in my opinion it’s because our wellbeing is not a priority for them like it is for us. Researchers and clinicians want to keep us out of prison, make us easier for parents/teachers/employers to manage, make us contribute more to society, make us more outwardly successful. They are typically less concerned with our anxiety and self-esteem. A lack of interest also leads to a lack of funding for vital research in the area. If I propose a study about how rejection sensitivity causes people with ADHD to have fewer friends, and another person proposes a study about how a certain ADHD medication reduces anti-social crime, you can guess which one is going to get prioritised for the scant available funding.

TL;DR: Scientific evidence suggests a link between ADHD and rejection sensitivity. Be cautious about what you read online about RSD and its treatments. But don’t stop talking about it. Maybe one day the diagnostic criteria and research priorities will catch up.

Katy Bartzis

Sources:

(tip – if any are behind a paywall, try googling the title – the PDF may be legally accessible for free elsewhere)

[1] Downey, G. & Feldman, S. I. 1996. Implications of rejection sensitivity for intimate relationships. Journal of Personality and Social Psychology, 70(6), 1372-1343. https://doi.org/10.1037/0022-3514.70.6.1327

[2] Dodson, W. 2017. New insights into rejection sensitive dysphoria. ADDitude. https://www.additudemag.com/rejection-sensitive-dysphoria-adhd-emotional-dysregulation/

[3] Downey, G., Lebolt, A., Rincón, C., & Freitas, A. L. (1998). Rejection sensitivity and children’s interpersonal difficulties. Child Development, 69(4), 1074-1091. https://doi.org/10.1111/j.1467-8624.1998.tb06161.x

[4] Preti, E., Casini, E., Richetin, J., De Panfilis, C., & Fontana, A. (2020). Cognitive and Emotional Components of Rejection Sensitivity: Independent Contributions to Adolescent Self- and Interpersonal Functioning. Assessment, 27(6), 1230-1241. https://doi.org/10.1177/1073191118817866

[5] Bondü, R., & Esser, G. (2015). Justice and rejection sensitivity in children and adolescents with ADHD symptoms. European Child & Adolescent Psychiatry, 24(2), 185-198. https://doi.org/10.1007/s00787-014-0560-9

[6] Wu, Q., Ran, G., & Zhang, Q. (2020). Rejection sensitivity and trait anxiety: The indirect effects of regulatory emotional self-efficacy and shyness. Current Psychology. https://doi.org/10.1007/s12144-020-01070-y

[7] Bunford, N., Evans, S. W., & Wymbs, F. (2015). ADHD and emotion dysregulation among children and adolescents. Clinical Child and Family Psychology Review, 18, 185-217. https://doi.org/10.1007/s10567-015-0187-5

[8] Adler, L. A., Faraone, S. V., Spencer, T. J., Berglund, P., Alperin, S., & Kessler, R. C. (2017). The structure of adult ADHD. International Journal of Methods in Psychiatric Research, 26(1), e1555. https://doi.org/10.1002/mpr.1555

[9] Babinski, D. E., Kujawa, A., Kessel, E. M., Arfer, K. B., & Klein, D. N. (2019). Sensitivity to peer feedback in young adolescents with symptoms of ADHD: Examination of neurophysiological and self-report measures. Journal of Abnormal Child Psychology, 47(4), 605-617. https://doi.org/10.1007/s10802-018-0470-2

[10] van Meel, C. S., Oosterlaan, J., Heslenfeld, D. J., & Sergeant, J. A. (2005). Telling good from bad news: ADHD differentially affects processing of positive and negative feedback during guessing. Neuropsychologia, 43(13), 1946-1954. https://doi.org/10.1016/j.neuropsychologia.2005.03.018

[11] Canu, W. H., & Carlson, C. L. (2007). Rejection sensitivity and social outcomes of young adult men with ADHD. Journal of Attention Disorders, 10(3), 261-275. https://doi.org/10.1177/1087054706288106

[12] Mowlem, F., Agnew-Blais, J., Taylor, E., & Asherson, P. (2019). Do different factors influence whether girls versus boys meet ADHD diagnostic criteria? Sex differences among children with high ADHD symptoms. Psychiatry Research, 272, 765-773. https://doi.org/10.1016/j.psychres.2018.12.128

[13] Levkovich, I., & Elyoseph, Z. (2020). College students with ADHD and their reasons for becoming teachers despite negative childhood experiences [Article]. Asia-Pacific Journal of Teacher Education, 1-16. https://doi.org/10.1080/1359866X.2020.1789912

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admin, Dave, David, planetdave, le grande fromage (LGF) - it's all me. I was diagnosed with ADHD in 2006 and usually take medication. My path to diagnosis was so painful that I swore I'd do whatever I could to make things better for other ADHDers.
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