Rejection Sensitive Dysphoria

How ADHD Ignites RSD: Meaning & Medication Solutions

Rejection sensitive dysphoria, or RSD, can mean extreme emotional sensitivity and emotional pain for people with ADHD or ADD — and it may imitate mood disorders with suicidal ideation and manifest as instantaneous rage at the person responsible for causing the pain. Learn more about ways to manage RSD here.

William Dodson, M.D.
By William Dodson, M.D., LF-APA Verified Medically reviewed by Sharon Saline, Psy.D. Reviewed on February 28, 2020
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RSD: Meaning & Impact on ADHD Adults

Rejection sensitive dysphoria (RSD) is extreme emotional sensitivity and pain triggered by the perception that a person has been rejected or criticized by important people in their life. It may also be triggered by a sense of falling short—failing to meet their own high standards or others’ expectations.

Dysphoria is Greek for “difficult to bear.” It’s not that people with attention deficit disorder (ADHD or ADD) are wimps, or weak; it’s that the emotional response hurts them much more than it does people without the condition. No one likes to be rejected, criticized or fail. For people with RSD, these universal life experiences are much more severe than for neurotypical individuals. They are unbearable, restricting, and highly impairing.

When this emotional response is internalized (and it often is for people with RSD), it can imitate a full, major mood disorder complete with suicidal ideation. The sudden change from feeling perfectly fine to feeling intensely sad that results from RSD is often misdiagnosed as rapid cycling mood disorder.

It can take a long time for physicians to recognize that these symptoms are caused by the sudden emotional changes associated with ADHD and rejection sensitivity, while all other aspects of relating to others seem typical. RSD is, in fact, a common ADHD trait, particularly in adults.

When this emotional response is externalized, it looks like an impressive, instantaneous rage at the person or situation responsible for causing the pain.

[Self-Test: Could You Have Rejection Sensitive Dysphoria?]

RSD can make adults with ADHD anticipate rejection — even when it is anything but certain. This can make them vigilant about avoiding it, which can be misdiagnosed as social phobia. Social phobia is an intense anticipatory fear that you will embarrass or humiliate yourself in public, or that you will be scrutinized harshly by the outside world.

Rejection sensitivity is hard to tease apart. Often, people can’t find the words to describe its pain. They say it’s intense, awful, terrible, overwhelming. It is always triggered by the perceived or real loss of approval, love, or respect.

People with ADHD cope with this huge emotional elephant in two main ways, which are not mutually exclusive.

1. They become people pleasers. They scan every person they meet to figure out what that person admires and praises. Then they present that false self to others. Often this becomes such a dominating goal that they forget what they actually wanted from their own lives. They are too busy making sure other people aren’t displeased with them.

[ADHD, Women, and the Danger of Emotional Withdrawal]

2. They stop trying. If there is the slightest possibility that a person might try something new and fail or fall short in front of anyone else, it becomes too painful or too risky to make the effort. These bright, capable people avoid any activities that are anxiety-provoking and end up giving up things like dating, applying for jobs, or speaking up in public (both socially and professionally).

Some people use the pain of RSD to find adaptations and overachieve. They constantly work to be the best at what they do and strive for idealized perfection. Sometimes they are driven to be above reproach. They lead admirable lives, but at what cost?

How Do I Get Over RSD?

Rejection sensitivity is part of ADHD. It’s neurologic and genetic. Early childhood trauma makes anything worse, but it does not cause RSD. Often, patients are comforted just to know there is a name for this feeling. It makes a difference knowing what it is, that they are not alone, and that almost 100% of people with ADHD experience rejection sensitivity. After hearing this diagnosis, they’re relieved to know it’s not their fault and that they are not damaged.

Psychotherapy does not particularly help patients with RSD because the emotions hit suddenly and completely overwhelm the mind and senses. It takes a while for someone with RSD to get back on his feet after an episode.

There are two possible medication solutions for RSD.

The simplest solution is to prescribe an alpha agonist like guanfacine or clonidine. These were originally designed as blood pressure medications. The optimal dose varies from half a milligram up to seven milligrams for guanfacine, and from a tenth of a milligram to five tenths of a milligram for clonidine. Within that dosage range, about one in three people feel relief from RSD. When that happens, the change is life altering. Sometimes this treatment can make an even greater impact than a stimulant does to treat ADHD, although the stimulant can be just as effective for some people.

These two medications seem to work equally well, but for different groups of people. If the first medication does not work, it should be stopped, and the other one tried. They should not be used at the same time, just one or the other.

The second treatment is prescribing monoamine oxidase inhibitors (MAOI) off-label. This has traditionally been the treatment of choice for RSD among experienced clinicians. It can be dramatically effective for both the attention/impulsivity component of ADHD and the emotional component. Parnate (tranylcypromine) often works best, with the fewest side effects. Common side effects are low blood pressure, agitation, sedation, and confusion.

MAOIs were found to be as effective for ADHD as methylphenidate in one head-to-head trial conducted in the 1960s. They also produce very few side effects with true once-a-day dosing, are not a controlled substance (no abuse potential), come in inexpensive, high-quality generic versions, and are FDA-approved for both mood and anxiety disorders. The disadvantage is that patients must avoid foods that are aged instead of cooked, as well as first-line ADHD stimulant medications, all antidepressant medications, OTC cold, sinus, and hay fever medications, OTC cough remedies. Some forms of anesthesia can’t be administered.

Rejection Sensitive Dysphoria: Next Steps

Dr. William Dodson is a member of ADDitude’s ADHD Medical Review Panel.

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