New Insights Into Rejection Sensitive Dysphoria

What Is Rejection Sensitive Dysphoria?

Rejection sensitive dysphoria isn't a proper analysis, however relatively one of the crucial common and disruptive manifestations of emotional dysregulation — a not unusual however under-researched and oft-misunderstood symptom of ADHD, particularly in adults. Rejection sensitive dysphoria is a brain-based symptom this is likely an innate feature of ADHD. Though the revel in of rejection sensitive dysphoria can also be painful and even hectic, RSD is now not regarded as caused by means of trauma.

Dysphoria is the Greek word which means unbearable; its use emphasizes the serious physical and emotional ache suffered through folks with RSD once they encounter actual or perceived rejection, grievance, or teasing. The emotional depth of RSD is described by way of my sufferers as a wound. The response is way past all percentage to the nature of the event that brought about it.

One-third of my grownup sufferers record that RSD used to be probably the most impairing aspect of their private enjoy of ADHD, partially as a result of they by no means found any effective tactics to regulate or take care of the pain.

What Triggers Rejection Sensitive Dysphoria?

Sometimes referred to as hysteroid dysphoria in Europe, rejection sensitive dysphoria is characterized via intense mood shifts precipitated by way of a distinct episode, usually some of the following:

  • rejection (the true or perceived withdrawal of love, approval, or admire)
  • teasing
  • criticism, regardless of how positive
  • power self-criticism or negative self-talk brought on by a real or perceived failure

The new temper sweeps in straight away and it matches the individual’s perception of the cause. If these induced feelings are internalized, the person can instantaneously appear as if they have a complete Major Mood Disorder syndrome entire with suicidal thinking. If the emotions are externalized, they are regularly expressed as a rage on the individual or scenario that wounded them so severely. The moods go back to customary very quickly in order that a person with ADHD could have more than one episodes of mood dysregulation in a single day.

[Self-Test: Rejection Sensitive Dysphoria in Adults]

Many folks with RSD say it’s at all times been a part of their lives, alternatively some record rising significantly more sensitive in early life.

What Are the Outward Signs of Rejection Sensitive Dysphoria?

Individuals affected by rejection sensitive dysphoria may showcase the following behaviors:

  • Sudden emotional outbursts following actual or perceived criticism or rejection
  • Withdrawal from social scenarios
  • Negative self-talk and thoughts of self-harm
  • Avoidance of social settings during which they might fail or be criticized (for this reason, RSD is often onerous to tell apart from Social Anxiety Disorder)
  • Low self-esteem and deficient self-perception
  • Constant harsh and unfavourable self-talk that leads them to turn into “their very own worst enemy”
  • Rumination and perseveration
  • Relationship issues, particularly feeling continuously attacked and responding defensively

What Does Rejection Sensitive Dysphoria Feel Like?

The excruciating pain of RSD is often beyond description. Patients describe the intensity of RSD as “terrible,” “terrible,” “catastrophic,” or “devastating,” however they can not verbalize the standard of the emotional enjoy.

[Watch This: The Emotional Dysregulation of ADHD]

No one loves to be rejected, criticized, or to be observed as a failure. It is unpleasant, so other people steer clear of those scenarios if they are able to. RSD is distinguished through its extreme, unbearable depth, which sets it excluding normal emotional responses acquainted to people who are neurotypical.

This intense ache is frequently skilled as a bodily “wound;” the patient feels as though they were stabbed or punched in the chest. Commonly, other people will droop over, grimace, and grasp their chests after they describe their RSD enjoy.

How Is Rejection Sensitive Dysphoria Different from a Mood Disorder?

RSD is characterized by means of intense but short-lived emotional pain brought on by means of a definite match of actual or perceived rejection, criticism, or teasing. Mood disorders, however, are characterized through the next:

Mood Disorder RSD and ADHD
Mood changes are untriggered; immediately Mood adjustments always have a clear trigger
Moods are unbiased of what's going on in the person’s lifestyles Moods match the perception of the cause
Mood shift is sluggish over weeks Mood shift is immediate
Offset of mood episode is gradual over a duration of weeks to months Episodes finish briefly in a question of hours
Duration of episode should be > 2 weeks Episodes hardly ever last longer than a couple of hours.

In different words, the moods of ADHD and RSD are customary in each manner excluding their depth.

Is Rejection Sensitive Dysphoria a Symptom of ADHD?

Rejection sensitive dysphoria is not included within the DSM-V for attention deficit hyperactivity dysfunction (ADHD or ADD); it is not a proper symptom of ADHD in the United States, then again emotional dysregulation is among the six basic features used to diagnose ADHD in the European Union.

It’s widely understood that the diagnostic criteria for ADHD in the DSM-V handiest have compatibility smartly with basic school age youngsters (6-12) and feature by no means been validated in a bunch of folks over the age of 16.1 They are according to most effective observational or behavioral standards that can be seen and counted. The conventional diagnostic standards deliberately steer clear of signs associated with emotion, thinking kinds, relationships, sleeping, etc. because these options are exhausting to quantify. For clinicians who work with later children and adults, the DSM-V standards are virtually needless as a result of they forget about so much which is important to working out how other people with an ADHD nervous device revel in their lives.

When other people started writing and researching the concepts of RSD and emotional dysregulation about 5 years ago, this new consciousness of the emotional component of ADHD was once enthusiastically permitted by sufferers and their households as a result of they matched their lifestyles reports so precisely. The reception from clinicians and plenty of researchers, however, used to be decidedly cool. Many pros didn't absolutely clutch that the emotional part of ADHD had all the time been there however intentionally no longer pursued. It gave the impression to them that the idea that had no real and historic foundation. What’s extra, there used to be little or no published analysis just Five years in the past and maximum research got here from the European Union, which used the time period emotional dysregulation (ED), now not RSD.2

These stumbling blocks to recognizing RSD/ED as a significant and defining function of adult ADHD and to using medications to provide some relief from the disruptions and pain of this option of ADHD are being impulsively addressed. There has been a rapid building up in to be had analysis in an excessively short period of time.3 The redefinition of adult ADHD in the EU — adding emotional self-regulation as a elementary part of the standards for the prognosis of ADHD — has furher assured that RSD/ED is actually “a factor” that can't be omitted any further.

Still, there are a minimum of 3 explanation why emotional dysregulation or RSD may never be incorporated within the diagnostic standards for ADHD, regardless of how prevalent:

  1. RSD/ED are not always present. It is available in caused episodes.
  2. People with RSD/ED are generally ashamed of their over-reactions and conceal them so that they're going to now not be additional embarrassed and regarded as mentally or emotionally unstable
  3. Even when RSD/ED is present, it will possibly’t be measured, and, therefore, can’t get revealed in analysis.

As a outcome, emotional dysregulation was consciously excluded from the diagnostic standards for ADHD and effectively forgotten for a few years. Over the decade, researchers have developed a number of new techniques of having a look at ADHD throughout the lifecycle. By the tip of 2019, this re-evaluation of the very elementary aspects of ADHD led the European Union to issue its 10-year update of the Consensus Guidelines on Adult ADHD4, which redefined adolescent and adult ADHD to include issue with emotional regulation as one among only six fundamental options within the ADHD syndrome:

  1. inattention and hyperfocus
  2. impulsivity
  3. hyperactivity
  4. emotional dysregulation
  5. over the top mind wandering
  6. behavioral self-regulation (which they equated with govt serve as deficits)

Although the EU has chosen the extra inclusive term of emotional dysregulation (ED) as a substitute of RSD, the concepts are fundamentally the similar. Emotional dysregulation is described as:

“The form of emotional dysregulation seen in ADHD has been characterized as poor self-regulation of emotional symptoms reminiscent of irritability, frustration and anger and low frustration tolerance, mood outbursts, emotional impulsivity, and temper lability.5 Emotional dysregulation in ADHD isn't like episodic signs corresponding to marked sustained irritability occurring throughout the context of altered mood states, reminiscent of an episode of extreme disappointment or mania. In ADHD, emotional signs tend to reflect short-lived exaggerated adjustments, regularly in line with day-to-day events, with speedy return to baseline within a few hours”.6

Is Rejection Sensitive Dysphoria a New Concept?

Rejection sensitive dysphoria and emotional dysregulation are outdated ideas associated with ADHD that are gaining new publicity in analysis and scientific settings. Dr. Paul Wender, who spent four a long time accomplishing the pioneering studies on ADHD beginning within the Sixties, was once the primary to acknowledge emotional dysregulation as a chronic, prevalent, and extremely impairing element of what we now name ADHD.

The most up-to-date contribution to this new serious about the temper law part of ADHD comes from Dr. Fred Reimherr, one of the founding fathers of ADHD who established the present youth standards for ADHD at the side of Wender more than 50 years ago (the unique standards for what we now call ADHD had been at the start referred to as the Wender-Reimherr Criteria). His recent replication7 of his learn about of the validity of each diagnostic criterion has led him to now conceptualize ADHD as being divided into simplest two subtypes: the well-known inattentive type and an emotional dysregulation type.

This is a big change in pondering. A feature of ADHD that was once disregarded for fifty years now could be abruptly turning into one of the defining options of the syndrome in both the European Union and North America.

In 2019, Faraone printed “Emotional dysregulation in attention deficit hyperactivity dysfunction – implications for scientific recognition and interventions” within the Journal of Child Psychology and Psychiatry.8 It states that there's “forged theoretical rational” for emotional impulsivity and poor emotional self-regulation “as core symptoms of ADHD.”

How is Rejection Sensitive Dysphoria Treated?

Although the alpha agonist medications, guanfacine and clonidine, were FDA-approved for the treatment of ADHD for many years, they were indirectly related to the terms of rejection sensitivity and emotional dysregulation for all of the causes famous above. Nonetheless, it has been my scientific enjoy and the enjoy of others that the indications of RSD/ED can also be considerably relieved with clonidine and guanfacine in about 60% of adolescents and adults. To me, this remark strongly signifies that RSD is neurological and not one thing that is because of a loss of talents. Skills do not are available in pill form.

There recently exists no formal analysis on using alpha agonist medications to regard signs of RSD or ED on patients with ADHD.

If a patient advantages from an alpha agonist drugs, they describe the new enjoy as considered one of “placing on emotional armor.” They still see the same things going down that may have emotionally devastated them last week, however now on medicine they simply watch those triggers fly past them “with out being wounded.” Often folks report that, with time, they come to appreciate that this armor is not wanted after all “because I came to peer that the arrows I used to be protected from were not arrows first of all.” They are very transparent, however, that they would by no means have advanced this emotional regulate until that they had had some preliminary coverage from the pain of RSD.

If a affected person does not have the benefit of medication, they have little keep watch over over an episode of RSD as soon as it starts. The incidents need to run their path. Some people with ADHD, however, record that getting occupied with one thing new and interesting can help to end an RSD episode extra temporarily than it will another way. In my medical enjoy, neither training nor conventional mental or behavioral treatments — like CBT or DBT — offer any prevention or aid from impairments. Nonetheless, many people file that it is vitally useful for them to know that this highly disruptive experience is real, commonplace, and shared by people with ADHD. “It helps me to understand what is occurring to me and that it's ultimately going to finish.”

Rejection Sensitive Dysphoria: Next Steps


1 Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder. AACAP Official Action. (2007). Journal of the American Academy of Child and Adolescent Psychiatry. 46 (7):894-921. This article is within the public area and can also be accessed at

2 Kooij Sandra JJ, et al. European consensus commentary on analysis and treatment of grownup ADHD: The European Network Adult ADHD. BioMedCentral – Psychiatry (2010), 10:67. Pages 1-24.

3 Graham J, Banaschewski T, Buitelaar J, Coghill D, Danckaerts M, Dittmann RW, et al. European guidelines on managing adverse results of medication for ADHD. European Child and Adolescent Psychiatry (2011) 20:17–37. DOI 10.1007/s00787-010-0140-6

4 Kooij J.J.S., Bijlenga D, Salerno L, Jaeschke R, Bitter I, Balázs J, Thome J, Dom G, Kasper S, Nunes C, Filipe S.Stes. Mohr P, Leppämäki S, Casas M, Bobes J, Mccarthy JM, V.Richarte, Philipsen AK, et al. Updated European Consensus Statement on prognosis and treatment of adult ADHD. (2019) European Psychiatry 56: 14–34.

5 Skirrow C, Asherson P. Emotional lability, comorbidity and impairment in adults with attention-deficit hyperactivity disorder. Journal of Affective Disorders, (2013);147 (1-3):80–6.

6 Surman CB, Biederman J, Spencer T, Miller CA, McDermott KM, Faraone SV. Understanding deficient emotional self-regulation in adults with attention deficit hyperactivity dysfunction: a managed study. Attention Deficit Hyperactivity Disorders2013;5(3):273–81.

7 Reimherr FW, Roesler M, Marchant BK, et al, Types of grownup Attention Deficit/Hyperactivity Disorder: A Replication Analysis. (2020) Journal of Clinical Psychiatry 81 (2) e1-e7.

8 Faraone SV, Rostain A, Blader J, et al. Practitioner Review: Emotional dysregulation in attention deficit hyperactivity dysfunction – implications for clinical reputation and interventions. Journal of Child Psychology and Psychiatry (2019) 60(2): 133-150.

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