What is Rejection Sensitive Dysphoria and How Does it Relate to ADHD?

A participant in my most recent ADHD couples seminar recently made a life-changing discovery – he has suffered all of his life from Rejection Sensitive Dysphoria along with his ADHD.  He wrote movingly of the impact this has had on his life.

What is Rejection Sensitive Dysphoria (RSD)?

Most adults with ADHD have an incredibly deep and painful aversion to rejection.  This is not a learned behavior, but rather part of the physiology of their ADHD.  It goes beyond the emotional lability* that is now recognized as a part of ADHD.  With RSD, rejection is so hard to bear that those who have it build life skills around avoiding it.  As you’ll see from the story below, it also greatly impacts how ADHD adults respond to those around them.

What Does RSD Look Like in Your Life?

According to William Dodson, MD, RSD encourages those who have it to compensate for the pain they feel from rejection in three basic ways – striving for perfection (nothing to reject); rejecting those who critique (move away from the pain); or intermittently raging to hurt or punish those who reject.  How does this show up in your life?  Here’s one man’s story:

"Last week, 23 years into a challenging and often rocky marriage with a non-ADHD partner, with 6 kids ranging from elementary school to college, with 10 years diagnosed and medicated (but not well-treated) for ADHD, and 15 months into marital and individual therapy, I stumbled on William Dodson’s ADDitude articles about Rejection Sensitive Dysphoria. They were revelatory. Through this model so much more of my life makes sense, from my childhood to now.

Every direct human interaction is impacted by my deep aversion to rejection, and every personal and private action is as well, because anything I think or do can ultimately come to light. Rejection avoidance, in the context of RSD, has been so great a motivation that I’d place it as one of the lower levels in my own Maslow hierarchy.

My general approach to personal and relational life has been to either seek perfection so there is no grounds for rejection (which I did in my youth through religious zeal and academic success, and do at work and some other environments), or throw in the towel and withdraw and people please so there’s nothing objectionable to reject (in my adult relationships after repeated moral failures burst the delusion of moral and relational perfection). And in interactions with my family, I can see how I internalize “rejection-events” as mini-depressions, and externalize them as fits of rage toward the one “rejecting” me. I use quotes because I had to use my reactions as cues to the trigger, and discover that yes, there’s a deep sense of rejection I’m feeling in those moments. Though I would have never recognized it this way without the model Dr Dodson presents. “Emotional disregulation/lability” is too general to get there, and “Shame” is really close, but not nuanced enough as to what it’s attached to. It’s the deep feeling of failure/rejection in other people’s eyes - real or perceived - so deep that avoidance of it becomes a primary motivation in life that manifests itself in so many now identifiable ways.

And for what it’s worth, this is not simply a conditioned response to being shamed as children because of other ADHD symptoms. Mine didn’t come from years and years of adults telling me I was a disappointment or a bad person. I overachieved as a kid academically to get praise and adoration from parents and teachers, despite my undiagnosed ADHD and despite having parents who saw no wrong in me ever. Even so, any negative judgment from them or any adult was so personally shame-inducing (dysphoric) that I avoided or hid failure at all costs to avoid the perceived rejection that would follow. "

What Happens to Your Relationship if you Have Rejection Sensitive Dysphoria?

RSD will contribute to volatility in your relationship because you will be more likely to misinterpret basic behaviors in a partner.  For example, if your partner is quite busy, you might interpret that as a rejection and feel particularly hurt, even though there is nothing personal at all about the action.  In addition, sensitivity to potential rejection is so strong that any whiff of potential disapproval or rejection might send you into one of the three types of behaviors above.

Another issue would be a greater likelihood of cover-ups and lying to avoid pain.

How To Treat Rejection Sensitive Dysphoria

There are medicinal ways to help manage RSD.  William Dodson, M.D. recommends either guanfacine and clonidine in combination or MAOIs off label.  See this article in ADDitude Magazine for more details.

Another good article on RSD (but without the treatment suggestions) is How RSD Derails Relationships.


*Emotional lability is when a person typicaly responds emotionally more extremely and more quickly than others might expect in the situation.  It is thought to be a core characteristic of ADHD.