What is Rejection Sensitive Dysphoria RSD with Autism or ADHD?

“We have two lives, and the second begins when we realize we only have one.” – consistently attributed to Confucius although he probably never said it.

That describes where I’m at – past the hypothetical prime of my life, and so very acutely aware of how precious and yet how very brief our little lives really are. It’s an awareness that makes me wish I didn’t have rejection sensitive dysphoria. I don’t like experiencing it, and I don’t like how it affects my relationships.

Let me say before diving in that rejection sensitivity or rejection sensitive dysphoria (RSD) is not a universal trait that all neurodivergent people experience. There is consensus and there is research, and we’ll look at both here in this write-up. It does seem that RSD is fairly common among both ADHD and autistic people.

Of course neurotypical people don’t love critique and rejection either. Nobody likes rejection. But RSD is a different animal, set apart by its magnitude. Dysphoria comes from Greek root words and means anguish, or unbearable pain. As always, if you are neurotypical and reading, I ask you to try to resist concluding that “everybody feels that” because they don’t.

Lots of Rejection All Around

Before we get into rejection sensitivity, there’s a whole lifetime behind us. Researchers say that RSD is not a result of childhood trauma (Dodson 2016), although trauma doesn’t help anyone, does it?

The reality is that ADHD/autistic people typically experience a crap ton of negative social feedback in the form of bullying (i.e. from peers, or parents), and critique (i.e. from teachers, or supervisors, or spouses, or neighbors), depending on their age.

An autistic grandma will have heard a lot of critique from her grandchildren. ADHD kids might have heard 20,000 additional critiques of their person before they turn twelve, as compared to neurotypical kids (Dodson 2016:9).

And then on top of that, social researchers frame the problem of rejection sensitivity not as a lack of accommodations, but that autistic people are so awkward that they deserve social rejection. Check this out.

In a recent paper published by the New York Academy of Sciences, researchers summarize that autistics are “often rejected by peers or marginalized by social groups, and they experience greater levels of loneliness compared to matched controls… Hence, the frequent social rejection experienced by the ASD population, mostly due to their poor social skills [emphasis added], is considered as an important contributing factor to their high rates of psychological distress” (Lin et al. 2022:287).

It’s interesting that the authors decided that frequent social rejection is mostly due to (the autistic people’s) poor social skills when the cause of social rejection of an entire social group would more likely be structural. This was in their literature review, not their findings. They were clarifying their starting points, as if everyone thinks this way.

This is to say that autistic and ADHD folks are very familiar with rejection, and with being blamed for our own rejection.

When something does not work, we are often told that it’s our fault that it doesn’t work. When one of us has problems in school, lack of accessibility isn’t the go-to explanation of what went wrong. It’s us. This is especially true for Black students in the U.S., who can get expelled from kindergarten rather than offered in-school supports (Zulauf-McCurdy 2023).

I haven’t even gotten into rejection sensitive dysphoria yet! So far, I’m just talking about the life-long experience of frequent rejection, that of being ADHD or autistic in a world that doesn’t seem (to us) to value our presence.

So, what is RSD then?

RSD Definition

RSD is a predisposition to expect, sense and then emotionally react bigtime to perceived or actual interpersonal rejection, and to unavoidably feel unbearable pain about all of it.

How is RSD different from social anxiety or social phobia?

RSD begins after the incident. Social anxiety begins before an incident and is anticipatory.

What triggers RSD?

A perception of having been rejected, made fun of, criticized, insulted, that they have disappointed or let down someone important to them, or that they have failed to live up to their own personal standards for themself.

How is RSD different from a mood disorder?

Mood disorders such as major depression or bipolar disorder involve changes in mood that are gradual, have no clear precipitating factors, and usually last for weeks or more. RSD is a mood change that is immediate, is always very clearly triggered by a real or perceived rejection, and is usually over in a couple of hours.

Is RSD a formal “symptom” of ASD or ADHD?

Not in the U.S., although the U.K. includes emotional dysregulation as a diagnostic feature of ADHD. Also, diagnostic criteria for ADHD are only validated for children, thus much is missing, including this. That doesn’t make RSD less real.

Is RSD called something else in the U.K.?

Yeah. What is called Emotional Dysregulation (ED) in the U.K. is called Rejection Sensitive Dysphoria (RSD) in the U.S. These are equivalent terms or synonyms. Actually, it’s becoming apparent that ED/RSD may be a central feature of ADHD for many people.

What does someone with RSD do observably differently in general?

Extra, extra meticulous work quality, perfectionistic because the idea of rejection or critique may be too much to bear; perseverating about potentially minor rejections; often replaying social events to determine where or whether they did something wrong; generally striving to prevent rejection, whatever form that takes; heightened awareness of injustice and a more intense response to witnessing injustice (Bondü and Esser 2015).

What does the RSD reaction look like if externalized?

The immediate externalized reaction can resemble anger, or possibly hurt or devastation, directed at the perceived source of rejection. Because the feelings that accompany RSD are all-consuming, the RSD reaction often is as well, which makes the reaction exhausting to feel and burdensome to observe or receive.

To the observer, the anger, hurt, or devastation likely appear disproportionate, as if the person is having a very big response to a relatively small rejection. This is a part of emotional dysregulation, common with autism and ADHD.

What does the RSD reaction look like if internalized?

The immediate internalized reaction can resemble major depression, if major depression could instantaneously initiate itself, which isn’t a thing. A person might cry, immediately withdraw, cease involvement in tasks, and appear dejected. Here the RSD feelings are also all-consuming, but the person has chosen to internalize their reaction rather than to externalize. It is not a smaller reaction to experience, although it can appear quieter to observe or receive.

What follows the initial RSD reaction?

People vary. Maybe the person is reluctant to return to the social context where the hurt took place. They may behave as if everything feels like a threat. They may be more self-protective than usual. They are probably exhausted, and scared. And they’re probably going to perseverate about the situation for way longer than what you think makes sense at all.

When does it end?

Well, that will also vary. For me, if I’ve had an RSD reaction to a perceived rejection (one that is not real), I will try really hard to be back to my own baseline by the following day. I can get there if I’m able to talk it through and understand that the rejection, although perceived, was not real. I also need to verify what was correct and what was incorrect in my earlier perceptions. And my hope, always, is that I can get it right next time. I don’t expect that I will, but I wish I could, and I try.

When it comes to actual rejection? My honest answer is that my reaction, in many ways, never ends. If it’s real, and it really happened the way I perceived it, and I’ve talked it through with a trusted person or thirty, and it still comes out as an injustice, I find infinite things to think about and reasons for it to stay in my mind. And my emotional response has a hair trigger reaction to even just mentioning the topics.

RSD is not something that therapy can do much to alleviate in general, as this is a physiological response to a trigger. Some ADHD medications have helped some people.

A Personal RSD Situation From Our Marriage

Yeah, this happened today. And with permission and some vulnerability I’m sharing it, with the hope that it’s useful to the reader seeking a better understanding of someone else in their life.

Here is the plot

Rachael and I have a good marriage, with a ton of trust. We have good communication, honesty, directness, and kindness. And even with all of that, I can still misinterpret a slight change in my wife’s tone of voice, and from that little difference, I can somehow infer that she wants nothing to do with me, and I can feel painfully hurt by a perceived, not-real, rejection. Yes, I can.

Setting: Afternoon, in our living room, Rachael was home from a busy day at work at the end of an unusually busy work week, the kind that made her feet sore from extra running around. She was eating her regular afternoon meal and would normally take a nap after this meal on this day.

Verbatim

Erika: Yeah, so I was thinking we could give Morgan the Dog another meal of chicken and rice and just watch him outside today…

Rachael: Yeah *said in a tired tone of voice*

Erika: Okay! I will put my headphones back on and stop talking now.

Rachael: What?  

Erika: I will shut up.

Rachael: I hate when you do this.

Erika: …

Rachael: You ended the conversation before it was over. I didn’t get a chance to say what I wanted to say.

Erika: You are tired. I heard it in your voice. I thought you wanted me to shut up because I was preventing you from sleeping.

Rachael: …

Erika: Don’t you?

Rachael: I do want to take a nap, yes. In a few minutes. I had wanted to finish our conversation about Morgan first.

Erika: Okay. (We finished the conversation about Morgan.)

… Then Rachael took her nap, and Erika spent the next two hours trying to sort herself out over this. After the nap, I apologized for assuming she wanted me to shut up and end a conversation when all she probably did was yawn.

Closing Thoughts?

RSD is one of my more annoying qualities, I suspect. It’s exhausting to experience on my part, and I assume this has got to be annoying as hell to deal with on a regular basis. And the unfortunate irony of that is that it makes it worse.

Because I do not want to be annoying, or a burden, to this amazing woman who married me, I may err on the side of “shut up” again next time too, because I think of it as yielding space, you know? As discussed earlier in this article, there are internalized and externalized RSD reactions.

I never have anger toward Rachael, even if she were to actually tell me with words to shut up. I’d assume I probably deserve to hear the imperative, for all the crap she puts up with.

It’s hard.

This article has way more real talk than most. It is my hope that bearing my soul a bit here helps someone reading this. If it helps you in some way, I hope you’ll let me know.

ADHD/Autistic friends, what’s your experience with RSD? 

Want to discuss this topic? There is a thread about it on the facebook page.

 

References

Bondü, Rebecca and Günter Esser. 2015. “Justice and Rejection Sensitivity in Children and Adolescents with ADHD Symptoms.” European Child & Adolescent Psychiatry 24(2):185-98. doi: https://doi.org/10.1007/s00787-014-0560-9.

Dodson, William W. 2016. “Emotion Regulation and Rejection Sensitivity.” Attention.

Lin, Xinxin, Shiwei Zhuo, Zhouan Liu, Junsong Fan and Weiwei Peng. 2022. “Autistic Traits Heighten Sensitivity to Rejection‐Induced Social Pain.” Annals of the New York Academy of Sciences 1517(1):286-99. doi: https://doi.org/10.1111/nyas.14880.

Zulauf-McCurdy, Courtney 2023. “Why Are Black Preschoolers with ADHD Expelled?” Attention.