In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is Rejection Sensitive Dysphoria.

You may have heard of rejection Sensitive Dysphoria (RSD), perhaps in the context of ADHD (attention deficit/hyperactivity disorder). I was going into writing this post thinking that it was a well-established thing, and I ended up being rather surprised by what I found.

Rejection sensitive dysphoria isn’t a psychiatric diagnosis. It’s not in the DSM-5 diagnostic criteria for ADHD, although it is mentioned as an associated feature that supports making the diagnosis. The ICD-11 diagnostic system describes emotional dysregulation as being common in ADHD, but again, it’s not part of the diagnostic criteria. One diagnosis where rejection sensitivity does show up up is the DSM-5 criteria for major depressive episode with atypical features, which includes a longstanding pattern of interpersonal rejection sensitivity as a possible symptom.

The earliest scholarly mention of rejection sensitive dysphoria that I came across was in a 1982 paper on atypical depression in the journal JAMA Psychiatry, although Donald Klein had earlier called this hysteroid dysphoria back in the 1970s. There were some papers on RSD when I did a Google Scholar search, but not many. There’s a lot of research on rejection sensitivity, but not on the more specific term rejection sensitive dysphoria.

The Dr. Dodson show – part I

Psychiatrist Dr. William Dodson seems to be one of the more prominent voices talking about RSD. Some sources, including Metro UK, incorrectly credit him with coining the term. The Metro said he came up with it in 2017, but linked to a 2016 article by him posted on the CHADD (Children and Adults with ADHD) website, although I’m not sure if they’re the original publisher.

Anyway, in that article, he writes that RSD can be triggered in people with ADHD when they’ve been rejected, teased, or criticized, disappointed people who are important to them, or stopped approving of themselves because they didn’t meet their own standards/goals. He adds, “If this emotional response is internalized, it looks like an instantaneous but triggered major depression.” This presentation may lead to misdiagnosis as conditions like borderline personality disorder, rapid cycling bipolar disorder, or social anxiety disorder.

He says that 1/3 of adolescents and adults with ADHD report RSD as being the element of their ADHD that causes the most impairment, although it’s not clear where that figure came from. He explains that “since RSD is genetic and neurological, psychotherapies have been found to have little benefit.” However, he suggested that the alpha-2 adrenergic blocking medications clonidine and guanfacine can be helpful for some people, as can the monoamine oxidase inhibitor (MAOI) antidepressant tranylcypromine. Taking MAOIs requires being on a low-tyramine diet, but he minimized this, saying “people who eat a balanced diet in moderation usually do not have to make any changes.” That struck me as somewhat irresponsible.

The Dr. Dodson show – part II

In a 2022 article in ADDitude Magazine, Dr. Dodson refers again to that 1/3 figure again and relates it to his adult patients with ADHD. He repeats the idea of instantaneous mood episode if the feelings are internalized, and says this can include suicidal ideation; if the feelings are externalized, this can lead to intense rage. These episodes typically last under 2 hours. In this article, he mentions that in his clinical experience, therapies like CBT (cognitive behavioural therapy) and DBT (dialectical behaviour therapy) don’t help with RSD, so presumably he was also referring to his own experience in the 2016 article as well.

In terms of observable behaviours due to RSD, Dr. Dodson identifies:

• abrupt emotional outbursts
• withdrawal from social situations
• avoidance of situations where failure or criticism is likely to occur
• relationship difficulties, including responding defensively

People with RSD may also experience negative self-talk, thoughts of self-harm, low self-esteem, and rumination.

ADHD diagnostic criteria

Dr. Dodson writes that the “DSM-V” (which is actually the “DSM-5”) diagnostic criteria for ADHD “intentionally avoid symptoms associated with emotion, thinking styles, relationships, sleeping, etc. because these features are hard to quantify.” Um, has he looked at the criteria for other diagnoses that include exactly those things? That’s a weird thing to say.

He writes that the idea of rejection sensitive dysphoria being linked to ADHD has received a cool reception from many clinicians and researchers, adding, “Many professionals did not fully grasp that the emotional component of ADHD had always been there but intentionally not pursued.” Ooh, bring on the cover-up drama! He offers some reasons why RSD may never be included in the diagnostic criteria, including this reason that struck me as making no sense: “Even when RSD/[emotional dysregulation] is present, it can’t be measured, and therefore, can’t get published in research.” Emotional dysregulation is a core element of borderline personality disorder, and there don’t seem to be any issues researching that.

European Union consensus statement

Dr. Dodson argues that rejection sensitive dysphoria or emotional dysregulation should be included as a diagnostic criterion for ADHD. His ADDitude article refers to the 2018 Updated European Consensus Statement on Diagnosis and Treatment of Adult ADHD, saying that it lists emotional dysregulation as “one of the six fundamental features used to diagnose ADHD in the European Union.” Not exactly, though. The consensus statement says, “Although emotional dysregulation may dominate the clinical presentation, it is not a criterion for classifying individuals as it lacks specificity, occurring in many other mental health conditions.”

The consensus statement further describes emotional dysregulation in ADHD as poor self-regulation of emotions like irritability, frustration, and anger, along with low frustration tolerance, emotional impulsivity, and rapid changes in mood. It adds, “Whether the type of emotional instability seen in ADHD is qualitatively different to that seen in other chronic conditions such as borderline personality disorder or post-traumatic stress remains unclear.”

What does this mean?

All of this seems to mean that Dr. Dodson decided to run with an idea and quite a few people jumped on the bandwagon. And maybe I’m just cynical, but I can’t help but wonder if there’s any sort of secondary gain associated with said bandwagon. There doesn’t seem to be any real question that emotional dysregulation is a common issue in people with ADHD, given that it’s mentioned in both the DSM and ICD, but whether rejection sensitive dysphoria is a specific, discrete thing that is distinct from other things doesn’t seem to have been clearly established yet.

Another issue that I see is that many (or even most) of us like to self-label. I highly doubt that anyone likes rejection, although some people handle it better than others. For anyone with low self-esteem or a sense of self-worth that’s highly dependent on external sources, rejection is likely to feel really shitty. In that case, self-labelling with rejection sensitive dysphoria may seem appropriate, but it’s not necessarily the same issue as the emotional dysregulation that tends to occur in ADHD.

Had you heard of RSD before? Did any of this surprise you?

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