What Is Rejection Sensitive Dysphoria?
Now gaining more attention, RSD can pack an emotional wallop.
Posted Jul 25, 2019
Most people are concerned with being liked at one point or another, and it's not an uncommon preoccupation of people who are in therapy. So many of us wish that we didn't care what others think, and yet, it's virtually impossible not to at least care a bit. (If we don't at all, that leads to problems of its own.)
It's even evolutionary for us to worry about whether we belong; in cave-dweller days, we needed others in our tribe to help us survive. If we were on the verge of being ousted from our group, that could put us in physical danger–and so it behooved our species to develop physical and psychological reactions to rejection that were aversive enough that they'd keep us wanting to belong. All this leads to the fact that for most of us, being rejected is a fundamentally distressing experience.
It can even be physically painful. Social rejection activates the same parts of the brain as does physical pain, and the experience of each can have many similarities on a brain scan. That said, some of us are more hypersensitive to the possibility of rejection than others, and perceive that we are being rejected far more often than we actually are.
In these cases lies the possibility of Rejection Sensitive Dysphoria. It is a new label that is only now starting to be researched in depth. Individuals who have this condition respond extremely negatively to the perception of being rejected: It goes far beyond the run-of-the-mill discomfort that most of us experience.
People with RSD have such a strong emotional reaction to negative judgments, exclusion, or criticism from others that it sends them into a mental tailspin, leading to rumination and the pit-of-the-stomach malaise that won't let them move forward with their day. They feel like failures, disproportionate to what has actually occurred. They may feel rage and want to lash out. They often exaggerate how people are against them, or how much people dislike them, or they carry long-term shame.
Or they may overcompensate and bend over backward in a desperate attempt to keep themselves in others' good graces. Other people may see those with RSD as overly perfectionistic, over-sensitive, or overly reactive to even the mildest types of criticism.
Is Rejection Sensitive Dysphoria Real?
One question I field quite often as a clinical psychologist in practice, an Abnormal Psychology professor, and a mental health advice columnist is whether Rejection Sensitive Dysphoria is "real." It is most certainly real as in it is a cluster of symptoms that exists and can cause great impairment and distress. It is not as of yet, however, an official disorder listed in the Diagnostic and Statistical Manual of Disorders (DSM-5). So it is not a condition with its own official code label, but instead is a constellation of symptoms that are often (though not always) associated with other conditions.
It is possible that RSD will be included as an official diagnosis in a future version of the DSM-5, but its absence in the meantime should not be taken as evidence that it is not legitimate, even if it lacks standalone status as an official DSM condition.
Rejection Sensitive Dysphoria Versus Social Anxiety
Social Anxiety Disorder, which is an official disorder within the DSM-5, is one of the most prevalent psychological disorders in the U.S. At its core, it involves preoccupation or distress related to the fear and worry of being judged negatively by others.
Some people with Social Anxiety disorder (formerly referred to as "Social Phobia") experience it in any type of social interaction, from chatting in an elevator to small talk at a party. Their distress is significant enough that they tend to avoid the interactions or be absolutely miserable when they push themselves (or are otherwise forced) to endure them. (Some people with Social Anxiety Disorder may turn to substances in order to make the experiences less uncomfortable.)
Other people with Social Anxiety Disorder have a subtype of the disorder that involves only performance situations, meaning that it is not everyday social interactions that cause them significant distress or impairment, but rather situations where they are on display. Public speaking, music performances, and athletic performances are most common. Even the most talented of athletes or musicians can experience this debilitating anxiety or stage-fright, which by definition, gets in the way of their functioning.
Rejection Sensitive Dysphoria naturally has some overlap with Social Anxiety Disorder, and the two constellations of symptoms may occur in the same person and even contribute to each other. That said, Rejection Sensitive Dysphoria does have some distinctions from Social Anxiety Disorder.
People with Social Anxiety Disorder may feel worst around people they are not yet comfortable with, becoming preoccupied with potential embarrassment when among strangers, for instance. Someone with RSD, however, does not necessarily feel any less distress around those who are closest to them when it comes to feeling rejected, their main concern. In fact, feeling rejected by a loved one will likely hurt even more.
Moreover, someone with RSD may not be as anxious before an interaction (like someone with Social Anxiety Disorder will be) but instead will have an outsized and extreme reaction afterward if they felt it went badly. Shame, guilt, sadness or even rage about what they perceive as a rejection, rather than the preemptive, debilitating nervousness that comes in advance of interaction (more common with Social Anxiety Disorder), is what's key in Rejection Sensitive Dysphoria.
Rejection Sensitive Dysphoria and ADHD
A lot of the attention that RSD has recently gotten has stemmed from more awareness of it within the community of people who have ADHD. And it is true that having ADHD does appear to raise your risk of RSD significantly. It is not entirely clear why this is, but one potential explanation is that the central nervous system tends to be triggered in different ways in those with ADHD.
Furthermore, people with ADHD may sometimes have behaviors that put them outside of the typical social norms, like the child who gets the cold shoulder from his or her friends because he or she tends to interrupt, or the adult who keeps veering off track at a staff meeting. So this, ironically, could further create situations where those with ADHD sense signals that they are being seen as "other," creating a vicious cycle.
Moreover, the tendency toward impulsivity that typically accompanies ADHD can make someone interact in ways that sabotage the interaction further. Due to their extreme upset with what they believe is rejection, they may quit a game, say something rejecting to the other person, or remove themselves abruptly from a situation without explanation.
If they had taken more time before responding, they might have mitigated the damage, but not reacting immediately to strong emotional upset can be quite difficult, especially for someone with underlying impulsivity issues.
Rejection Sensitive Dysphoria in Relationships
As you may expect, RSD can have a significant impact on having relationships—or even the seeking of them. Dating can be especially hard for someone with RSD, as they are hyperfocused on any perceived slight whatsoever (Why did it take so long for them to text back?), and they may assume they are being rejected when that is far from the case. They may ruminate on what they said or did "wrong," or isolate themselves to the point of self-sabotaging and actually driving the other person away due to seemingly not being interested themselves.
Within relationships, people with RSD can have different ways of manifesting their underlying discomfort and fear, and sometimes, gender roles can make a difference. A person may continually second-guess their actions, wanting frequent reassurance from their partner that everything is "OK" within the relationship. They may grow timid and afraid of sharing their real feelings because of the fear that those feelings won't be deemed acceptable. They may escalate conflicts with anger that feels out of proportion to the situation.
Surprisingly, some controlling partners may be reacting out of underlying Rejection Sensitive Dysphoria, as their anxiety makes them want to keep their partner on a tighter and tighter leash because they are terrified that their partner will leave them otherwise. (Make no mistake, controlling behavior can be dangerous and needs to be taken seriously in its own right. Signs of that are here.)
Do I Have Rejection Sensitive Dysphoria?
Since it is not a mental health condition in the DSM-5, there are not a set of empirically-quantifiable criteria to determine whether you "officially" meet a diagnosis for RSD. But you may have a strong suspicion if you recognize yourself in several of the characteristics below:
- High sensitivity about the possibility of rejection
- Overly high standards for yourself
- Feeling easily triggered toward guilt or shame
- Isolating yourself in a preemptive strike not to be rejected
- Aggressive or rageful behavior toward those who have been perceived to have slighted you
- Frequently feeling an uncomfortable physical reaction due to "not fitting in" or being misunderstood
- Self-esteem that is entirely dependent on what others think, and rises and falls accordingly
- Frequent and intense ruminating after an interaction about how you did or said something wrong
Rejection Sensitive Dysphoria Causes
Like most mental health conditions, there are many different paths that can lead to Rejection Sensitive Dysphoria; no two people are exactly alike in what brought about their conditions, even when their symptoms are similar. Because RSD involves an overreaction of the HPA axis, then the possibility remains that some people may be more genetically predisposed to it than others.
But genetics alone do not singlehandedly cause RSD. Social and psychological triggers in the environment can contribute to its development, like growing up with overly perfectionistic standards, experiencing an extremely upsetting rejection at a young age, being made to feel overly guilty or ashamed for normal behavior, or having had a disrupted or dysfunctional attachment with your parents or caregivers. Trauma, abuse, and neglect can also overly sensitize someone to the possibility of rejection,
Rejection Sensitive Dysphoria Treatment
The best treatment option for Rejection Sensitive Dysphoria depends on the intensity of your symptoms and the overlap with other disorders. Due to the physiological nature of the reaction for some sufferers, it is possible that medication will be necessary, and indeed certain medications that can calm the physiological reaction—like some originally intended to treat high blood pressure—have shown promise for those with Rejection Sensitive Dysphoria.
Furthermore, certain antidepressants could be helpful if you have co-occurring depression or additional kinds of anxiety. If ADHD is clinically significant for you, then medication for that may be indicated as well.
Psychotherapies will work best that focus on improving your understanding of your emotional reactions at the moment and learning better paths toward responding to those emotions. It will also be beneficial to learn to challenge the accuracy of some of the automatic, dysfunctional thoughts that make you believe you have been rejected, learning to label them as invalid and let them pass.
Overall coping mechanisms that can increase resilience through uncomfortable feelings will also be helpful. Targeted types of Cognitive-Behavioral Therapy, Acceptance and Commitment Therapy, and Dialectical Behavior Therapy do just that.
In short, there is certainly promise in treating these symptoms, and the first step is awareness. Do you suffer from RSD? Let me know in the comments below. You are not alone!