Rejection Sensitive Dysphoria (RSD) refers to an extreme emotional sensitivity and intense physical or emotional pain triggered by perceived or actual rejection, criticism, or failure. This reaction can occur in response to anticipated, perceived, or actual social rejection, leading to overwhelming emotional distress that goes far beyond typical feelings of disappointment or hurt.
Individuals with RSD often describe the emotional pain as crushing or unbearable, with responses that can include swift mood changes, intense sadness, anger, or withdrawal. Given the intensity of feeling involved with perceived rejection, individuals can find it difficult to rationalise their way out of their emotional responses at the time.
RSD is most commonly observed as a profile associated with Attention Deficit Hyperactivity Disorder (ADHD). Rejection Sensitive Dysphoria (RSD) isn’t an official diagnosis. But it is often seen in people with ADHD or Autism, who can have strong emotional reactions.
RSD in ADHD may relate to neurobiological mechanisms involving emotional regulation challenges. A history of repeated negative social interactions, such as bullying or criticism, may sensitise individuals to rejection.
The difficulty in regulating these intense emotions can significantly impact a person’s daily life, social relationships, performance at school or work, and overall wellbeing. People with RSD may engage in people-pleasing or perfectionist behaviours to avoid rejection or criticism, or conversely, show withdrawal or “why bother” attitudes after repeated experiences of perceived social rejection.
How can we recognise RSD as clinicians?
Identifying RSD helps clinicians validate these distressing emotional experiences and guide supportive interventions focusing on emotional regulation, cognitive behavioural approaches, and environmental support strategies.
Key identification features include
1. Intense emotional response: Individuals with RSD experience abrupt, intense emotional reactions that may feel overwhelming or even physically painful. These emotions can include profound sadness, anger, frustration, or hopelessness. The intensity of these responses is disproportionate to the triggering event, often lasting from hours to days.
2. Maladaptive coping behaviours: Common behaviours include over-reassurance seeking (frequent checking in for approval), withdrawal or avoidance from social situations, school or work, perfectionism, people-pleasing behaviours.
3. Unhelpful thinking patterns: Affected individuals often scrutinise social cues minutely and may misinterpret neutral interactions (such as a casual sigh or averted gaze) as rejection or criticism. There can be anticipatory anxiety about rejection that impacts self-esteem and social functioning.
4. Physiological symptoms: Some individuals experience somatic symptoms like feeling physically sick in response to rejection or criticism which parallels with their emotional distress.
5. Functional impact: The emotional and behavioural reactions over time can significantly impair relationships, academic or occupational participation, and general quality of life.
To identify RSD, a comprehensive functional assessment is essential, considering whether emotional outbursts or behaviours are disproportionate to events, whether the approval of others strongly ties into the individual’s self-esteem, and whether avoidance leads to missed opportunities or social withdrawal. Understanding the specifics of social interactions and triggers, alongside emotional regulation capacity, helps differentiate RSD from other conditions.
Recognising RSD requires sensitivity to both the cognitive and emotional challenges underlying the behaviours presented, and an awareness that clients may have a history of repeated criticism or social rejection that exacerbates their emotional responses. This understanding supports more empathetic, effective interventions across allied health disciplines.
Potential signs of RSD across allied health disciplines may include
1. Positive behaviour support or psychological services:
- Sudden, intense emotional outbursts disproportionate to the triggering event.
- Withdrawal or avoidance of social settings to prevent perceived rejection.
- Frequent apologising, reassurance-seeking, or people-pleasing behaviours.
- Perfectionism or “why bother” attitudes reflecting either overcompensation or giving up in response to anticipated failure or rejection.
- Poor sleep functioning
- Low self-esteem or preoccupation on being like/approved of
- Tendencies to ruminate over past interactions.
2. Speech pathology services:
- Selective mutism
- Social withdrawal
- Refusal to attempt activities for fear of failure.
- Social avoidance
- Low speech volume for fear of being perceived the wrong way or disapproved of by others.
- Social communication differences
- Difficulties with self-advocacy and assertive communication
- Difficulty speaking up or asking for help.
3. Occupational Therapy:
- Avoidance of new or challenging physical tasks, not due to inability, but due to fear of judgment or failure.
- Over-exertion in attempts to prove competence, leading to physical strain.
- Refusal/resistant to engage in treatment.
- Refusal to follow through with homework exercises.
- Over compliance with homework tasks
- Avoiding challenging self-care tasks
- Avoiding handwriting
4. Dietetics:
- Disordered eating possibly linked to body image concerns and perfectionism.
- Emotional eating behaviours as a means to regulate distress.
- Heightened sensitivity to feedback relating to diet, weight, or health behaviours.
How do we manage RSD?
Managing Rejection Sensitive Dysphoria (RSD) involves a multifaceted approach focusing primarily on emotional validation, psychoeducation, emotional regulation skills, environmental modifications, and sometimes medication. Management is often integrated within treatment for associated disorders such as ADHD or autism spectrum disorder. Most interventions focus on minimising the occurrence and impact of perceived rejection before the dysphoria hits.
Cognitive Behavioural Therapy (CBT), in particular, can be highly beneficial.
CBT helps individuals with RSD to:
- Understand their emotions and reactions better.
- Identify triggers that lead to intense emotional responses.
- Develop coping strategies to manage their emotional responses effectively.
Some general strategies include
1. Validation and Psychoeducation:
Begin by validating the individual’s emotional experiences and normalising RSD as a common part of conditions like ADHD. Helping the person understand that their intense emotional responses are not their fault and are linked to their neurological makeup can reduce shame and self-blame.
2. Emotional Regulation Skills:
Since emotional dysregulation is core to RSD, teaching and reinforcing emotion regulation strategies is vital. It’s important to tailor strategies to the intensity of the emotional reaction and focus on managing emotions before crises occur.
3. Environmental and Relational Adjustments:
Educating family, teachers, colleagues, and support people about RSD can improve social interactions and reduce triggers. Adjustments might include changing the way feedback is given to minimise perceived criticism, and setting healthy boundaries in relationships, which decrease the stress associated with anticipated rejection.
4. Values-Based Work:
Assisting individuals to align their behaviours with their personal values rather than seeking external approval may reduce avoidance behaviours and support self fulfillment and engagement in meaningful activities despite fears of rejection. Promoting self-compassion and acceptance may also be useful in breaking the cycle of perceived rejection.
To learn more about ways to manage RSD, a referral to a psychologist can be helpful. Contact ORS today.
