What Is Rejection Sensitive Dysphoria

Introduction

Rejection-sensitive dysphoria (RSD) is where an individual experiences intense emotional pain and extreme sensitivity to rejection or perceived rejection. The term “dysphoria” is of Greek origin, meaning unbearable, which highlights the profound sense of distress, unease and discomfort that is experienced by these individuals when experiencing rejection. 

Many individuals may experience negative feelings when being rejected, but in those with RSD, these feelings can often become overwhelming, impacting relationships and leading them to avoid opportunities in the fear of anticipated rejection.¹ It has been found that neurodivergent populations, such as those with attention deficit hyperactivity disorder (ADHD) and autism, are more susceptible to RSD.² However, it is not exclusive to these individuals.⁵

Understanding rejection-sensitive dysphoria  

RSD is currently not a formal diagnosis and, therefore, is not included in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5).⁶ However, the growing accounts of individuals' experiences of RSD and its expanding use by experts in connection with common conditions suggest that it is vital to understand and manage the symptoms. This can help to better control the negative impact it can have on an individual's life and the mental health issues which can occur as a result.    

Emotional dysregulation and rejection-sensitive dysphoria 

Emotional regulation is defined as an “individual's ability to modify an emotional state to facilitate adaptive, goal-oriented behaviours”.⁷ It is the process that allows the individual to select and assess emotional stimuli, which then go on to trigger behavioural and physiological responses that can be adapted accordingly to the goal or situation.⁷

However, emotional dysregulation refers to when these adaptive mechanisms are impaired, leading to difficulties in self-regulating emotions, which is linked to the cause of RSD.⁸ Those with RSD often understand that their reactions are disproportionate to the situation but may find it difficult to control these emotions.⁸ This explains why neurodivergent individuals, usually with core traits of emotional dysregulation, are more likely to experience RSD.⁹

Symptoms and characteristics

Those with RSD show may show a combination of the symptoms below:

• Intense feelings when rejected or criticised, often finding it difficult to contain these emotions
• Intense feelings after rejection or perceived rejection may lead to depressive episodes or sudden emotional shifts.
• High self-criticism and often blaming themselves for the rejection or perceived rejection
• Hypervigilance for signs of rejection
• Ruminating over the unpleasant emotions
• Low self-esteem
• Problems with relationships
• Often act as “people pleasers” in order to gain approval from others due to the fear of rejection.
• Anxious in social settings, easily embarrassed or self-conscious
• May avoid new experiences or relationships due to fear of rejection
• Difficulty starting new projects and may procrastinate due to fear of failure
• May compensate for fear of failure or rejection by striving for perfectionism.⁸

Causes and triggers

RSD is not an official diagnosis, and therefore, there is a lack of evidence regarding its cause. However, some research in the field does suggest that it is linked to differences in emotional regulation processes in the brains of those with ADHD and autism.^{9, 2} 

Triggers can include perceived abandonment of loved ones or feeling excluded in social situations, as well as receiving negative feedback at work or academic underperformance.⁸

Genetic factors in RSD

Considering its link with ADHD and autism, which both have a strong genetic component, genes are also likely to be a contributing factor to RSD.^{10, 11}

Early experiences and RSD

There is also evidence pointing to a link between rejection sensitivity and neglect, abuse or rejection experienced earlier in life by a caregiver or in social settings. This may then cause the individual to act in ways to avoid any future possibilities of experiencing rejection.¹² 

Diagnosis and assessment 

As mentioned above, RSD is not a condition on its own in the DSM-5, which is the professional reference book for mental health and brain-related conditions for clinicians and medical professionals. However, it is listed as an associated feature that supports the diagnosis of ADHD and autism.⁶

Rejection sensitivity also forms the diagnostic criteria for mental health conditions such as social anxiety disorder, depression, borderline personality disorder, avoidant personality disorder, bulimia, body dysmorphia, suicidal ideation, and substance or alcohol abuse disorders.

Management and treatment

Medications

The treatment for RSD depends on the severity of symptoms and the overlapping of other conditions. Medications which treat underlying conditions such as ADHD may also help with RSD symptoms as the same areas of the brain are affected.¹⁴

These include:

• Stimulant medications: these increase neurotransmitters, such as the levels of free dopamine in the brain.
• Alpha-2 receptor agonists: these stimulate alpha-2 receptors in the prefrontal cortex, strengthening signals of the neurotransmitter norepinephrine, which is often deficient in those with ADHD.¹⁵
• Monoamine oxidase inhibitors: these include medications such as Selegiline, which is used to treat ADHD and depression. The medication inhibits the enzyme monoamine oxidase, which is responsible for removing neurotransmitters such as serotonin, dopamine, and norepinephrine, leading to increased levels of these in the brain.¹⁶

Psychotherapy

Psychotherapy can help identify thought patterns which may be contributing to the severe emotional responses to rejection. With a trained therapist, you can learn to manage and process the feelings so they are less overwhelming, as well as learn to challenge some of the irrational thoughts, which are contributing to the emotions that are being felt.¹⁷

The role of self-help techniques in RSD

Specialists recommend techniques to help reduce negative thoughts, including: 

• Developing positive affirmations such as, “I am stronger than I think”, “Everything will be okay”, “I am doing great”, and “It is okay to take risks and see what happens”.
• Identifying and remembering individual strengths, which allows a shift from negative self-talk to more acknowledgement of what you have achieved and can do despite your difficulties.
• Avoid rushing to conclusions about the rejection you have experienced or perceived to have experienced. 

Other useful notes to help manage RSD include:

• Meditation, learning to calm down the nervous system and be more in the present moment when your emotions become too overwhelming.
• Prioritising self-care.
• Having self-compassion.
• Surround yourself with family and friends who you feel accepted around.¹⁹

If you believe you may have RSD, it is important to seek help from a healthcare professional. Visit your GP to discuss treatments or refer you to a mental health specialist for therapy.

Long term outcomes

Those who have RSD may develop “defence mechanisms” or unhelpful behaviours in order to minimise the chance of experiencing anticipated rejection.²⁰ They also tend to experience social anxiety, loneliness and low self-esteem as a result of the fear of rejection and learned behaviours. This can go on to affect their work, school and social life, particularly friendships and relationships.²⁰ 

They are also more likely to develop mental health conditions such as depression.²¹ Identifying that you may be experiencing these symptoms and getting help from a professional who can provide treatment, as well as practising self-help techniques, can help you learn to control emotional responses and adapt your behaviours. This will help to manage the condition better and minimise the impact on your daily life.

Summary

Rejection-sensitive dysphoria is when an individual experiences intense emotional pain to rejection or perceived rejection, to the point it may become overwhelming. This can result in learned behaviours or “defence mechanisms”, causing the individual to avoid entering situations or taking on opportunities in which they anticipate rejection, real or perceived. This can relate to relationships, work, academia or social situations, eventually leading to feelings of loneliness and low self-esteem. 

Although RSD is not a recognised medical condition on its own, it is often linked to conditions such as ADHD and autism, where it forms part of the diagnostic criteria for these conditions. Treatments include medications, therapy and self-help techniques, which can help better manage emotions and adapt behaviours in response to rejection.

If you feel you may have RSD and it is impacting your daily life, it is important to talk to a GP or mental health professional who can help you better understand and manage it.