“I think I have ADHD partly because I suffer from Rejection Sensitivity Dysphoria”. This is something people sometimes say at the beginning of an online adult ADHD Assessment”.
But is Rejection Sensitivity Dysphoria actually a symptom of ADHD?
In an ADHD Assessment in the UK, we use the DSM 5¹ to diagnose ADHD. So, in this formal sense, “a symptom” is one of the 9 symptoms of Inattention or one of the 9 symptoms of Hyperactivity/Impulsivity named in the DSM 5.
If you haven’t come across the term before, Rejection Sensitivity Dysphoria (RSD) is an experience described by the researcher William Dodson, as, “an experience of perceived rejection which indicates a sensitivity to rejection and creates dysphoric mood which causes distress and impairment”. “Dysphoric” literally means something which is hard to bear, or in other words very intense and emotionally painful. RSD is not a formal diagnostic category although it is very commonly used in social media and in some academic contexts.
The psychologist Dr Megan Neff, who writes as someone who has ADHD and experiences rejection sensitivity herself, describes it as typically consisting of:
Intense Emotional Pain: Feelings of sadness, anger, or worthlessness that can be overwhelmingly intense in response to perceived rejection or criticism.
Physical Discomfort: Physical sensations like a heavy chest, racing heart, or knot in the stomach when facing situations that trigger RSD.
Avoidance Behaviours: Going to great lengths to avoid situations, conversations, or interactions that might lead to rejection or criticism.
Hypervigilance: Constantly scanning and analysing social cues, looking for signs of potential rejection.
Low Self-Esteem: A pervasive sense of inadequacy and self-doubt, often stemming from the fear of not measuring up to others’ expectations.
Negative Self-Talk: Engaging in harsh self-criticism and negative self-talk, often believing oneself to be fundamentally flawed or unlovable.
Defensive Reactions: Reacting defensively or with anger when faced with even mild criticism or perceived rejection.
Emotional Instability: Rapid shifts in mood and emotions, especially in response to perceived slights or rejections.
Social Isolation: Withdrawing from social interactions or relationships to minimize the risk of experiencing rejection.
Research by Modestino and colleagues in 2024² , found that rejection by others also leads to, “the person’s rejection of themselves, because they believe they have failed or fallen short of their standards”. In all the literature, RSD is associated with the more general emotion dysregulation which many people with ADHD experience. Emotion dysregulation is when someone struggles to manage their emotions. So, if someone with ADHD becomes very upset, they may find it extremely difficult to move out of this feeling and it may last for several hours or days. People with ADHD also often report that they their moods are “very up and down” and that their emotional experience is very intense. All of these factors are a part of emotion dysregulation. It’s as if someone’s emotional thermostat isn’t working properly and so their emotional temperature fluctuates wildly and is hard to moderate or bring back to a steady baseline.
A group of researchers at the University of Sussex, led by Annabel Rowney-Smith³, interviewed people with ADHD who experienced rejection sensitivity. They found that these people typically described 3 themes: withdrawal, masking and bodily sensations. They said that the participants in their study, “explained how rejection sensitivity elicited unpleasant bodily sensations, anxiety and misery and how they used masking to camouflage these feelings”. The researchers concluded that the process of hiding their feelings led to individuals being disconnected from themselves and withdrawing from others. They said that this process had a negative impact “on mental wellbeing and social function”.
So, many people with ADHD experience an intense sensitivity to rejection which they struggle to manage and which causes them high levels of distress. However, there is no research to indicate what proportion of people with ADHD may experience rejection sensitivity. Rejection sensitivity is also experienced by many people who do not have ADHD, such as those who have social anxiety or are highly sensitive in general. More broadly, Emotion dysregulation, which most clinicians would say is very typically experienced by people with ADHD, is also not a formal diagnostic category of ADHD as diagnosed within the UK by the DSM 5. Although, interestingly, it is 1 of 6 diagnostic categories for ADHD used by the European Union. In the UK, one of the reasons for not including emotion dysregulation as a diagnostic category for ADHD (and therefore as a formal “symptom”) is that emotion dysregulation occurs in a very broad range of mental health conditions and so it is not very helpful as a characteristic which distinguishes ADHD from many mental health conditions.
In the UK, rejection sensitivity is not a formal symptom or diagnostic category of ADHD.
¹ Diagnostic and Statistical Manual of Mental Disorders, 5th edition
² E. Modestio et al “Rejection Sensitivity Dysphoria in Attention Deficit/Hyperactivity Disoder: A Case Series”. Acta Scientific Neurooldy 7.8, (2024) 23-30.
³ A.Rowney-Smith et al, The lived experience of rejection sensitivity in ADHD – a qualitative exploration. (Pre-print. Not yet peer reviewed 2024).
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