Rejection Sensitive Dysphoria (RSD)

What is rejection sensitive dysphoria (RSD)?

Rejection sensitive dysphoria (RSD) is when a person feels intense emotional pain related to rejection. The word “dysphoria” comes from an ancient Greek word that describes a strong — if not overwhelming — feeling of pain or discomfort. Though RSD isn’t an officially recognized symptom or diagnosis, it’s still a term that experts use in connection with recognized conditions.

While rejection is something people usually don’t like, the negative feelings that come with RSD are stronger and can be harder to manage or both. People with RSD are also more likely to interpret vague interactions as rejection and may find it difficult to control their reactions.

What’s the difference between rejection sensitivity and rejection sensitive dysphoria?

RSD and rejection sensitivity are closely linked, but there are subtle differences. To understand the differences, it helps to first know about an issue known as emotional dysregulation.

What is emotional dysregulation?

The human brain has an elaborate network of connections between its different areas. Those areas have different jobs, with some areas managing memories, emotions, input from your senses, etc. As you get older, your brain learns to regulate those signals, keeping them at manageable levels. This is much like the volume control on a TV when it keeps the sound at levels you find comfortable.

Emotional dysregulation happens when your brain can’t properly regulate the signals related to your emotions. Without that ability to manage them, it’s as if the TV volume control is stuck at a disruptively or painfully high level. In effect, emotional dysregulation is when your emotions are too loud for you to manage, causing feelings of being overwhelmed, uncomfortable or even in pain.

Emotional dysregulation can happen with many conditions, especially those affecting your brain’s structure or how it processes information. It happens commonly with personality disorders, mood disorders and more.

Emotional dysregulation and rejection sensitivity

Emotional dysregulation happens with both rejection sensitivity and RSD. Dysphoria doesn’t. People with rejection sensitivity can do one or more of the following:

• Feel severe anxiety or other negative emotions before an anticipated rejection.
• Have trouble seeing nonpositive interactions (such as neutral or vague reactions) as anything but rejection and react accordingly.
• Overreact to feelings of rejection, leading to behavior that reflects negative emotions like anger, rage, extreme sadness, severe anxiety, etc.

While all of those are also possible with RSD, there’s one more component: People with RSD describe feeling an intense — if not overwhelming — level of emotional pain.

What are the symptoms of rejection sensitive dysphoria?

As mentioned, the key symptom of RSD is intense emotional pain. That pain usually has to be triggered by rejection or disapproval. However, people with RSD often have difficulty describing what it feels like because it’s so intense and unlike most other forms of pain (emotional or otherwise).

People with RSD often show the following traits and behaviors:

• It’s very easy for them to feel embarrassed or self-conscious.
• They show signs of low self-esteem and trouble believing in themselves.
• They have trouble containing emotions when they feel rejected. This is often noticeable in children and teenagers with this condition. Some may react with sudden shows of anger or rage, while others may burst into tears.
• Instead of losing control of their emotions outwardly, some people with RSD may turn their feelings inward. This can look like a snap onset of severe depression, and sometimes, it’s mistaken for sudden emotional shifts that can happen with bipolar disorder or borderline personality disorder.
• They’re often “people pleasers” and become intensely focused on avoiding the disapproval of others.
• They may avoid starting projects, tasks or goals where there’s a chance of failure.
• They compensate for their fear of failure or rejection by going all-out or striving for perfectionism. However, the downside of this is that they often experience intense anxiety and may not easily make self-care or downtime a priority.

Who does rejection sensitive dysphoria affect, and how common is it?

There’s limited available research on exactly who experiences RSD and how common it is. But the condition seems to happen most often in people with ADHD. Experts have also linked it to other personality and mood disorders, but more research is necessary regarding who experiences this issue and how common it is.

What causes rejection sensitive dysphoria?

Experts aren’t sure exactly why RSD happens. But they suspect it involves issues with the structure of your brain and that it happens for similar reasons as ADHD.

Researchers do know that social rejection — even when it’s vague or uncertain — causes similar brain activity to pain. They also know that the brain of someone with ADHD doesn’t regulate internal communication the same way as the brain of someone without ADHD. The brain areas that filter and regulate signals aren’t as active. This means there’s less of a filter on brain activity.

This difference in regulating internal communication is why people with ADHD commonly have trouble processing information from their senses. It also makes them prone to feeling overwhelmed by loud noises, bright lights or sudden changes in what’s happening around them. The brain of someone with ADHD might not be able to regulate pain-like activity, which would explain why rejection is so much more troubling and painful to someone with RSD.

Genetic connections

ADHD is a condition that has a genetic component, which means it commonly runs in families. Likewise, RSD — which has strong links to ADHD — is also more likely to have a genetic link.

Is rejection sensitive dysphoria contagious?

RSD isn’t an infectious condition. You can’t catch it from or spread it to others.

How is rejection sensitive dysphoria diagnosed?

RSD isn’t an officially recognized medical condition. It’s also a condition for which there’s limited scientific research available. As a result, healthcare providers may not know much about it or have a great deal of experience with it.

Instead, clinicians may suspect that you have it based on the symptoms you describe and whether you have other conditions like ADHD. Unfortunately, providers may not diagnose it because they aren’t familiar with RSD, or they mistake it for another condition.

How is rejection sensitive dysphoria treated, and is there a cure?

While there’s much that experts don’t know about RSD, there are still ways that experts can treat it. The treatment approaches can also take different forms, and it’s common to use multiple treatment approaches at the same time.

Medications

Medications are the main way to treat RSD. The drugs in question typically treat ADHD and related conditions. That’s because treating these conditions affects the same brain areas responsible for RSD symptoms, so treating one condition affects both. Other conditions have very similar effects on the same brain areas as RSD, and treatments for those conditions can often help.

Because RSD isn’t an officially recognized medical condition, there aren’t any medications specifically approved to treat it. Instead, healthcare providers use a practice known as “off-label prescribing.”

Off-label prescribing means a healthcare provider prescribes a medication for conditions other than the ones they’re specifically approved to treat. This kind of prescribing is legal, medically acceptable and justified when evidence shows a medication has a low risk of causing harmful side effects and is effective for off-label use.

The following medication types can treat RSD:

• Alpha-2 receptor agonists. This type of medication activates a specific type of chemical receptor found on neurons (brain cells) in specific brain areas. Medications that activate those receptors, such as clonidine and guanfacine, make those areas more active. Activating those brain areas makes it easier for your brain to regulate internal communication, reducing the effect of RSD.
• Stimulant medications. These medications increase the levels of certain neurotransmitters in your brain. Neurotransmitters are chemical messenger molecules that your brain uses to communicate and activate or deactivate certain processes. Increasing certain types of neurotransmitters can increase activity in specific brain areas. That’s how stimulant medications such as amphetamine/dextroamphetamine (commonly known as Adderall®) and methylphenidate (better known as Ritalin®) make brain areas that regulate communication more active.
• Monoamine oxidase inhibitor (MAOI) medications. This class of medications treats depression, but experts also know medications such as tranylcypromine can help with RSD. However, you can’t take these medications at the same time as other common medications for ADHD. You also have to be careful with what you eat because certain foods (such as aged or strong cheeses, aged meats, etc.) can interact with MAOIs and cause a dangerous spike in blood pressure.

Psychotherapy

Psychotherapy (also known as mental health therapy) can help people with RSD. Therapy doesn’t stop RSD from happening or affect the symptoms. Instead, therapy can help a person learn how to process and manage feelings so they’re less overwhelming. That can help a person with RSD feel more in control of their emotions.

What are the possible side effects or complications of treatment?

The possible side effects and complications of the various treatments depend on various factors, especially the treatments themselves. Because of that, your healthcare provider is the best person to tell you what side effects or complications are possible or likely, and what you can do to limit how they affect you.

How do I take care of myself or manage the symptoms on my own?

If you think you have RSD, it’s important to see a healthcare provider to get a diagnosis of a related condition like ADHD and then to follow up with a mental health provider. Some people can learn to manage RSD on their own, but it’s difficult to do so. That’s because RSD happens based on how your brain functions.

People with RSD also commonly have other mental health conditions, including anxiety and depression. In most cases, it takes a combination of medication and mental health therapy to learn to live with this condition. Your provider can recommend treatment options and guide you on what you can do to help yourself as you learn to manage RSD.

How soon after treatment will I feel better?

The time it takes to notice a difference from treatment depends on the treatments you receive. Medications can help with the symptoms, but mental health therapy offers the best chance of learning to live with RSD.

Because no two people’s brains are alike, and conditions like ADHD and RSD affect people differently, the time it takes to notice changes and improvements can also vary. Your healthcare provider is the best person to tell you more about when you should expect to notice changes and what else you can do to help yourself manage this condition.

How can I reduce my risk of developing rejection sensitive dysphoria or prevent it entirely?

Unfortunately, RSD happens for unpredictable reasons that experts don’t yet understand. Because of that, it’s impossible to prevent it or reduce your chances of developing it.

What can I expect if I have RSD?

People with RSD typically develop behaviors and mental health issues that stem from their fear of rejection. Children with ADHD and RSD also face potential problems with low self-esteem, fear of failure and severe social anxiety. These issues can affect performance in school, building social relationships and friendships, and more. Researchers have also linked rejection sensitivity to a higher risk of having a personality disorder.

Adults with RSD are more likely to experience anxiety, depression and loneliness. People with RSD often avoid situations where the outcome or success is uncertain. This can lead to avoiding job opportunities, forming friendships or romantic relationships, and more.

How long does RSD last?

There’s limited available research to show how long RSD lasts. People may grow out of ADHD as their brains develop, meaning that the condition eventually resolves on its own. For people who don’t grow out of ADHD, a condition like RSD is most likely a permanent, lifelong concern.

However, diagnosis and treatment — especially earlier in life — make it possible for people to adapt and manage it. Eventually, people with RSD may overcome the effects or at least learn how to limit its impacts on their lives.

What’s the outlook for this condition?

RSD on its own isn’t dangerous. But it does have connections to conditions that can be dangerous. Among these are anxiety and depression, which may increase the risk of self-harm or dying by suicide.

When to seek emergency care

You should get immediate help if you have thoughts about harming yourself, including thoughts of suicide, or about harming others. You should also seek immediate help if you suspect someone you know is in imminent danger of harming themselves.

To get help in these situations, you can call any of the following:

• National Suicide Prevention Lifeline (United States). This line can help people who are struggling with suicidal thoughts or impulses. To call this line, dial 988.
• Local crisis lines. Mental health organizations and centers in your area may offer resources and help through crisis lines if you are struggling with thoughts of suicide, self-harm or harming others.
• 911 (or your local emergency services number). You should call 911 (or the local emergency services number) if you feel like you are (or someone you know is) in immediate danger of self-harm or suicide. Operators and dispatchers for 911 lines can often help people in immediate danger because of a severe mental crisis and send first responders to assist.

How do I take care of myself?

If you think you have RSD, it’s important to talk to a healthcare provider who specializes or has experience with treating ADHD and its related conditions. A healthcare provider is best prepared and qualified to diagnose RSD and guide you on possible treatments and how to manage this condition.

You should also keep in mind the following:

• Medications make a big difference. If medication is part of your treatment plan, it’s important to build taking medication into your routine. These medications can help make RSD and its effects easier for you to process and manage.
• Find a therapist you click with and see them regularly. Learning to adapt your thought processes and behaviors is crucial to managing RSD. Mental health providers like therapists or counselors can help you develop new ways of thinking and strategies that limit the impact of RSD on your life.
• Make self-care a priority. Stress and anxiety can make RSD feel even worse. Finding ways to limit your stress can help you adapt to RSD.
• Be nicer to yourself. Failure and rejection are something that everyone experiences at some point in life. Understanding and accepting that’s a part of managing RSD. If you find yourself facing these feelings, finding healthy ways to accept and process how you feel can help you avoid immediate reactions that you might later wish you could take back.

How do I help my child if I think they have RSD?

Children who have ADHD have a much higher risk of also having RSD. If your child shows symptoms of either, you can do the following to help them:

• Talk to a healthcare provider. Early diagnosis and treatment can make an enormous difference when it comes to the overall effect of RSD and its related conditions.
• Understand that RSD is real and how it works. Research shows that ADHD is a condition that happens because of specific differences in an affected person’s brain. Those same changes are likely what causes RSD to happen, too. That means children with these conditions are often unable to manage their behavior because of how their brains work, no matter how badly they want to or how hard they try.
• Be patient. Children with ADHD face challenges (see our article on what it means to be neurodivergent to learn more), and frequent criticism can intensify the effects of RSD and make it feel much worse.
• Help your child learn resilience. Failure and rejection happen to everyone. Teaching children how to learn from failures and recover can help your child cope with RSD and its effects.

A note from Cleveland Clinic

Rejection sensitive dysphoria (RSD) is a problem that interferes with your ability to regulate your emotional responses to feelings of failure and rejection. While rejection is almost always unpleasant, people with RSD experience overwhelming levels of emotional pain. This can lead to long-term mental health issues, fear of failure and behavior changes that negatively affect them throughout their lives.

While RSD isn’t an officially accepted medical condition, there’s growing evidence and understanding of how this condition works. It’s also possible for healthcare providers to treat it using treatments and approaches that help similar or related conditions. If you suspect you have RSD, you should talk to a healthcare provider specializing in conditions like ADHD. These professionals are best equipped to help you understand and learn to manage this issue.