rejection sensitive dysphoria

rejection sensitive dysphoria (RSD), a feeling of severe emotional pain in response to rejection, criticism, or failure, whether real or perceived. RSD is closely associated with attention-deficit/hyperactivity disorder (ADHD), though it can affect persons who are not diagnosed with ADHD. It is not formally recognized as a clinical diagnosis in the text revision of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (2022).

Characteristics

The term dysphoria describes a profound state of unease or dissatisfaction, and in RSD it refers to extreme emotional pain that occurs when an affected individual feels rejected, ridiculed, or criticized. Indeed, those who experience RSD tend to anticipate rejection and feel extreme anxiety about the possibility of rejection. The cause of the condition is not fully known, though, as in ADHD, differences in emotional processing in the brain may be an underlying factor. Experiences in early life, such as being rejected by friends, being subjected to frequent criticism, or being bullied, as well as social isolation in adulthood, likely heighten sensitivity to rejection.

Persons affected by RSD often find it difficult to convey the nature and intensity of their pain, which differs from other types of physical and emotional pain. Many affected individuals interpret otherwise innocuous behaviors as rejection and, especially in the case of children and teenagers, overreact emotionally, generally in the form of anxiety, rage, or sadness. Emotions may be expressed outwardly, such as by crying or yelling, or they may be internalized, which can give an appearance of severe depression.

Impacts and physical symptoms

In addition to having impacts on emotional regulation, RSD can significantly affect self-esteem, leading to decreased confidence and a propensity to feel self-conscious and embarrassed. Some individuals become perfectionists in a bid to avoid failure, though such efforts can add to stress-related impacts on health. To avoid rejection, others become people pleasers—always striving to please others, often at the expense of their own well-being; fear of rejection can lead to difficulties in forming or maintaining relationships. Fear of criticism or failure often causes individuals to avoid challenges, which can impact performance at school or work.

Although primarily an emotional and psychological phenomenon, RSD also sometimes manifests in physical symptoms, which can develop as a result of chronic emotional distress. Examples of physical symptoms include fatigue and physical exhaustion, gastrointestinal disturbances, headaches, high blood pressure, muscle tension, sleep disturbances, weakened immunity, and weight gain or weight loss.

RSD frequently occurs alongside other mental health conditions, particularly anxiety and depression. Individuals affected by RSD may also be at increased risk of borderline personality disorder and increased risk for self-harm or suicide. Symptoms of RSD may fade over time, particularly through adolescence, owing to ongoing brain development and maturation; for others, however, it is a lifelong condition.

Treatment

Treatment for RSD often consists of a combination of psychotherapy and medication. Psychotherapy can help individuals learn to manage their pain and emotions. Medications that augment brain activity, including alpha-2 receptor agonists and stimulants such as amphetamine, can help improve emotional regulation. Antidepressants such as monoamine oxidase inhibitors and sedatives such as benzodiazepines may be used to manage symptoms of depression and anxiety, respectively.

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