More threads by Retired


How ADHD Ignites Rejection Sensitive Dysphoria
ADDitude, William Dodson, M.D.
Posted July 5, 2017

The extreme emotional pain of perceived rejection is a feeling unique to people with ADHD, and it can be debilitating. Learn how RSD may be impacting your patients.

Rejection sensitive dysphoria (RSD) is an extreme emotional sensitivity and emotional pain triggered by the perception – not necessarily the reality – that a person has been rejected, teased, or criticized by important people in their life. RSD may also be triggered by a sense of failure, or falling short – failing to meet either their own high standards or others’ expectations.

Dysphoria is Greek for “difficult to bear.” It’s not that people with ADHD are wimps, or weak; it’s that the emotional response hurts them much more than it does people without the condition.

When this emotional response is internalized, it can imitate full, major depression complete with suicidal ideation. The sudden change from feeling perfectly fine to feeling depressed that results from RSD is often misdiagnosed as rapid cycling bipolar disorder.

It can take a long time for physicians to recognize that these symptoms are caused by the sudden emotional changes associated with ADHD and rejection sensitivity, while all other object relations are totally normal.

When this emotional response is externalized,
it looks like an impressive, instantaneous rage at the person or situation responsible for causing the pain. 50% of people who are assigned court-mandated anger-management treatment have previously unrecognized ADHD.

RSD can make people with ADHD anticipate rejection — even when it anything but certain. This can make them vigilant about avoiding it, which can be misdiagnosed as social phobia. Social phobia is an intense anticipatory fear that you will embarrass or humiliate yourself in public, or that you will be scrutinized harshly by the outside world.

Rejection sensitivity is hard to tease apart. Often, people can’t find the words to describe its pain. They say it’s intense, awful, terrible, overwhelming. It is always triggered by the perceived or real loss of approval, love, or respect.

People with ADHD cope with this huge emotional elephant in two main ways, which are not mutually exclusive.

1. They become people pleasers. They scan every person they meet to figure out what that person admires and praises. Then, that’s the false self they present. Often this becomes such a dominating goal that they forget what they actually wanted from their own lives. They are too busy making sure other people aren’t displeased with them.

2. They stop trying. If there is the slightest possibility that a person might try something new and fail or fall short in front of anyone else, it’s just too painful and too risky to even consider. So, these people just don’t. These are the very bright, capable people who become the slackers of the world and do absolutely nothing with their lives because making any effort is so anxiety-provoking. They give up going on dates, applying for jobs, or speaking in meetings.

Some people use the pain of RSD to find adaptations and overachieve. They constantly work to be the best at what they do. Or, they are driven to be above criticism/reproach. They lead admirable lives, but at what cost? They strive for perfection, which is never attainable, and are constantly driven to achieve more.

How to Treat RSD
Rejection sensitivity is part of ADHD. It’s neurologic and genetic. Early childhood trauma makes anything worse, but it does not cause RSD. Often, patients are comforted just to know there is a name for this feeling. It makes a difference knowing what it is, that they are not alone, and that almost 100% of people with ADHD experience rejection sensitivity. After hearing this diagnosis, they know it’s not their fault, that they are not damaged.

Psychotherapy does not particularly help patients with RSD because the emotions hit suddenly and completely overwhelm the mind and senses. It takes a while for someone with RSD to get back on his feet after an episode.

There are two possible medication solutions for RSD.

The simplest is to prescribe the alpha agonists guanfacine and clonidine together. These were originally designed as blood pressure medications. The optimal dose varies from half a milligram up to seven milligrams for guanfacine, and from a tenth of a milligram to five tenths of a milligram for clonidine. Within that dosage range, about one in three people feel relief from RSD. When that happens, the change is life altering. The treatment can make an even greater difference than a stimulant does to treat ADHD.

According to information apparently originating from the author, Dr. Bill Dodson, the above paragraph contains typographical errors in the original ADDitude article, that erroneously refers to medications that should not be used together. The paragraph has been struck through and any inquiries about the use of medications should be directed to one's physician. Steve, Psychlinks

One study by Harvard University found that raising the dose of guanfacine to four milligrams and clonidine to seven or eight milligrams (above the dosage limits the FDA approves), achieved a 40% higher response rate. However, this comes with side effects that can include dry mouth, mild sedation, and sometimes orthostatis, or becoming dizzy when you stand up too quickly.

The second treatment is prescribing monoamine oxidase inhibitors (MAOI) off-label. This has traditionally been the treatment of choice for RSD among experienced clinicians. It can be dramatically effective for both the attention/impulsivity component of ADHD and the emotional component. Parnate (tranylcypromine) often works best, with the fewest side effects. Common side effects are low blood pressure, agitation, sedation, and confusion.

MAOIs were found to be as effective for ADHD as methylphenidate in one head-to-head trial conducted in the 1960s. They also produce very few side effects with true once-a-day dosing, are not a controlled substance (no abuse potential), come in inexpensive, high-quality generic versions, and are FDA- approved for both mood and anxiety disorders. The disadvantage is that patients must avoid foods that are aged instead of cooked, as well as first-line ADHD stimulant medications, all antidepressant medications, OTC cold, sinus, and hay fever medications, OTC cough remedies. Some forms of anesthesia can’t be administered.


The Fear of Failure Is Real - and Profound
Posted July 6, 2017

Researchers have ignored the emotional component of ADHD because it can?t be measured. Yet emotional disruptions are the most impairing aspects of the condition at any age.? Powerful insights into rejection-sensitive dysphoria.

You cannot manage the impairments of ADHD until you understand how you process emotions and shame. Researchers have ignored the emotional component of ADHD because it can?t be measured. Yet emotional disruptions are the most impairing aspects of the condition at any age. Fortunately, medications like Intuniv can provide some relief.

Nearly everyone with ADHD answers an emphatic yes to the question: ?Have you always been more sensitive than others to rejection, teasing, criticism, or your own perception that you have failed or fallen short?? This is the definition of a condition called rejection-sensitive dysphoria. When I ask people with ADHD to elaborate on it, they say: ?I?m always tense. I can never relax. I can?t just sit there and watch a TV program with the rest of the family. I can?t turn my brain and body off to go to sleep at night. Because I?m sensitive to my perception that other people disapprove of me, I am fearful in personal interactions.? They are describing the inner experience of being hyperactive or hyper-aroused. Remember that most kids after age 14 don?t show much overt hyperactivity, but it?s still present internally, if you ask them about it.

The emotional response to the perception that you have failed, or even the fear of failure, is catastrophic for those with the condition. The term ?dysphoria? means ?difficult to bear,? and most people with ADHD report that they ?can hardly stand it.? They are not wimps; disapproval hurts them much more than it hurts neurotypical people.

If emotional pain is internalized, a person may experience depression and loss of self-esteem in the short term. If emotions are externalized, pain can be expressed as rage at the person or situation that wounded them.

One Foot. The Other. Repeat.
In the long term, there are two personality outcomes. The person with ADHD becomes a people pleaser, always making sure that friends, acquaintances, and family approve of him. After years of constant vigilance, that person becomes a chameleon who has lost track of what she wants for her own life. Others find that the pain of failure is so bad that they refuse to try anything unless they are assured of a quick, easy, and complete success. Taking a chance is too big an emotional risk. Their lives remain stunted and limited.

For many years, rejection-sensitive dysphoria has been the hallmark of what has been called atypical depression. The reason that it was not called ?typical? depression is that it is not depression at all but the ADHD nervous system?s instantaneous response to the trigger of rejection.

Until recently, all that a person with ADHD could do was to wait for his dysphoria to dissipate over time. Clinical experience has found that up to half of people with rejection sensitivity can get some relief from the alpha agonists, either clonidine (Kapvay) or guanfacine (Intuniv). More investigation and research are called for, but if you think that you may have rejection-sensitive dysphoria, talk with your doctor about it.


Hello, Steve

I read the above article and having done some research concerning the treatment of RSD with a combination of Clonidine and Guanfacine, I chose to contact the author directly, and received the following email.

Dear Mr. Pxxxxx,

First of all, be careful of what you find on the web. Most of it is wrong and/or intentionally misleading.

Second, ADDitude made a misprint when it wrote Clonidine and guanfacine rather than Clonidine or guanfacine. They are not used at the same time, they are used sequentially if the first one tried does not provide dramatic benefits. About 30-35% of people do very well on clonidine and another different 30-35% of people get a very good response to guanfacine for a total of about 60% of people who try both sequentially who get a very robust response. Unfortunately, that also means that about 40% of people do not get benefits and for those people we try a Monoamine oxidase inhibitor (MAOI) such as Parnate.

I share your frustration at trying to find further published research on Rejection Sensitive Dysphoria (Hysteroid Dysphoria) especially as it pertains to ADHD. There is virtually nothing out there. The best I can do is tell you how I came to the understanding I have now and share with you the materials I have written or pulled together from a number of sources.

I am a great admirer of Dr. Paul Wender who was the first person to lay out the basics of what ADHD is and how to treat it 40 years ago only to be promptly ignored and thwarted by the researchers at the major Universities (he was in Salt Lake City Utah). Wender got it right the first time and got beaten up his entire career.

His work was going on simultaneously with the first work on dysphoria. People see what they are trained to see. Researchers in mood disorders saw the phenomenon as a type of atypical mood disorder (despite the fact that RSD has not one single feature required for the diagnosis of a mood disorder). People who were doing the first work on Borderline Character Organization saw RSD in terms of BCO and disturbed object relations (again despite the fact that the vast majority of people with ADHD having absolutely normal object relations). Wender talked all around the subject of Rejection Sensitive Dysphoria but never could bring himself to say that RSD was an intrinsic and universal feature of ADHD. I would have loved to have had the opportunity to ask him why he never wrote the words despite clearly having figured it out.

The research guys have to publish or perish and so needed things they could count and do statistics on in order to make it "scientific." As a result they used only observational / behavioral criteria that could be seen and counted for the diagnostic criteria and actively avoided anything that had to do with emotion, thinking styles, relationships, etc. etc. The emotions of RSD have 3 strikes against them. RSD isn't always there, it can't be measured, and people with RSD are usually shamed by their over-reactions and hide them.

That is a long preamble to the fact that I am a practitioner and not a researcher. When I hear the same thing from 1000 people in a row I know it is vitally important even if I don't yet understand it. This type of experiential knowledge is sneered at and devalued by the research guys even though they have been wrong 82 times in a row using their pure methods.

So you now have all that I have been able to pull together in the last 12 years. I fully understand that it is not the level of authority with which we all feel most comfortable but for the reasons I laid out that type of data will not come in my lifetime.

My validation comes from 2 sources. First, my patients tell me that they feel understood for the first time in their lives and feel a tremendous relief that they are not alone with this sensitivity. Second is the simple validation that these medications work. And when they work, the are life changing. That is something that no traditional researcher is able to say.

I hope this is helpful.

Dr. Bill Dodson
Replying is not possible. This forum is only available as an archive.