ADHD 101: RSD(REJECTION SENSITIVE DYSPHORIA)
What is RSD?
REJECTION SENSITIVE DYSPHORIA was first coined by Dr. William Dodson as a mood disorder that could be defined was emotional hyper sensitivity. He labeled it as a mood disorder related to ADHD impacted individuals
In his own words, “RSD is an extreme emotional sensitivity and emotional pain triggered by the perception or imagination by the person with ADHD that they have:
● been rejected
● been teased
● been criticized
● disappointed important people in their lives
● withdrawn their own approval of themselves when they failed to attain their own standards or goals”
Unfortunately (and this was true in my case) an ADHD impacted individual can spend years, decades even in talk therapy with uninformed mental health professionals and be misdiagnosed with a host of various disorders. In my case, it was Depression. I spent years explaining away this internal shame, guilt and feeling of not being good enough to therapists. None of it changed how I felt inside. Nor were there really any explanations for these feelings. It was very easy to “blame” my abusive, alcoholic father – that only went so far. It seemed that this depression was much deeper and regardless of the talk therapy I did, nothing seemed to shake it. I would be driving home from seeing friends think to myself “they all hate you”. I would wake up next to my amazing wife and wonder when she was going to leave me.. these thoughts were not rational and made no sense given the evidence in front of me.
I used to think I had social anxiety, I would often tell people I was shy.. but the doctor has a very clear distinction between the two:
“Social phobia is an intense anticipatory fear prior to a public event that the person is going to do or say something embarrassing in public or be scrutinized harshly. Once the person is in the anxiety-provoking situation, the anxiety diminishes or even goes away. RSD is a triggered, wordless emotional pain that occurs after a real or perceived loss of approval, love, or respect.”
What fascinates me about my history with this is that often once I was in the anxiety producing event, I could “fake it”. But the minute I was off stage or away from the group, I would settle into this emotional pain about who I am and how the people must be judging me. I never accepted the complaints given and felt everyone was lying to me. I trusted them as much as I trusted myself.
To make RSD more difficult for ADHD impacted individuals seeking treatment is that the internalization of RSD can be misdiagnosed as borderline personality disorder and bipolor and of course for rapid cycling depression.
RSD manifests in two distinct fashions:
Internalized – This looks like a catastrophic emotional reaction. When triggered it can be very dramatic complete with a depressive episode featuring suicidal thoughts and tendencies. It seems out of the blue and instant to both the sufferer and surrounding support system. The interpersonal nature of the trigger makes the individual seem borderline. They are not, they are hyper sensitive with a triggered response to a perceived rejection. Due to the RSD, the person can be thought of as “over sensitive” and someone who needs to be “talked down” often.
Externalized – The reaction looks like a flash rage. The rage is typically targeted at the person or situation that the sufferer perceives as having opened this wound. According to Dr. Dodson’s data “50% of individuals court mandated to anger management training for domestic violence or road rage has previously undiagnosed ADHD”
For adults with RSD, it can be a lifetime of being a people pleaser as a coping skill to stave off any form of potential rejection. This also handicaps adults from asking for their needs to be met, speaking up, applying for new jobs, taking on new challenges or trying new things as the risk of not being perfect, then being rejected is too great for these adults. The doctor states:
“To some degree or another, most people with RSD become people pleasers. They quickly scan every person they meet and have a remarkable ability to figure out exactly what that person would admire or praise. They then present that very pleasing false self to the world. They are so intent on avoiding the possibility of displeasure from others and keeping everyone happy that they often lose track of their own goals and desires. By the time they get to their forties, they have built up a huge well of resentment about having given up their own lives to attend to the perceived needs of everyone else and getting nothing in return.”
Treatment
There are pharmacological approaches to the treatment of RSD. Unfortunately, these medications also conflict with the standard stack of ADHD medication as one in particular MAOI inhibitors has been known to cause elevations in blood pressure. Secondly another set of medications, alpha-agnostics are FDA approved for ADHD treatment but in studies, only about one in three patients got the full benefit of the medication. The rest reported mild sedative effects.
Talk therapy is an obvious choice for treatment of this disorder, but for ADHD individuals but such therapy should be conducted with a professional who is educated in this disorder and how to navigate it with clients. Dr. Dodson suggests having a “cheerleader” for these individuals to help shine lights on their worthiness, value, accomplishments and overall good nature. For people with RSD, they have spent most of their lives with the perception that they are constantly falling short, so having a trusted individual showcasing the real evidence of their lives and accomplishments could help re-align the impacted individual’s perception.
Informed clinicians and ADHD coaches work with clients to develop evidence to help defeat the negative RSD thought patterns and replace them with positive messages based on facts.
This style of work is very much coaching based with a set of exercises designed to help these individuals:
- Locate positive emotional value in their accomplishments
- Have facts based on their life experiences and accomplishments to combat negative RSD messaging
- Reframe immobilizing thoughts with attention to pausing and mindfulness.. Awareness of thought patterns
- Being mirrored and reflected by a coach and therapist in their struggle and their triumphs
- Build a tool set of positive messaging (things that make the individual feel good) like music , books, movies, etc.. that can help influence or elevate moods
- Having an individual that they can “reality check” thoughts with to verify validity or RSD based.
- Utilizing a clinician or coach, the impacted individual is no longer physically and emotionally isolated, but get to experience the healing that only a human connection can provide.
My own experience requires daily reminding of emotional worth and reminding of my value I present to this world and what I feel proud of. I try to “drop in” to my relationships instead of live in my head about them. I am aware of these thought patterns and their impact. I will admit, criticism can still be difficult, but I am getting stronger at taking it , self reflecting and coming back to the induvial to discuss. I just seem to need a moment to process and de-personalize it.
This has been accomplished by building lists of accomplishments, lists of moments of emotional well being and more importantly – having a therapist and coach who I feel “see me” and to whom I can validate some of these thoughts and situations with.
RSD is a very crippling part of ADHD, the work of Dr. Dodson to identify this disorder has opened a world of possibility if you suffer from it. As with new methods to help manage and work with it, there is hope for all of us who identify with this mood disorder.
Or as I like to think… Its not ME.. its my brain and it just needs to be reminded that I am not broken, I am not defective. I am actually Ok.
Sources: ADHD Coach Academy 2016 CHADD talk on RSD (2016-2017) by Barbara Luther , citing Dr. William Dodson
Emotional Regulation by Dr. William Dodson, CHADD Magazine Oct. 2016