Rejection Sensitive Dysphoria: Do I have it and what do I do about it?

Today's blog will cover the question of 1) what is "rejection sensitive dysphoria", 2) how it's different than rejection sensitivity, 3) what the experience is like, 4) the impact it can have, 5) what strategies, tools, and frameworks help, 6) the role of support from loved ones, and 7) getting professional support.

Isn’t everyone at least somewhat sensitive to rejection?

Yes, all humans are built with the evolutionarily advantageous survival mechanism of caring whether others will approve of us and stay close. Think of it like this: an infant needs their caregivers to do just that: provide care. If an infant is abandoned or given insufficient care, that baby will die. All the cooing, and smiling, and giggling a baby does is based upon their instinct to engender warmth and delight in the surrounding adults. When it seems to fail to garner care and attention, that baby will experience distress, it will cry to notify the adults that it has unmet needs. If the crying still fails, the distress grows more extreme. The famous Still Face experiment is an excellent, if difficult to watch, example of the importance of these survival strategies.

Even as adults, our thriving still depends on the relationships in our lives. Relationships help us do everything: get and keep jobs, get medical care, meet our access needs, feel held in community, feel loved (a fundamental human need, even out of infancy), and more. In short, relationships make life livable and worth living. We are all sensitive to rejection because it represents the original (and sometimes current) threat of annihilation that it meant in our earliest years.

The difference is that those with RSD feel this sensitivity more frequently, more intensely, and often with less external triggering than others. Since it can be excruciating, those with RSD may also be more prone to make rash decisions in relationships to try and relieve RSD-related pain. RSD is most typically associated with ADHD, and there are some autistic folks who identify with RSD as well.

"A woman covering her face with her hands" by Simran Sood via Unsplash

What is the experience of RSD? 

As a retired punk, I bring in this reference more frequently than I’d like to admit: in This is Spinal Tap, a mockumentary about a heavy metal band, there’s a scene where Nigel (vocalist and guitarist) is showing Rob Reiner the band’s amps and explains what a bummer it is that most ordinary amps only “go to 10”. Reiner and the audience realize that 10 is an arbitrary number that doesn’t necessarily correlate to a specific volume in decibels. Reiner asks something like “couldn’t you just turn the volume up so 10 goes higher” and Nigel dumbfoundedly says, “but these go to 11”. RSD is kind of like that — intense, but so much so that it also defies definition. When you’re in the throes of it you know that it's A LOT, but often it is just these moments where you cannot describe it or convey it to anyone else, and you cannot look for reasonable solutions.

RSD is an experience of intense distress at real or perceived rejection. It typically includes elements of perfectionism, as many of us worry that if we are anything less than perfect, we will not be good enough for others. RSD regularly tells us we are "too much" or “not enough” or somehow both at once. RSD might also include elements of rumination or preoccupied thoughts. It can include somatic intensity, strong waves of emotion, tension, and even, physical pain. It might feel like our inner critics are shouting at us relentlessly, or that they've been proven right. We might feel that we are a horrible person. We could feel intense fear and anxiety. Perhaps we feel anger, irritation, and frustration at others for not giving us what we need or want. Sometimes RSD will feel like severe discomfort, unease, and feeling “off”. It might lead to shutdowns, meltdowns, and dissociation.

"Black and white guitar amplifier photo" by Anastasia Zhenina via Unsplash.

What is the impact of RSD?

RSD can have a significant impact on all aspects of a person’s life. RSD in the workplace might result in a worker avoiding promotions and taking on added responsibilities to avoid possible rejection. It might also mean that a worker prone to externalized RSD episodes in the form of emotional outbursts or meltdowns gaining a negative reputation or being considered untrustworthy that can harm job stability or future opportunities.

In personal relationships, folks with RSD may have a difficult time bringing up important topics for discussion, avoiding conflict, engaging in people pleasing behavior or fawning, even in martyrdom to be “above” reproach. It can also look like intense defensiveness, difficulty owning one’s part in conflict, focusing only on how others have been hurtful or harmful, becoming so emotionally reactive that others are fearful to bring issues to light, and so on. This can harm trust and repair in relationships, and many with RSD may experience either distanced and unsatisfying relationships or volatile and reactive relationships that do not last. This effect can be compounded when relational trauma is in the mix as well.

What can be done about RSD?

There are resources that can help RSD, and sometimes we may still need to let the intensity of an RSD episode pass in its own time.

One resource is medication. Because RSD is not an official diagnosis and is still not part of the DSM (Diagnostic and Statistical Manual for Mental Disorders, the book that dictates what mental health diagnoses can be assigned in the United States) for ADHD, there are no officially approved medications for RSD. William Dodson, MD, LF-APA, who coined the term Rejection Sensitive Dysphoria, does a good job breaking down the DSM’s inadequacy when it comes to ADHD and RSD. The alpha-agonist, non-stimulant class of ADHD medications, specifically Clonidine and Guanfacine, are anecdotally thought to help about 60% of RSD sufferers. If one is not a responder to one medication, they may be a responder to the other.

The response to medications indicates the likelihood that RSD has a neurological basis. Therefore, adding practices that support your nervous system will also be a useful strategy to adopt in addition to pharmacological supports. As neurodivergent folks, nervous system resourcing is already important — we live in sensitive bodyminds as autistic and ADHD people.

Here are some of my favorite forms of care for neurodivergent bodyminds:

• Grounding practices like feeling my feet on the floor or my back body against the couch or chair if seated upright or the floor if laying down

• Parts work practices to get in touch with my hurt vulnerable parts or reactive protectors

• Breathing practices like the physiological sigh to release excess activation and box breathing and ocean’s breath when coming into a more regular rhythm

• Movement practices like dancing, vigorous exercise (depends on physical capacity and safety), throwing a pillow onto the floor from standing, punching or screaming into a pillow (the latter two might need to be negotiated if in a shared space)

• Intentional stimming like fidgets, rocking, swaying, listening to the same song on repeat, echolalia, watching a comfort show, etc. 

• Self-touch practices like a butterfly hug paired with squeezing up and down the arms, EFT tapping, bilateral tapping as in EMDR, acupressure, and self-massage. I find that pairing these with affirmations can be useful at times. 

If cognitive processing is something that helps you, you might consider journaling or recording voice notes. The caveat with this technique is to make sure you are holding space for the possibility that your thoughts during an RSD episode are a story, not the whole truth of the situation. Whatever thoughts you capture are a reflection of the state you’re in, and that’s okay. I strongly advise those who experience RSD episodes to wait until after the storm of the episode has passed before deciding on a course of action.

"A man wearing headphones sitting in a chair photo" by Nubelson Fernandes via Unsplash.

The three quotes that guide me during these times are:

1) “Story follows state” from Deb Dana, a therapist and a prolific author on Polyvagal Theory (PVT). I find that PVT is a useful framework for bringing our felt experiences of the nervous system into more conscious awareness. “Story follows state” means that we create stories in our mind based on the state of our nervous system (aka how we *feel*). If we keep this in mind, we can leave some room for questioning if we've got all the information we need before we decide to act. I've got a couple of older blog posts on Polyvagal Theory, if you would like to learn more about the topic.

2) A similar message to Dana’s words, but this quote, usually attributed to Holocaust survivor, psychiatrist, and philosopher, Viktor Frankel, is one of my favorites: “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” Now there is some debate as to whether this quote was really ever uttered or written by Frankel. Even if it truly was not Frankel’s words, this quote lived as the background on my phone for years, in large part because the reminder helped me in moments of RSD. 

3) The last is more of a writing concept popularized by Anne Lamott in her well-known book, Bird by Bird, that I think about as applied to mental health and relationships. Lamott wrote about the concept of “Shitty First Drafts”, as the important first step to getting to the second and third drafts (and beyond) that could be great works of literature. I think of journaling similarly. The moments we turn to our journal are often the times we are most inside a story we won't fully agree with later on. Sometimes, though, the feelings are a truth that needs expression, once we understand them. The story we told ourselves might indicate the parts of us that need tending to. The story might point to boundaries we need to set with others or ways we've crossed our own. They might point to before- or after-care we could request. The advantage of knowing we might need to write a shitty first draft is that we protect our relationships and our own nervous system by taking a beat and looking at the story first and deciding what to share (and how to share it). If you've ever gotten into a conflict when you were really activated and felt deeply misunderstood or unable to articulate yourself the way you'd like to, you might benefit from a shitty first draft before engaging.

What about co-regulation?

Co-regulation is the act of two (or more!) nervous systems syncing up and impacting the nervous system of the other person. We usually refer to co-regulation as a positive process. It’s a beautiful demonstration of human capacity for connection and safety. And it can work in reverse sometimes. A person’s dysregulated nervous system can dysregulate the other person’s. When we and our loved ones are sensitive the way neurodivergent folks tend to be, it’s a good idea to be intentional about how we seek and offer co-regulation.

Ellyn Bader and the Developmental Model for Couples gives us a good concept here to consider: “holding steady”. When a person can “hold steady” and hear the hurt feelings of someone in emotional distress, they can offer care, empathy, and resourcing, without being hijacked by emotional reactivity, the need to defend themselves, or get dysregulated right alongside their partner or loved one.

If we are doing and have done some self-regulating and tending to our own nervous system, it will be much more likely that our loved one can hold steady and stay available as a resource to us. That’s why I always recommend a break in heated moments to the couples, polycules, and friends I see in relationship therapy before they come back together; whether it’s to discuss a conflict or to simply offer co-regulation to each other without verbal processing. When we can tend to our own nervous system first, we enhance the chances of repair and reconnection efforts going in a positive direction.

We can also co-regulate with nature and pets!

"Two person in bed close-up photography photo" by canweallgo via Unsplash.

However you decide to care for yourself…

You are worthy of care. Your worst fears about yourself are not the truth, as hard as that is to believe and feel in the storm of RSD. RSD episodes are temporary and this will pass. RSD can be a reminder that you care, you’re invested, and you have a bodymind that needs tending to.

For more support

If you want some support navigating RSD and building your toolbox of resources, please reach out and book a consultation. For RSD-informed therapy in NY state: Individual Therapy and Relationship Therapy. 

Sources: 

Baruch, V. (n.d.). What is differentiation? Vivian Baruch Online. Retrieved May 31, 2025, from https://vivianbaruch.com/what-is-differentiation/

Casale, P. & Neff, M.A. (Hosts). (2023, December 25). Inside Rejection Sensitivity Dysphoria: Insights on RSD, Mental Health, and Relationships (No. 27) [Audio podcast episode]. In Divergent Conversations. https://www.divergentpod.com/blog/ep-27.

Dana, D. (2018). The Polyvagal Theory in Therapy: Engaging the Rhythm of Regulation. New York: W.W. Norton & Company.

Dodson, W. (2020, May 9). New Insights Into Rejection Sensitive Dysphoria. ADDitude. Retrieved May 31, 2025, from https://www.additudemag.com/rejection-sensitive-dysphoria-adhd- emotional-dysregulation/

‌Lamott, A. (2005). Shitty First Drafts. In P. Eschholz, A. Rosa, & V. Clark (Eds.), Language Awareness: Readings for College Writers. (9th ed. pp. 93-96). Bedford/St. Martin’s. Retrieved May 31, 2025, from https://wrd.as.uky.edu/sites/default/files/1- Shitty%20First%20Drafts.pdf

Neff, M.A. Rejection Sensitive Dysphoria Workbook Bundle. Neurodivergent Insights. Retrieved May 31, 2025, from https://neurodivergentinsights.com/bundles/rejection-sensitive- dysphoria-bundle/

Tronick, Edward, Heidelise Als, Lauren Adamson, Susan Wise and T. Berry Brazelton. "The Infant's Response to Entrapment between Contradictory Messages in Face-to-face Interaction." Pediatrics, September 1978, vol. 17(1), pp. 1-13.