Who is “Most Likely” to Experience Rejection Sensitivity?

Am I The Only One?

Let’s talk about one of the aspects of ADHD that might not be the first thing you think of when you think of someone with ADHD, at that is difficulty regulating emotions. Emotional dysregulation, including rejection sensitivity, has been proposed as a formal and fundamental criterion of ADHD on several occasions but ultimately assigned as an “associated feature”, which has been a subject of debate. Young adults with ADHD are reportedly twice as likely to experience emotional dysregulation, which is associated reduced quality of life. Interestingly, one study revealed that those with ADHD and substance abuse said that they struggled to recognize or understand their own emotions and tended to cope with this frustration and difficulty with substances. In fact, some with ADHD felt as though the current criteria did not fully describe their experiences, especially when executive dysfunction was at the forefront with co-occurring intense emotions and emotional lability. Many expressed a preference for “attention dysregulation” as opposed to “attention deficit” to characterize their experience, including hyper-focusing/ruminating on their successes or failures or spending significant time trying to compensate for their weaknesses (real or perceived). Presently, the American Professional Society of ADHD and Related Disorders is working to establish an evidence-based diagnostic criteria for adults with ADHD that includes emotional dysregulation. Recently, mental health practitioner James Ochoa coined “emotional distress syndrome” (EDS), describing the neurological processing differences and behavioral challenges causing reduced frustration tolerance, reduced stamina, and reduced psychological well-being. The idea is that RDS is an acute experience, while EDS is a chronic experience.

So what exactly is RSD? Well, rejection sensitivity was introduced to explain why some people are more sensitive to rejection experiences than others by social psychologists Geraldine Downey and Scott Feldman in 1996. The term Rejection Sensitivity Dysphoria (RSD) was coined by psychiatrist William Dodson in 2010 to describe an experience in which certain people have more intense expectations, perceptions, and reactions to rejection experiences. Many describe experience significantly physical and emotional pain, guilt/shame, and feeling ostracized when others withdraw their love, approval, or respect by rejection, criticism, or own perceived failures/perfectionism. For some these”episodes” were described as goin from 0 to 100 with little to no warning, the intensity of “episodes” is seen as catastrophic or devastating, sometimes requiring significant time to “recover.” Some describe replaying social events over and over in their minds and may extrapolate information from peoples responses without data or information to support their interpretations. As such, RSD can even occur when there was no rejection or negative feelings intended by the other parties. Anticipated social rejection can trigger RSD, secondary to either imagined perception of being rejected or from self-criticism about truly falling short in social situations, both which result in a dysphoric mood. Even heightened perception of rejection can lead to an exaggerated emotional reaction, either secondary to a singular experiences or a serious of experiences. When triggered, some will “hyperfocus” or “spiral” about the worst parts of their identity, sometimes reportedly feeling like “outcasts” or “freaks.” Many are more affected by their own self-criticism and negative self-talk than actual rejection by others.

It has been found that people with ADHD struggle with intermittent reinforcement, which alters internal cognitive algorithms and understanding of behavioral contingencies (e.g., this happened because of my behavior, rather than an external cause, or last time he called me back immediately, so he must be mad at me). Moreover, some experience time blindness, difficulty understanding emotions, and irritability when interrupted when hyper-focusing, which can lead to interpersonal conflict or misunderstandings, those reinforcing the cycle. Some are so perfectionistic they cannot tolerate any social rejection or not being clearly admired or needed. Often perfectionism and/or overcompensation in reaction to social or academic failure. Additionally, there is a strong overlap between rejection sensitivity and justice sensitivity (JS). People with strong justice sensitivity often perceive different forms of injustice, especially when they feel they are a victim, and show intense negative responses such as anger, guilt, and rumination and helplessness. Both RS and JS involve hyper-vigilance leading to misinterpretations to ambiguous social cues. RSD seems to be present in most, but not all, who are diagnosed with ADHD and it has been found to be present amongst all 3 types of ADHD (inattentive, combined, and hyper/imp). Some are misdiagnosed with depression, social anxiety, avoidant personality disorder, borderline personality disorder, PTSD or sometimes one or more are truly co-occurring diagnoses. Generally more females endorse RSD than males, but this is cultural and depends on the age, as women are more relationship focused while men are more achievement focused and men are generally more likely to endorse fear of intimacy, rather than rejection per se.

In today’s day and age, in is not surprising that RSD would translate to the online social community. Online RSD may result in threats and risks of poor social interaction via high anticipatory and post-event rumination regarding social encounters, potential rejection, and are often continuously activated secondary to frequent social media use. Increased instances of online RSD was consistent with increased depression and brooding/rumination. It has been found that social rejection sensitivity tends to increase during adolescence and then decrease as you age; however, from a social media standpoint it is hard to analyze because generally there is less social media use the older you are. RSD is often more intense for teens to begin with, because of co-occurring puberty and changes/lack of maturation in frontal and limbic systems coupled with strong desire for acceptance at this age.

So why do we think some are so sensitive to rejection or exclusion? It is theorized that RSD may be caused by a “fundamental violation of the evolutionarily adaptive human need to belong.” Some propose that RSD is a “learned behavior” secondary to frequent rejection and struggles with social interactions. Rejection feelings can also originate from feeling misunderstood by parents, peers, teachers, employers, romantic partners, etc. Significant research has tied insecure attachment patterns in childhood with RSD, specifically parental rejection/acceptance in combination with early peer acceptance/rejection in terms of learned behavior and/or self-image. RSD can be exacerbated by parents of those with ADHD, if they reject or neglect their child’s needs or if for whatever reason the child perceives rejection by their parents/caregivers.

In terms of neurobiology, there have been associations between social rejection and activities and the dorsal ACC (“alarm” for interpreting goal-incongruent events like rejection, and unexpected disappointments), posterior cingulate cortex (PCC; reduced in anxiety), medial and ventrolateral prefrontal cortex (behavioral/emotional control; reduced in RSD), and posterior inferior temporal gyrus (face cognition, deciphering nonverbal reactions, related to social exclusion). Social stressors including social rejection elicit pro inflammatory responses, activation in dorsal ACC and anterior insula (often activated when rejected by “high value peers”) were associated with inflammatory brain response, as the brain attempts to prepare for a physical threat/possible injury, and thus releases chemicals that prepare the body to engage in wound healing. This demonstrates a connection between physical and emotional pain, as the brain recognizes them as the same. It is also suspected that neurotransmitters involved in social cognition and social behavior may have a role in rejection sensitivity (oxytocin, vasopressin) similar to reward/loss experiences in frontal lobe/limbic system. Clonidine and guanfacine have been recommended by some psychiatrists as a treatment for RSD, as they have both been on-label for ADHD since 2010 and are generally well-tolerated. Per the research, about 60% responded well in terms of RSD for one of the two medications.

RSD, aside from being exhausting, frustrating, confusing, and distressing, can also lead to a variety of long-term consequences. Some experience intentional social isolation, and difficulties with romantic relationships, vocational opportunities, educational tasks, or fear of rejection and emotional pain. When a person perceives that the potential benefit of a social interaction is critically low and can lead to rejection, exclusion, or failure, they often choose to reduce their social risk taking, and engage in submissive behaviors, and/or hyper-vigilance. Some are greatly affected by criticism or teasing but mask it and pretend to be unaffected or becoming self-deprecating, which can significantly impact self-image and self-esteem. Some struggle to leave their homes or complete tasks after being ridiculed or criticized by others, while some become people pleasers and struggle to form their own identity. This can lead to a self-fulfilling prophecy and/or negative feedback loop of adverse responses to others and negative social interactions leading to loneliness, and hopelessness, which can results in depression and anxiety. RSD affects trust and vulnerability with others, leading to difficulties forming and maintaining relationships as fear of intimacy/inability to be vulnerable can greatly affect romantic relationship outcomes. RSD can also lead to an inhibited wish and capacity for intimate relationships in emerging adulthood, as some with RSD tend to withdraw or self-disclose less, if they withdraw and don’t disclose, they can be seen as emotionally unavailable, which maximizes interpersonal distance and reduced intimacy. Those with high interpersonal anxiety tend to have more negative thought patterns that result in social avoidance. Some with take an opposite approach and tend to disclose quickly, in an effort to allow for a potential quicker and less ambiguous rejection.

What has been shown to be helpful for these children and adults and how can we best assess for RSD? There are two newer questionnaires that may be helpful to assess for both “classic” and “online” RSD; the Rejection Sensitivity Questionnaire (18 items) where clients rate how anxious or concerned certain social situations with potential rejection would make them and how likely they would expect to be rejection in these situations and the Online and Offline Social Sensitivity Scale assesses social evaluation, biased perception of social self, and social risk taking, specifically talks about reaction to social media posts, fear of online criticism, fear of reaching out to others on social media. Additionally, CBT, DBT, mindfulness, social-emotional learning, guanfacine, clonidine, amphetamines, and SSRIs have been successful for many. In fact, mindfulness has been found to increase size of parts of the brain while mediate anxiety. Many report being able to see themselves and others differently when under the care of a therapist. People with RSD are more successful in relationships if they have developed efficient self-regulation skills. Additionally, parental acceptance (mostly maternal depending on culture) appears to provide a buffering effect for interpersonal relations and better psychological adjustment (trust and mutuality). Fostering social connectedness on social media or internet can also be protective for those who struggle to be accepted “offline.” Try to learn from past experiences, hype self up, and understand others’ projections. Sometimes helpful to hyper focus on another task or problems, especially when able to use humor to cope. Need radical acceptance of self, self-love, and self-compassion. Trying to look at things logically and understanding other possible reasons for what might be perceived as rejection, exclusion, or failures, as interpersonal adjustment is greater when rejection expectations are conscious and explicit than when unrealistic or ambiguous. ADHD Coach and Advocate Casey Dixon: Need to learn to disappoint others instead of inadvertently disappointing others through negligence or fear. Important to figure out how to communicate clearly and authentically to others that you cannot satisfy a particular prior agreement, which will free you from shame/stress/burden of rejection.