There’s a new pathological term picking up speed in the ADHD community: Rejection Sensitive Dysphoria. It describes that feeling we are all familiar with, the intense pain of criticism, both real and perceived, and the tendency to avoid situations in which we might experience it.
It’s not in the DSM yet, but many people are advocating that it should be. When I first read about it, I was comforted. I thought, YES, wow, a name for The Thing! This is why I’m like this!
But as I’ve begun to read about the ADHD industry more critically, I’m starting to wonder if framing RSD as a purely biological difference without considering environmental influence is accurate or helpful.
Am I sensitive to rejection because I am genetically predisposed to be, or am I predisposed to be because people with ADHD get rejected constantly from birth?
We know that stress can change the ways certain genes express and it has been theorized (and debated) that trauma can be passed down in our DNA, but these ideas are often missing from the RSD conversations I see online.
It’s usually “this is just how I am”, with no examination of why that might be.
The way the ADHD industry talks about RSD as if it is scientific fact (despite the fact that Dr. Dodson, who coined the term, cannot seem to provide any research supporting its biological nature beyond his own anecdotal evidence), is also alarming.
Dodson is on the board of ADDitude Magazine, an ADHD trade journal that presents itself as “peer-reviewed” yet frequently cites itself (a practice that is a journalistic integrity no-no at best, and intentionally misleading propaganda at worst).
He made a claim in this ADDitude article that “Psychotherapy does not particularly help patients with RSD because the emotions hit suddenly and completely overwhelm the mind and senses,” which flies in the face of much evidence that distress tolerance skills can be successfully learned through modalities like Dialectical Behavior Therapy.
Originally developed to treat Borderline Personality Disorder, a diagnosis characterized by emotions that also “hit suddenly and completely overwhelm the mind and senses”, DBT has been shown to be more effective for suicidality and emotional regulation than other forms of psychotherapy.
Dodson’s generalization about psychotherapy is entirely unscientific considering how many different modalities exist. One has to wonder which kind of psychotherapy (and studies, if any) this assertion is based on. Not surprisingly, none are cited.
As viable solutions to RSD, Dodson goes on to present the medications guanfacine and clonidine, which relax blood vessels and lower blood pressure. Interestingly, these meds are also prescribed to treat the symptoms of Post-Traumatic Stress Disorder.
PTSD is usually characterized as something war veterans and rape victims experience, and many of us who cannot pinpoint One Big Trauma Event in our history assume that we don’t have any trauma at all.
But there’s another type of PTSD that’s being discussed in psychology circles and slowly making its way into the mainstream — Complex PTSD.
It’s also not in the DSM yet, and it differs from PTSD in that it’s not caused by one big, singular traumatic event, but a series of traumas over time.
For instance, the trauma of being raped would cause PTSD, whereas the trauma of surviving an abusive relationship (which may include many instances of physical and sexual assault, emotional neglect, psychological abuse, and gaslighting over a period of time) would cause CPTSD.
I started to think about how many symptoms RSD and CPTSD share.
RSD symptoms include:
shame, low self-esteem, social isolation, emotional dysregulation, hopelessness, approval-seeking behavior, anxiety, aggression, and irritability
CPTSD symptoms include:
shame, low self-esteem, social isolation, emotional dysregulation, hopelessness, fight/flight/fawn/freeze responses to triggers, negative worldview, mistrust of people, anxiety, aggression, and irritability
The “approval-seeking behavior” of RSD calls to mind the trauma response of fawning, which is essentially people-pleasing to avoid conflict.
CPTSD sufferers also tend to avoid places where they previously experienced trauma, much like how people with RSD can avoid social situations for fear of rejection.
They say there are two types of RSD, aggressive and anxious.
I would argue that aggressive RSD, where people get overly defensive or seek out revenge, is a lot like the fight response in CPTSD, and that anxious RSD, which causes people to avoid, withdraw socially, or ruminate, are akin to flight or freeze responses.
RSD is triggered not only by actual rejection or criticism, but the perception of it, too. Likewise, most CPTSD flashbacks are triggered by the perception of danger, not the immediate physical reality of it.
The argument I often hear against this is that people with RSD don’t suffer from flashbacks, but I also think a lot of people have a very cinematic understanding of what flashbacks are like.
It’s not always a visceral re-experiencing of an event, where the real world falls away and you are transported to a battlefield in your mind. Sometimes it’s just a strong emotion brought on by a trigger. Sometimes it’s recurring nightmares.
People with CPTSD often find their own perceptions of their abusers shift. They may idealize their abusers, or accept their abuser’s rationalizations and beliefs as absolute truth.
What is RSD but an acceptance of the neurotypical belief that we are not enough?
What is RSD but a reaction to constant subconscious messages from neurotypical society telling us we are doing everything wrong?
Trauma is not just rape and war. Emotional neglect also causes PTSD. How often were your feelings invalidated growing up? How many times were you told that you’re “too sensitive”?
Emotional neglect is one of the most destructive effects of patriarchy, and it is traumatic. White supremacy is traumatic. Capitalism is traumatic. Being neurodivergent in a neurotypical world is in itself traumatic.
To pathologize a very human response to all this trauma with a label like Rejection Sensitive Dysphoria is yet another way the medical system attempts to call us disordered while evading any social criticism.
There’s a very good reason that we fear rejection! There’s a good reason that it hurts us so much! When you continually re-open an old wound, does it fester?
This, combined with the fact that neurodivergent people have more sensitive nervous systems already, means that we are going to feel more intense pain when someone criticizes us, and behind that pain is the very natural fear of being othered and shunned.
What seems like a dysfunctional overreaction to a small critique is actually a response rooted in fear about our ability to survive, which depends on our ability to fit in and get by.
It’s not like there are two different biological processes happening here, either. Whether you label the process RSD or CPTSD, it’s still just your autonomic nervous system overreacting to perceived danger.
It’s still just cortisol and adrenaline — and the fact that doctors are prescribing the same blood pressure medications for both conditions is evidence of that. I believe that the difference is not biology, but perspective.
RSD says: your responses are biologically dysfunctional. It puts the onus on you to fix yourself.
CPTSD says: your responses are a human reaction to trauma. It forces us to examine and address the ways society causes us harm.
That’s not a thing those in power want us to do, so the medical system focuses on disorder instead of trauma. The medical system says trauma is exceptional and rare, not systemic. The medical system blames the victims of trauma by assigning us disorders, which disempower us by making us believe that we are inherently broken.
We see a similar thing happening in the pathologizing of trans trauma with the label “Gender Dysphoria Disorder”, and the new, controversial “Rapid Onset Gender Dysphoria”. Both of these labels ignore the fact that trans and genderqueer people suffer because of societal pressures, not because we are inherently disordered.
I understand the need for labels to feel like we have explanations for our painful experiences, and I don’t want to take that comfort away from anyone. Use the labels that help you. But please do be careful not to pathologize every single thing about your humanity.
The medical industrial complex would love for you to think that you are broken, because then they can sell you more “fixes”, but I want you to know in your heart that it’s not true.
Your intense pain is valid and justified. It’s real, and there is a reason for it. It’s not wrong, and it’s not your fault. You don’t exist in a vacuum — society is not blameless, and psychology is not objective. Bias permeates everything humans create, and science is infamously lacking in social critique.
Trying your entire life to fit into a world not designed for you is traumatic.
Experiencing criticism and rejection from birth due to every aspect of your brain and personality falling outside societal norms is traumatic, and it will make you sensitive to rejection.
That’s not disorder. That’s just human.
A version of this essay was originally published on Patreon. Special thanks to Marta Rose for her work deconstructing RSD and the ADHD Industrial Complex.