Feeling profound pain from criticism or rejection in ADHD is not uncommon, but there are ways you can cope.
When you’re being criticized or rejected, do you have an intense reaction and feel like you can’t control your behavior? Do you experience extreme emotional pain that feels physical?
If you live with attention deficit hyperactivity disorder (ADHD), it’s understandable to sometimes be more sensitive to criticism. Some people with ADHD are faced with judgment and blame for their behaviors.
People around you might not understand the condition. They might encourage you to just “try harder” or label you as “lazy” or “unmotivated.”
These types of comments can be hurtful when you live with ADHD. Your first instinct may be to react negatively, but there are ways you can cope and respond more calmly.
RSD is “a near ubiquitous experience for ADHDers,” says Joel Schwartz, PsyD, an ADHD clinical psychologist in San Luis Obispo, California.
“So much so that I think it should be part of the diagnostic criteria,” Schwartz adds.
Currently, RSD isn’t listed as an official symptom in the current version of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), but it’s real all the same.
At her therapy practice in Texas, Adrienne Clements estimates that RSD affects about 90% of her clients with ADHD.
Her clients don’t use the phrase rejection sensitive dysphoria, but once they explore the issue underlying their avoidance, perfectionism, social anxiety, or fear of failure, this term precisely explains it, says Clements.
“An RSD episode feels like being hit by a tsunami of emotion out of nowhere,” says Clements, an educator and consultant passionate about supporting therapists to become more inclusive and neurodiversity-affirming.
One minute, she says, you’re feeling fine, and then a rejection trigger hits and you’re completely overwhelmed.
“The amygdala — the emotional command center of our brain — gets hijacked and the fight, flight, or freeze response takes over the body,” Clements explains.
This response looks different in every person. For Schwartz, it’s “a deep pain in the center of my chest, anxiety in multiple systems, flushed face, and a desperation to take some kind of action to undo whatever it is that caused the RSD.”
For others, Clements says, an RSD episode may look like:
- instant rage or anger with blaming others
- all-consuming sadness and withdrawal, even triggering suicidal ideation
In some cases, RSD can be so extreme it’s misdiagnosed as a mood disorder or personality disorder, says Clements.
Schwartz describes RSD as taking “the deepest shame you’ve ever felt and double it, and then doubl[ing] it again. And then once more. And then stick a knife in your chest and twist it. That begins to approximate it.”
“Although I’m being hyperbolic, it really isn’t that far from the experience,” he says. “It is an exquisitely deep shame and trauma reaction that can literally feel like physical pain at times.”
Once an RSD episode is over, people tend to experience more shame about what happened, leaving them feeling even worse, adds Clements.
According to Clements, RSD signs and symptoms may include:
- extreme emotional sensitivity when you think you’re being rejected or are rejected
- overwhelming sadness after being criticized that leads you to isolate or shut down
- an extremely harsh inner critic
- intense preoccupation with what others think of you and assuming the worst in everyday interactions
- people-pleasing or perfectionism to avoid being rejected
- fear of failure or rejection that leads to not pursuing goals or meeting new people
Of course, the intensity of symptoms can vary by episode and person.
Clements points out that in some cases, symptoms can be so intense they throw off someone’s entire day, while feelings of shame can linger for days afterward.
In other cases, RSD episodes are brief and quickly resolved.
Clements says that it all depends on the person’s:
- specific triggers
- window of tolerance at that moment
- coping tools
- support needs at that time
“The heaviness of RSD can have some profound impacts on people’s lives,” says Clements. She and Schwartz note that RSD may lead to:
- burnout, where the simplest tasks feel insurmountable and just getting up and starting the day feels like too many steps
- relationship ruptures, if you lashed out during an episode
- shame about your sensitivities, which might lead to feeling humiliated, self-judgment, and distress
- problems at work
- social isolation
- depression, or worsening of depression
- suicidal ideation
Everyone’s RSD triggers are unique, but according to Schwartz, they often fall into these categories:
- Being criticized for something you can’t control, like missing something your spouse said because you haven’t yet transitioned from your task.
- Being rejected or thinking you’re being rejected, like not hearing back from a friend you texted.
- Not living up to your own expectations, like forgetting something important at the store, feeling ashamed and angry with yourself, and saying “Why can’t I do the things others can do!?”
Research on RSD is scarce. Some ADHD specialists believe RSD is natural and brain-based, and only medication — such as guanfacine (Intuniv ER) and clonidine (Catapres) — makes a difference.
In her practice, Clements has also seen other medications — such as bupropion (Wellbutrin) — reduce the intensity of RSD.
Both Clements and Schwartz believe that RSD is a trauma response.
“ADHDers grow up with constant negative feedback from peers, teachers, and parents,” says Schwartz. “It is the death of a million paper cuts. You learn on a deep level that everything about you is wrong, and your sense of interpersonal and personal security is threatened by these mistakes.”
As such, trauma-focused therapies may be helpful, like:
- somatic experiencing
- eye movement desensitization and reprocessing therapy (EMDR)
- internal family systems (IFS)
- neuroaffective relational model (NARM)
Schwartz has heard from many that Brainspotting — a type of talk therapy using fixed eye positions to help you process trauma — can also be helpful, but it needs more research.
In general, she says, “navigating RSD usually takes a multi-modal approach and there’s no one silver bullet.”
Whether you’re receiving treatment or not, there are practical strategies you can use during and after an RSD episode.
Label what’s going on
You might tell yourself, “This is my RSD. I know it’ll pass,” which Schwartz says has been helpful for him. He’s also made a deal with himself not to act in the midst of intense RSD.
“If a few days go by and I still want to act, then I’ll do it,” he adds.
Unhook from unhelpful thoughts
When working with her clients and going through her own RSD, Clements uses an ACT technique called defusion.
Defusion creates distance between you and your thoughts, so you can see them for what they are, says Clements. It’s “words in our head” versus absolute truths or laws you have to obey.
According to Clements, during an RSD episode, you can try to:
- Label your thoughts as thoughts, such as: “I’m having the thought that I’m the worst person ever and everyone hates me.”
- Use a silly voice for the thoughts, such as a cartoon character like SpongeBob or Mickey Mouse, so “it’s a lot easier to take an unhelpful thought less seriously.”
- Play around with thoughts that come through as images, such as changing the image’s colors, slowing or speeding it up, adding funny background music, or adding a silly voice-over.
Use a distraction
Which distractions are helpful may depend on the severity of your reaction. For example, when her reaction is intense, Clements’s go-to distractions are:
- splashing cold water on her face or putting ice on the back of her neck to return to the present moment
- using a strong scent, like an essential oil, to distract her amygdala, since olfactory senses are close to it in the brain
When her reaction is more manageable, Clements might:
- play with her dogs
- spend time outside
- watch a show that brings her joy
- seek support from a loved one
Pick activities that specifically work for you
When picking calm-inducing activities, do what works best for you — which might be different from conventional advice. As Schwartz notes, “For many ADHDers, things that are calming or lowering stimulation may actually be activating for us.”
In other words, instead of deep breathing practices, you might feel calmer engaging in intense exercise or rocking out to complex or heavy music — something that Schwartz says “helps me like nothing else.”
Let the other person know
Because episodes can be all-consuming, Clements suggests telling loved ones that you’re experiencing one and can’t communicate until it’s passed.
Try to ask for what you need, such as:
- alone time
- a hug
- an ice pack to self-soothe
“We can’t get out of an RSD episode the same way we got in it: with criticism,” says Clements. Instead of further feeding your inner critic, use compassionate self-talk to help you cope, such as:
- telling yourself “that really hurt, may I try to be kind to myself?”
- giving yourself a hug
If you find self-compassion feels out of reach, consider listening to a guided self-compassion meditation.
In dealing with RSD, Schwartz has found it helpful to study the social theory of disability, which “states that disability is neither good nor bad, it is a part of life that is mostly mitigated by society.”
“Instead of blaming myself or taking on the negative feelings of others, I’m able to forgive myself for having a different brain,” Schwartz says. “I see how many societal forces are at play in how people judge me and how I cannot always be accommodated.”
Schwartz adds that he recognizes there are just some things that he cannot do: “And that is OK and not on me to fix — it’s on all of us to be accommodating and make room for different ways of being in the world.”
Many people with ADHD experience RSD — an intense emotional reaction to being criticized or rejected. While RSD is not always clinically recognized, it’s real and powerful.
There’s still a lot we don’t know about rejection sensitivity dysphoria, so more research is needed. Experts speculate that RSD may be innate and brain-based, or stem from trauma. Or, perhaps a complex combination.
Helpful ways to manage may include medication, trauma-focused therapies, and coping strategies.
If your loved one has ADHD, try to be extra gentle, patient, and supportive. As Schwartz notes, “You have no idea how much [criticism] hurts and how much we are already doing it. If we are having a hard time, come help and give us love. Let us know we are OK when we cannot perform as neurotypical people can.”