EP40: Rejection Sensitive Dysphoria and Autism

In this episode, I dive into rejection sensitive dysphoria (RSD) and how it connects to both ADHD and autism. I explore the intense emotional responses that come with RSD, the common triggers, and the ways it can impact relationships and self-worth. I also share some therapeutic approaches that might help and explain why it's so important to understand RSD — whether you experience it yourself or want to better support someone who does.

Watch this episode on YouTube.

Take the Rejection Sensitive Dysphoria test. If your score is 45-60, the website recommends that you "see a trained mental health professional as there is a possibility that you may be experiencing symptoms of rejection sensitive dysphoria."

If you'd like to know more about topics discussed in this episode, check out:

"Rejection Sensitive Dysphoria in ADHD and Autism" by Debra Bercovici

"New Insights Into Rejection Sensitive Dysphoria" by William Dodson

"Rejection Sensitivity Dysphoria in Attention-Deficit/Hyperactivity Disorder: A Case Series" by William W. Dodson et al.

"Associations Between Autistic Traits, Depression, Social Anxiety and Social Rejection in Autistic and Non-autistic Adults" by Emine Gurbuz et al.

"Recognising and Responding to Physical and Mental Health Issues in Neurodivergent Women" by Clive Kelly et al.

"What to Know About Autism and Rejection Sensitive Dysphoria" by Amy Marschall

"Rejection Sensitive Dysphoria and Autism Unveiled" by Ralph Moller

"Effects of Rejection Intensity and Rejection Sensitivity on Social Approach Behavior in Women" by Violetta K. Schaan et al. 

Theme music: "Everything Feels New" by Evgeny Bardyuzha.

All episodes written and produced by Kristen Hovet.

Send in your questions or thoughts via audio or video recording for a chance to be featured on the show! Email your audio or video clips to otherautism@gmail.com through WeTransfer.

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The views, opinions, and experiences shared by guests on this podcast are their own and do not necessarily reflect those of the host or production team. The content is intended for informational purposes only and should not be taken as medical or professional advice. Please consult with a qualified healthcare provider before making any decisions related to your health, fitness, or wellness.

Transcript

Kristen Hovet
Patient one was a 29 year old single male who was diagnosed with ADHD in the fifth grade and again in his first year of engineering school. Patient one made adequate grades to get into engineering school. His father forbade the use of medications for ADHD because he thought that the problem was that the patient was just lazy and unmotivated. For his entire life, patient one viewed his main problem as his episodic attacks of physical and emotional pain, intense shame, and feeling ostracized anytime he perceived that someone else had withdrawn their love, approval, or respect. 

These episodes hit suddenly, without warning, and were always triggered by his experience of being rejected, criticized, or not meeting his own goals and standards. He became socially isolated because, quote,

having people know me just wasn't worth the pain, end quote. He had never asked a girl out on a date or applied for a job because the possibility that he might be turned down was so anxiety provoking that it just wasn't worth it. He finally stopped going to class for fear of failing in public and soon after dropped out of college altogether. Patient four was a 42 year old married female who reported that her husband had gradually become

more and more critical. And when he ridiculed her, she would either, quote, lash out in a rage at him and give him the same he was doing to me, end quote, or she would, quote, dissolve in tears, it hurt me so bad, end quote. She often had to leave the house until her emotions were under her control. She reported that she had always been sensitive and that this had severely interfered with her ability to sustain relationships.

What I just read about patient one and patient four came from the Rejection Sensitive dysphoria Case Series Study led by William Dodson published in August 2024. This publication features the experiences of four patients presenting with ADHD and severe rejection sensitive dysphoria or RSD. All four of the patients went on to be treated with a combination of medications and psychological interventions.

I've included a link to this publication in the show notes. Welcome back to The Other Autism and Happy New Year. Today I'm talking of course about rejection sensitive dysphoria. But before I do, I have a couple of announcements. The Other Autism has merch now, hoodies, t-shirts, stickers, tote bags, and coffee mugs. I'm wearing the hoodie and it's just to show everyone that if you like a more kind of like subtle logo look, go with one of the darker colors.

If you like this to kind of pop, the logo to pop, get a lighter color like a gray or there's like a beige-y bone color. I'll include a link in the show notes to the merch site, but if you'd like to go there now without having to find the show notes, head over to the Other Autism's website and you'll see links there. The address is other-autism.com. Be sure to use code FREESHIP

all one word, F-R-E-E-S-H-I-P, to get free shipping on orders over $75 US. The Other Autism's merch logo was designed by autistic artist Zoe Alexandra Glass, who was a guest on the show last February. I'd also like to thank the Patreon patrons for their ongoing support and interest in the show. Because of you all, I've been able to start getting the word out about the show in ways that I was not able to before.

And your ongoing input and insights have literally shaped the podcast into what it is today. The topic of rejection sensitive dysphoria was suggested by a listener when I ran the anonymous listener survey last year. Rejection sensitive dysphoria is not a disorder in its own right, but it is rather a cluster of traits and behaviors experienced by many people who've been diagnosed with ADHD.

But more and more it's becoming known as an associated trait in autistic people as well. This could simply be because 50 to 70 % of autistic people also have ADHD according to recent estimates that I read. And it's known that nearly all people with ADHD have some degree of RSD. The research I've found on this says that anywhere from 90 to 99 % of those with ADHD have RSD. So super, super high.

In fact, the underlying emotional dysregulation seen in RSD may become a key component of the ADHD diagnostic criteria in the future. All that to say, this topic is extremely important to all of us in the neurodiversity space, since we either experience it or know someone who does. Very likely, if we don't experience it ourselves, someone in our family or someone we know and love definitely does,

especially since neurodivergent people tend to be drawn to other neurodivergent people. I think the topic of RSD is also especially important for those of us who are late diagnosed as autistic and or ADHD. Many of us experience rejection sensitive dysphoria without being aware that there's a word for it and without knowing just how much of the negative responses from others we've internalized to the point that this negativity starts to inform the ways we perceive or think about ourselves at the deepest level.

Before we go any further, let's set the scene a bit more and define some terms. If you've ever felt like criticism, rejection, or even a small misunderstanding left you feeling disproportionately hurt or even devastated, left you feeling like the wind was knocked out of you or that your entire being was wounded or gutted, you're not alone. Rejection-sensitive dysphoria involves very intense emotional responses to real or perceived rejection or failure,

reactions that can feel overwhelming and all-consuming. These responses can be well hidden by the person or on full display in either internalizing or externalizing coping or some combination of these. If you've struggled with RSD or even if this is your very first time hearing about it and it's already resonating with you, I hope this episode offers you some clarity, comfort, and maybe actionable insights.

Rejection sensitivity impacts everyone to some degree, but as with nearly every human characteristic, it's experienced on a spectrum. It's important to note that there are two issues at play here, so we have to take care not to confuse the two. The first is rejection sensitivity as a human trait. Any single one of us is either high or low in trait rejection sensitivity or somewhere in between.

And then there's rejection sensitive dysphoria, or RSD, and that's really our focus here today in this episode. The important aspect of RSD is the dysphoria part, because you can be someone with high trait rejection sensitivity, but not actually have RSD. Just as you can be someone with low or mid-level trait rejection sensitivity, and yet actually experience RSD in specific contexts or when it involves specific

kinds of rejection. To have RSD, you need to experience dysphoria in response to real or perceived rejection. This dysphoria has to impact your life quite a bit, including in your relationships and social life in general, your work and career pursuits, and the ways you think about yourself and your self-worth. RSD appears to touch pretty much every aspect of a person's life if they experience it.

And this may not be obvious if you've lived with it for a long time without knowing about it. I've included a link to a rejection sensitive dysphoria quiz in the show notes, as I think that might help some people with understanding whether they experience RSD. I remember when I first heard about RSD, I immediately thought I had it, but after doing more reading and digging, I realized that what I was relating to was being high in trait rejection sensitivity.

But I don't actually have RSD because I don't experience dysphoria as a result of feeling rejection. I have indeed felt rather sudden onset dysphoria a few times that I can recall, but this is not an ongoing issue for me, nor is it a defining feature of my life. For me personally, I think earlier abandonment issues, complex PTSD, and a tendency towards depression more likely explains some of my own high trait rejection sensitivity,

as well as my few occasions of dysphoria. Beyond that, I think it's also a highly genetic or inherited type situation. Let's dig into dysphoria a bit more since it's the key concept here. Dysphoria is defined in the Merriam-Webster dictionary as a state of feeling very unhappy, uneasy, or dissatisfied. It's the opposite of euphoria.

While euphoria can be thought of as extreme happiness, dysphoria can be thought of as extreme and almost tortuous unhappiness that at least in the context of RSD can come on very suddenly, like split second. The intense distress of dysphoria in this context is actually associated with a high risk of suicide, where in some scenarios the person literally goes from being relatively happy or neutral to being nearly suicidal

in a matter of minutes or hours. This is one of many reasons why I think it's so important to talk about. Rejection sensitive dysphoria, RSD, was coined by William Dodson around a decade ago. Dodson, along with other academics and clinicians he's worked with, have appeared to begin using the term rejection sensitivity dysphoria, replacing the word sensitive with the word sensitivity

as a way to help avoid confusion and to be consistent with scientific literature on the trait rejection sensitivity. I actually think this makes things more confusing. Dodson himself, though using the new term in a 2024 research paper that he co-authored with three others, goes on to use the original term in a 2024 article on ADDitude magazine's website. Whatever he ends up using, and at least in the meantime, I'm going to stick with the original

and currently more popular rejection sensitive dysphoria. So what kinds of experiences can trigger RSD? The kinds of experiences that can trigger RSD are just about infinite, but also dependent on the person. What can trigger one person's RSD might not trigger another's. However, as was at least somewhat clear with the case study examples I read at the very beginning of the episode, the scenarios share some characteristics and types of thought processes

leading up to an RSD episode. In an RSD triggering scenario, the neurodivergent person may be receiving real or perceived criticism or feedback that they perceive as rejection. They may be receiving information that is negative or they interpret it as negative. For example, a friend may have canceled a dinner date because an emergency came up, but the person with RSD may think that their friend canceled because they don't like them anymore.

They may feel excluded from a social event, whether or not the exclusion was intentional. They may be feeling teased or like they've been made the butt of a joke, or they may feel that some core attribute of themselves is being disrespected or disregarded. Underlying these perceptions, again, real or erroneously perceived, are quite negative views of the self and really low self-worth. So these all work together in a kind of cyclical

pattern, each feeding the other. RSD episodes kind of bolster this very negative view of the self, while the negative view of self makes RSD episodes way more likely to occur. It makes sense to me that someone with low self-esteem and low self-worth would perceive social and interpersonal interactions as automatically more negative, like skewing negative, or even tending toward catastrophizing of any social or interpersonal interaction that isn't obviously positive.

What does an episode of RSD look like? First of all, to be really, really clear on this point, an RSD episode can be triggered very quickly, like in a matter of seconds, and then go on to look like a severe depressive episode in some situations for some people. RSD episodes can vary quite a bit for one individual person, as well as between different people, so this makes RSD kind of difficult to pin down.

But again, it's about finding the underlying patterns behind the behaviors and experiences. In all the reading I did, the dysphoric mood that's triggered tends to be deep sadness and or pretty intense anger. Sometimes these emotions are thought to be two sides of the same coin. So it could just be that some of us have more access to one over the other due to both environmental and inherent or dispositional factors.

In any case, RSD-related episodes are typically discussed as internalized or externalized. Internalized episodes feature intense self-criticism and negative self-talk, sometimes total self-loathing. The person might disappear to be alone and avoid everyone else, but inside, they're punishing themselves. They may cry and need time alone, but this isn't any kind of usual sadness, if it's even possible to call such a thing usual.

It's a deep and intense sadness that may not be obvious to anyone but the person feeling it. In some cases, the person can have a sudden major depressive disorder episode, including suicidal ideation. This internalized RSD episode can also feature anger, but the anger is turned inwards and others don't really see it. Then there's externalized RSD episodes.

These episodes feature clear or obvious outbursts of anger or sadness directed toward the person or situation that they perceive as having hurt or wounded them in the moment. In very angry or rageful outbursts, the person experiencing the RSD episode can become quite emotionally and verbally abusive, especially without intervention or recognition of RSD. And in some rare cases, these have turned into physical abuse.

In an externalized RSD episode, the individual may also become suddenly and aggressively argumentative and accusatory, which can be baffling, confusing, and even frightening for others who witness it. To go on a bit of a tangent, when an autistic shutdown or meltdown is not caused by the usual overwhelm of sensory differences, frustrations related to cognitive challenges, and physiological fatigue or

burnout and other related obstacles, I'm fairly confident that a great many of these could be attributed to RSD. I mean, shutdowns and meltdowns are also episodic states that often feature numbness, sadness, and or displays of anger. I want to be clear that I'm not saying, though, that all autistic shutdowns or meltdowns are related to RSD. What I am saying is that those shutdowns and meltdowns that can't be traced back to a usual offender again, like sensory,

cognitive, or body-based challenges could in fact be more correctly labeled an RSD episode. Obviously, as long as that episode is the result of real or perceived rejection or criticism, one has to lead directly to the other. To get back to describing RSD episodes, for the person experiencing the episode, they usually have trouble describing what they're feeling or thinking, especially in the moment. They can have more insight later on, but in the moment, it's very, very hard.

Physically, some describe a sensation like they've been stabbed or punched in the chest, like they've been gutted, or like their entire being has been wounded. As Dobson points out, they're often able to describe the intensity of an episode or the overall sensation that they have, but they find it difficult to put their exact feelings or thought processes into words. To be RSD, these episodes have to have clear antecedents that trigger the mood shifts. According to Dobson and his team, the

quote, complete change from one mood to the other occurs instantaneously as opposed to a gradual insidious worsening of symptoms and impairments over several weeks as seen in a mood disorder, end quote. Also, RSD episodes often stop the person from functioning for a matter of hours and potentially days if it was a really severe one.

The overwhelming intensity of negative emotions experienced during RSD episodes sets RSD apart from other emotional responses. According to Dobson and team, quote, the severity of the pain gives the condition a part of its name. Dysphoric is Greek for unbearable, end quote. Due to the rapid shifts in mood that people with RSD experience, healthcare professionals risk

misdiagnosing them with bipolar disorder or borderline personality disorder or something along those lines. I couldn't find any numbers regarding the prevalence of these misdiagnoses, but I'm sure the experience is quite common, especially given the fact that RSD is a relatively new term and concept and given the fact that so many neurodivergent people get a series of misdiagnoses or incomplete diagnoses until they're identified as autistic

or ADHD or both. What are some ongoing traits or behaviors that develop as a result of RSD? As a result of RSD, ongoing traits and behaviors can include social avoidance and social withdrawal, distancing oneself from others, maintaining very surface level or shallow social connections, if at all, rejecting others before they can reject you, replaying or ruminating on social experiences in your head to figure out what you did wrong,

avoiding new activities where you feel you'll make mistakes, being a people pleaser to avoid anyone getting upset with you and rejecting you, and so on. One of the unfortunate main realities that many with RSD face is ongoing relationship problems, especially since those with RSD tend to respond quite defensively when they feel they're being critiqued. So this can result in lack of connection between two people, problems with communication,

keeping things kind of surface level just to avoid going into territory where there might be like negative feedback, critique, anything along those lines. Why are autistic people likely to develop RSD in addition to the factors we've already mentioned? Well, autistic people tend to have heightened emotional responses and they tend to process thoughts and emotions more deeply than non-autistic people.

Traditionally, this trait or series of traits has been called perseverating, but that seems to imply intention or a motivation to process deeply, like we're trying to or willing it to happen, whereas it's actually just something our brains do on their own and has to do with our neurons and their hyperconnectivity. If you're interested in this topic, don't forget to check out the episode from last January called Neural Pruning, Synesthesia, and Autism.

Many autistic people also have a hyper awareness of social cues, which I think goes against the traditional thinking or myths about autism. To a neurotypical person, the ways we socialize can be incorrectly interpreted to mean several things. For example, oh, they aren't emoting or expressing themselves in the way I expect. Therefore they must lack empathy or they're behaving oddly or at odds with what I expect or want in this situation. So

they therefore are not paying attention to social cues. And probably the worst example, oh, I can be mean to you because you're an unfeeling robot with no heart. On the contrary, we can be so overwhelmed with empathy and with keen awareness of subtle social cues and our own intense emotions that we can freeze or go numb, not sure how to respond. Like, ah, what do I do? Do we cry and run away or do we say something super

pointed and truthful that could offend someone and cause a scene? It's hard when we have everything going on at once. mean, all of us also have stored up experiences since childhood of unintentionally hurting or offending or shocking non-autistics with our tendency to tell the full truth and give our honest appraisals, especially when asked.

We've also likely stored up experiences of having annoyed or bored non-autistics with our intensity or passion, our curiosity, and our tendency to talk at length about topics we love. Not to mention we've been told outright that we're strange or weird or too much or too sensitive or too shy or too quiet, blah, blah, blah. The list goes on and on and on. Well, let me tell you, this has an effect.

You can't go through life like this and expect to not be pretty deeply impacted, pretty deeply hurt. In an article for Very Well Mind, an autistic individual named Kate states about her RSD that, quote, I tend to assume people are mad at me, upset with me, or like I did something wrong if they have short answers to my questions, take a while to reply, are quieter than usual, et cetera. I feel an intense sadness and insecurity,

also a sense of urgency, like I have to fix whatever is wrong with what I did or who I am to make the sense of rejection go away, end quote. These hurtful experiences build up and tend to make us shy away from unabashedly being our genuine selves, most especially in social settings. We've learned to mask and hide and pretend to fit into a non-autistic world. And some of us have even had formal training in how to be more

neurotypical. On top of all this, many of us tend to be what's called perfectionist, perhaps as a result of rejection sensitivity, but I think mostly as a result of our attention to detail. To a non-autistic person, our being so particular and precise is interpreted as perfectionism. I think I'd like to challenge that label. Is it perfectionism, wanting and needing something to be

perfect or is it wanting and needing to get something to align in all the ways in all the details? I don't know yet myself what to think about all this, but I think this detail oriented orientation and perfectionism can come from very different places. I've grown up calling myself perfectionist, but it's because people have told me that since I was like four. I simply like the way my brain feels when a task is done well,

whether it's folding my laundry or writing a paragraph that has no grammatical or spelling errors. I mean, it looks so good. It just looks and feels nicer to my brain to have things done well, properly, or in an ordered way. Like I said, everyone's called me perfectionist for these ways, like since I was really young, but I'm not doing it to be beyond reproach or to ensure that others are happy with me. I'm doing this because brain.

My brain approves of things done this way and that's pretty much it. Like that's all there is to it. Perfectionism tangent aside, autistic people, diagnosed or not, tend to experience much more social rejection, criticism, and bullying than non-autistics. And we know that these things negatively impact mental health. Because of this, most of us are quite primed to develop RSD and then

further social experiences tend to solidify the RSD responses and cycles. Those of us who don't develop RSD may be quite high-masking and highly focused on fitting in. Generally, masking and putting this type of pressure on oneself are also really bad for mental health, but could at least explain how some of us end up not having the RSD profile. I think some of us also might have RSD, but then with age and therapy, it

might tend to subside a bit. In fact, I have heard from some listeners that this is the case for them, that their pretty severe, in some cases, RSD kind of went away or greatly improved after therapy focused on addressing trauma, interpersonal and relationship challenges, and self-esteem. Eye movement desensitization and reprocessing or EMDR and dialectical behavior therapy or DBT,

which includes techniques like radical acceptance, are some forms of therapy that those who have experienced relief from RSD often bring up. And in terms of pharmacological support, our good friend, Dr. Dobson, again, the one who coined the term RSD and the one who works in clinical practice with ADHD folks, in the 2024 paper he wrote with three other clinicians states that patients with RSD respond to alpha-2 agonists such as clonidine

or guanfacine. There aren't many other super helpful tips on managing RSD that I could find, at least not research backed. I could find a lot on Reddit and some forums and places where people talk about their experiences of it, but in terms of research, there's a long way to go. Some articles I found online claim that mindfulness can help a great deal, especially in addressing and calming that part of the brain that in a split second floods itself

with the painful poisons from long forgotten but ever felt horrible, hurtful, distressing or abusive social experiences, telling itself that it must fight back somehow against another person or against oneself with anger or rage or rejection right back or extreme and all-encompassing sorrow.

As a reminder, apart from the very small study regarding clonidine and guanfacine, these claims are mostly anecdotal at this stage in the game, both for medication and therapy. But I hope in the years to come, we'll have more solid, tried and true treatment and support options for those living with rejection sensitive dysphoria. Well, that's all I have for you today. Thank you so much for being here. Until next time, bye.