Rejection Sensitive Dysphoria – why don’t we hear more about it?

Rejection Sensitive Dysphoria – why don’t we hear more about it?

So in my ADHD practice we get to the bit where I try to offer some psychoeducation to newly diagnosed people, or sometimes those diagnosed previously but who I haven’t seen before and this question is an absolute revelation:-

“Have you always been more sensitive than others to rejection, teasing, criticism, or your own perception that you have failed or fallen short?”

I promise you, about half the people I ask this of break down in tears in my office. Most people seeking a new adult diagnosis of adult ADHD, or indeed seeking to restart treatment they may have stopped on reaching adulthood, are not complaining of the so called “core” features. Hyperactivity is often not present at all, for those predominantly inattentive people…or if it was present is very much reduced as the person matures. Impulsivity – people develop strategies to manage it, or are completely unaware that it is an issue for them. And most people will not admit to inattentiveness due to deep shame – RSD – or again may be unaware that they are zoning out so much.

Adults with ADHD predominantly want help with either the sleep issues – delayed onset sleep phase disorder being the commonest problem in people with ADHD – or emotional issues, with RSD right on top of the list. But only once I have mentioned it. RSD is experienced as a very deeply shameful, very sensitive and secret vulnerability and it feels unbearable for many people even to volunteer it. What a relief to have it out in the open, mostly for the first time in someone’s life and to truly take stock of how much it has cost in terms of agonising soul searching, missed opportunities in all areas of life and just general misery and avoidance.

What a relief also to people who may have tried therapy and counselling over many years, to hear that it is often not effective in this condition – mainly because on the whole therapists haven’t heard of it, and are genuinely unaware that this sensitivity is neurobiological in origin. Of course people with ADHD classically zone out in therapy sessions but will be far too ashamed to admit it, so can oftgen miss big chunks of the session. And of course high functioning people with ADHD will probably own all the self help books and have combed the internet looking for answers, so there is little a therapist can suggest that they won’t already have tried, and failed at. So all too often therapy which is touted as being the route to cure, is experienced by our ADHD sufferer as another coal in the RSD furnace.

Fortunately like most other aspects of ADHD this most often improves dramatically with knowledge, diagnosis and ADHD treatment, although I often find myself adding in a mood stabiliser after the stimulant has been introduced and titrated, just to “turn down the sensitivity knob” for my patients which can be very effective.

And don’t even get me started on the mis diagnosis with personality disorder…..

By | 2018-06-20T09:33:50+00:00 June 20th, 2018|Categories: Uncategorized|2 Comments

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2 Comments

  1. Dylan Tweedy (@dylantweedy) 24/04/2019 at 21:57 - Reply

    Brilliant post! I found out about delayed sleep phase disorder years ago but my doctor just shrugged it off as something I read on the internet. Then once I discovered ADHD and was going through the process of being diagnosed I asked the ADHD specialist about rejection sensitive dysphoria and had the same experience! She hadn’t heard of it before! I’m at a bit of a loss really, as my GP also doesn’t have a clue and there doesn’t seem to be any additional support for me.
    What do you think about the studies on using Guanfacine or MAOIs on the treatment of RSD and ADHD?

  2. READHelen 18/08/2019 at 19:50 - Reply

    Hi, sorry it’s taken for time to get back to you. I normally treat sleep issues in ADHD very successfully, sometimes with clonidine, sometimes not! I don’t use guanfacine because it’s not available on the NHS formulary and so would be very expensive. There are a variety of options but it does depend on the exact presentation so it will be better to book a consultation to look into this a bit further. All good wishes, Dr Helen Read

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