Understanding and Managing Rejection Sensitive Dysphoria in ADHD: Helen's Journey

What is Rejection Sensitive Dysphoria?

Rejection Sensitive Dysphoria (RSD) is an intense emotional response to the perception of being rejected, criticised, or falling short of expectations and standards. Though not an official diagnosis, the term—coined in 2017 by Dr. William Dobson—describes a common experience for many adults with ADHD: an overwhelming emotional sensitivity that can be triggered by even mild criticism or perceived rejection.

For those experiencing RSD, the emotional pain can be so intense that it's often described as "unbearable" or "catastrophic." It's not simply feeling sad about rejection—it's a profound emotional response that can manifest as rage, panic, despair, or shame that seems vastly disproportionate to the situation.

Let me introduce you to Helen, whose story illustrates how RSD can impact someone's life, and how therapeutic approaches can help manage these challenging emotional experiences.

Meet Helen: A Case Study

Helen is a 34-year-old marketing specialist who was diagnosed with ADHD in her late 20s. She's bright, creative, and deeply empathetic—qualities that make her excellent at understanding client needs. However, Helen has struggled throughout her career with what she describes as an "overwhelming emotional reaction" to any form of criticism.

When her boss provides feedback on her work, even constructive suggestions delivered kindly, Helen often experiences a flood of shame and anxiety that can last for days. She describes it as "feeling like I've been emotionally hit by a truck," with physical symptoms including racing heart, tight chest, and sometimes tears she can't control.

In her personal life, Helen has noticed similar patterns. If a friend doesn't respond to a text quickly, she spirals into worry that she's somehow offended them. When her partner expresses minor frustrations unrelated to her, Helen often interprets these as indications that their relationship is failing.

"I know my reactions are out of proportion," Helen explained during our first meeting. "But in the moment, it feels like my entire world is collapsing. The feelings are so intense that I can't think clearly until the emotional wave passes."

The Impact of RSD on Helen's Life

Helen's rejection sensitivity has led to several challenging patterns:

Avoidance bbehaviours She rarely volunteers ideas in meetings, fearing potential criticism.
Perfectionism: She spends excessive time on projects, trying to make them "criticism-proof."
Relationship strain: Her need for reassurance has created tension with her partner.
Career limitations: She's turned down promotions that would involve more feedback-heavy responsibilities.
Physical symptoms: She experiences frequent headaches, digestive issues, and sleep problems that worsen during periods of heightened sensitivity.

"The worst part," Helen shared, "is that I'm constantly exhausted from emotional hypervigilance. I'm always scanning for signs that someone is disappointed in me."

The Therapeutic Approach: A Single-Session Framework

When working with Helen, I used a focused single-session approach to address her RSD, with the understanding that this would provide a foundation she could build upon with practice and potential follow-up sessions. Here's how our session was structured:

1. Education and Validation

We began by discussing what RSD is and how it connects specifically to ADHD. For Helen, learning that this experience had a name and was common among adults with ADHD was immediately validating.

"I thought I was just overly sensitive," she said with visible relief. "I didn't realise this was something other people with ADHD experience too."

We explored how RSD isn't a separate diagnosis but a manifestation of the emotional dysregulation that's central to ADHD. I shared that children with ADHD often receive significantly more criticism and correction before age 12 than their neurotypical peers, creating a foundation for heightened sensitivity.

For Helen, this information was transformative. "It makes so much sense. I was always being told to try harder, pay attention, stop daydreaming. No wonder my brain learnt to be on high alert for criticism."

2. Personal Experience Assessment

Next, we mapped Helen's specific RSD triggers and response patterns. Her main triggers included:

Performance evaluations at work
Her partner's tone of voice during disagreements
Not being invited to social gatherings
Making mistakes in public
Perceived indifference from others (slow text responses, etc.)

When triggered, Helen experienced a consistent pattern:

Physical sensations: chest tightness, racing heart, sometimes nausea
Emotional response: shame followed by anxiety or anger
Behavioral response: withdrawal, seeking reassurance, or occasionally lashing out
Thought patterns: "I'm a failure," "They hate me," "I'll never get this right"

By creating this personalised map, Helen could begin to recognise her RSD episodes as they were happening, rather than being completely overwhelmed by them.

3. Emotional Regulation Skills

The core of our session focused on teaching Helen a three-tiered approach to managing RSD responses:

Tier 1: Self-soothing & Down-regulation

We practised techniques that could help Helen calm her physiological arousal when RSD was triggered:

A 4-2-6 breathing pattern (inhale for 4, hold for 2, exhale for 6)
Progressive muscle relaxation, focusing on her shoulders and chest where she carried tension
Physical reset activities, like washing her face with cold water
Grounding techniques using the 5-4-3-2-1 method (identifying 5 things she could see, 4 she could touch, etc.)

Helen found the breathing technique particularly helpful: "It gives me something concrete to focus on when my emotions feel overwhelming."

Tier 2: Distraction and Reappraisal

Next, we worked on cognitive approaches:

Temporary distraction techniques to create emotional space
Cognitive reframing questions: "What are alternative explanations for this situation?"
Perspective-taking: "How would I interpret this if it happened to a friend?"
Timeframe shifting: "How important will this seem in one month?"

For Helen, the alternative explanations exercise was revelatory. When we applied it to a recent situation where her boss had been brief in an email, Helen realised there were numerous explanations beyond "My boss is disappointed in me."

Tier 3: Response Management

We discussed how to appropriately manage emotional responses in professional and social settings:

Recognizing when to temporarily step away
Scripts for taking a break without creating awkwardness
Planning for later emotional processing
Distinguishing between suppression and healthy containment

"I never gave myself permission to step away," Helen noted. "I felt like I had to immediately resolve the feelings or hide them perfectly."

4. Cognitive Restructuring

We examined Helen's thought patterns during RSD episodes and practised restructuring one recent example:

Situation: A colleague questioned one of Helen's recommendations during a team meeting.

Initial thought: "Everyone thinks I'm incompetent and shouldn't be in this role."

Restructured thought: "My colleague was questioning the idea, not me personally. Different perspectives help us reach better solutions, and my contributions are still valuable."

Helen practised identifying the distortions in her thinking (catastrophising, mind-reading, personalisation) and creating more balanced alternatives.

5. Creating Helen's Personal Management Plan

Together, we developed a personalised plan for Helen to manage her RSD:

Early warning signs to watch for:

Tightness in chest
Racing thoughts about others' perceptions
Urge to check emails/texts repeatedly
Feeling a "flood" of emotion beginning

Immediate response strategies:

4-2-6 breathing
Stepping away briefly if possible
Cold water on face or hands
Text support person with code word "reset"

Cognitive strategies:

Question catastrophic interpretations
List alternative explanations
Ask, "What would I tell my friend in this situation?"
Remind herself: "This feeling will pass."

Communication approaches:

With partner: "I'm feeling sensitive right now and need reassurance."
At work: "I'd like to think about that feedback and follow up later."
With friends: Being honest about her sensitivity when appropriate

Daily maintenance practices:

Morning mindfulness practice (5 minutes)
End-of-day reflection on successes, not just perceived failures
Regular exercise to reduce baseline anxiety
Adequate sleep and medication management

Helen's Progress: Six Months Later

Six months after our initial session and with regular practice of her management plan, Helen reported significant improvements:

"The emotions are still intense, but they no longer derail my entire day. I can recognise when I'm in an RSD episode and use my tools to ride it out rather than being consumed by it."

Specific improvements included:

At work: Helen started speaking up more in meetings and was able to receive feedback without spiralling into shame.

In her relationship: She developed a shorthand with her partner to communicate when she was feeling sensitive, which reduced conflict and increased intimacy.

Physically: Her sleep improved, and she experienced fewer stress-related physical symptoms.

Internally: She reported spending less mental energy on worry and rumination.

"The biggest change," Helen said, "is that I no longer see my emotional sensitivity as just a weakness. Yes, RSD is challenging, but my emotional responsiveness also makes me empathetic, intuitive, and passionate about my work. I'm learning to manage the difficult aspects while appreciating the strengths."

Key Takeaways from Helen's Journey

Helen's experience illustrates several important points about managing RSD:

Education and validation are powerful tools. Simply understanding that RSD is a common ADHD experience reduced Helen's shame and self-criticism.

Personalised awareness is essential. Identifying specific triggers, thought patterns, and physical responses made them easier to recognise and address.

A multi-level approach works best. Combining physiological techniques, cognitive strategies, and communication tools provides options for different situations.

Practice and consistency matter. Helen's improvement came through regular application of her management strategies, not overnight transformation.

Self-compassion is foundational. Learning to respond to herself with kindness rather than criticism was central to Helen's progress.

Supporting Someone with RSD

If someone you care about experiences rejection sensitivity, consider these approaches:

Validate their emotions without necessarily agreeing with their interpretations
Deliver feedback sandwiched between positive observations
Be clear and direct in communication to reduce ambiguity
Understand that their response may seem disproportionate but feels very real to them
Ask how you can help during difficult moments
Appreciate the positive aspects of their emotional sensitivity

Supporting colleagues — A supportive environment helps!

Conclusion: Sensitivity as Strength

RSD presents real challenges for adults with ADHD like Helen, but the emotional sensitivity at its core can also be a source of strength when properly channelled. With understanding, skills, and support, the intense emotional responses can become more manageable, allowing the positive aspects of emotional responsiveness—empathy, creativity, passion—to shine through.

If you recognise yourself in Helen's story, remember that you're not alone in this experience, and that effective strategies exist to help you through this. Your sensitivity doesn't have to define or limit you—with the right tools, it can become just one part of your rich emotional landscape.

Note: While this case study is based on composite clinical experiences, "Helen" is a fictional character created to illustrate typical RSD experiences and therapeutic approaches. This article is for educational purposes only and doesn't substitute for individualised professional advice.

Frequently Asked Questions About Rejection Sensitive Dysphoria

Understanding RSD

What is Rejection Sensitive Dysphoria?
Is RSD a real condition?
Is RSD part of ADHD?
How do I know if I have Rejection Sensitive Dysphoria?
What causes Rejection Sensitive Dysphoria?
Why are people with ADHD sensitive to rejection?

Symptoms and Impacts

What does RSD feel like?
How does RSD affect relationships?
Can RSD cause anxiety?
Is RSD related to trauma?
How does RSD manifest in the workplace?
Is perfectionism related to RSD?

Treatment and Management

How to treat Rejection Sensitive Dysphoria?
Does medication help with RSD?
Can therapy help with Rejection Sensitive Dysphoria?
What are the best coping strategies for RSD?
How to explain RSD to others?
How to support someone with RSD?

Specific Demographics

Is RSD more common in women with ADHD?
Can children have Rejection Sensitive Dysphoria?
Does RSD get worse with age?
How does RSD differ in men and women?

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Understanding and Managing Rejection Sensitive Dysphoria in ADHD: Helen's Journey

What is Rejection Sensitive Dysphoria?

Meet Helen: A Case Study

The Impact of RSD on Helen's Life

The Therapeutic Approach: A Single-Session Framework

1. Education and Validation

2. Personal Experience Assessment

3. Emotional Regulation Skills

Tier 1: Self-soothing & Down-regulation

Tier 2: Distraction and Reappraisal

Tier 3: Response Management

4. Cognitive Restructuring

5. Creating Helen's Personal Management Plan

Helen's Progress: Six Months Later

Key Takeaways from Helen's Journey

Supporting Someone with RSD

Conclusion: Sensitivity as Strength

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Frequently Asked Questions About Rejection Sensitive Dysphoria

Understanding RSD

Symptoms and Impacts

Treatment and Management

Specific Demographics

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