It’s Just My RSD! How A Common Neurodivergent Pattern Leads to Diagnoses You Probably Don’t Have

Hello, and thank you for joining me today, my friends. Today I'm covering Rejection Sensitive Dysphoria, which you may know something — or even a lot about — but most neurodivergent adults have never heard of it or have no idea what it is, and that matters. It's not inconsequential — the way it is for most of us to learn well into adulthood that bananas, cucumbers, and pumpkins are technically berries, while blackberries, raspberries, and strawberries are not. Coming into that information might rock your world for a moment, but it's unlikely to have affected your life up to that point or afterward. Being neurodivergent and not knowing about Rejection Sensitive Dysphoria, or RSD, is potentially life-altering — even life-threatening — and today I'll tell you why. There are two reasons actually, but one is far more nuanced than the other, so I'll spend much more time on that.

The more obvious problem with being neurodivergent and not knowing about or understanding RSD is that being in that situation very likely means that you have had no encounters with professionals who know about and understand RSD, so you may have received no support or assistance up to this point, or the support and assistance you've received all your life has probably been insufficient — or distinctly wrong —which often does more harm than good. That's not to say that every single neurodivergent adult struggles with RSD, but most do, and for most of us, it would be really nice to have known that.

Before I get into that, let me explain what RSD is. It is not a diagnosis, so if everything I say about it here resonates with you — like I've known you all your life — you don't need to start the search for someone who can confirm a new diagnosis of RSD for you, because no one can — at least not yet. RSD is a clinical syndrome, which means it's a collection of symptoms or experiences that occur together and get in the way of people doing what they want and need to do. Most people don't have the collection of experiences, because then it would just be part of typical life, but enough people do have the collection of experiences for that pattern to be recognized as something that is real and warrants understanding and possibly treatment.

Because Rejection Sensitive Dysphoria isn't something that a physician or psychologist can diagnose, we can extend a little grace to any professionals we've encountered who did not tell us about it. There are other aspects of evaluation and diagnosis that lend themselves to misdiagnosis and missed diagnoses that I've touched on in a previous episode so I won't go into detail today, except to note that RSD wasn't acknowledged as it's currently understood until 2010, and it's still mostly mentioned only in ADHD contexts.

The concept actually originated in the work of Paul Wender, a psychiatrist who was the first to prove a genetic link to ADHD and that people with ADHD have lowered dopamine levels. He was also among the first to study medication as ADHD treatment and is credited with convincing the rest of the world that adults have ADHD, too — and all of that was in the '70s and '80s. Dr. Wender noted in his writings that adults with ADHD often endorsed symptoms of depression that didn't meet the standard diagnostic criteria for a depressive disorder and didn't respond to treatment for depression. He called it "atypical depression," which included a heightened sensitivity to rejection, but that part of Wender's work didn't really go anywhere. Fast forward to Bill Dodson, also a psychiatrist and one of the first to ever specialize in treating adult ADHD. In that work, he found that the aspect of ADHD that impacts adults the most is being unable to control their emotions, whether it be excitement, anger, worry, sadness, or any other feeling they have. He formalized the term Rejection Sensitive Dysphoria to describe the facet of that emotional dysregulation adults report the most.

Since that time, there have been some, though arguably not enough, advances in overall understanding of neurodivergence. It's not as widely acknowledged as it should be, especially among therapists, psychologists, and psychiatrists, who should all know these things, but there is now plenty of evidence to support the significant overlap of experiences in ADHD, autism, and other neurodevelopmental differences. And research suggests that 99% of neurodivergent adults experience some degree of RSD, and we know why. Unlike the name strawberry for a fruit that is not a berry, the name Rejection Sensitive Dysphoria does a pretty good job of describing what it actually is. Dysphoria's Greek root word means "difficult to bear," and it describes a state of distress that can be understood as anything from being uneasy or unhappy to emotional pain that's severe enough to be experienced physically. And as the name implies, the dysphoria is caused by a person's sensitivity to rejection. Human beings are wired to avoid rejection as a matter of survival, and neurotypical people can be rejection sensitive and even experience RSD. However, neurodivergent people are especially prone to rejection sensitivity for a couple of reasons.

First, as Dr. Wender demonstrated when he found that adults with ADHD have significantly lower levels of dopamine in their brains, we know conclusively — though not comprehensively — that there are differences in neurodivergent people's brain chemistry, functioning, and possibly structure. There hasn't been enough research done in this area overall — and especially not in studies involving females, people of color, and specifically exploring the intersectionality of comorbid disorders, trauma and other adversity, and multiple types of marginalization. Historically, studies have disproportionately included white, middle class, male participants, and in the realm of neurodivergence, ADHD has been studied far more than other neurodevelopmental differences, which may be due to it being the only one of those diagnoses firmly connected to the pharmaceutical industry, but who knows?

Anyway, from the research we do have, we know that neurodivergence — in some or all forms — is associated with differences in the ways the prefrontal cortex functions, which is often related to focus — or what captures our attention and what doesn't, what we can ignore and what we can't — as well as decision-making, or being able to consider the possible impact and outcomes before taking action. Differences in the levels of dopamine and other neurotransmitters, as well as the ways they're processed by the brain, add to the differences in prefrontal cortex functioning by over-rewarding pleasurable experiences — which often causes us to prioritize them. And neurodivergent people often have overactive amygdalas. Put very simply, the amygdala is an ancient part of the brain that is responsible for automatic emotional responses to perceived threats, especially those related to deep, often subconscious, memories of past experiences. In neurodivergent people, experiences that are the same or similar to painful, past experiences result in emotional responses that are faster, more intense, and impact our behavior and cognition considerably more than is typical.

That was definitely a very basic explanation, but hopefully I included enough information for it to make sense that those three important brain differences can contribute to greater sensitivity to rejection — before, during, and after it is experienced. Our brain functioning can cause us to be on high alert for possible future rejection because intense, automatic emotions cause us to focus on the potential threat — to the exclusion of other information and experiences — which is chemically reinforced so we continue to prioritize it. Should we actually experience something that could be rejecting, those same processes increase the likelihood that we'll interpret it as such, even when there are logical alternative explanations and other things we could be thinking about or doing. Then afterward, the differences in our brain functioning often result in greater emotional distress as a response to the emotional harm of being or perceiving a threat of rejection, which keep our focus locked on it, impacting our capacity to think about it differently and our decisions about what actions to take.

If that description's not clicking for you, think about a time when you felt criticized or excluded — maybe because of another person's direct actions, like your fiancée saying they want to postpone the wedding until you get a better handle on your finances. But you might also have felt criticized or excluded because of assumptions you made about other people's actions that you didn't experience directly. Maybe something another person posted — like pictures of themselves with other friends looking amazingly happy at an event you knew nothing about — or something someone else told you — like that they heard your coworker told your other coworkers that they told your boss they have some ideas for improving the department you oversee. Now remember or imagine your immediate, gut response to the experience or information, which was probably a rush of sorrow, rage, fear, despair, or all of the above — and you may have even experienced that physiologically as pain, digestive distress, or physical numbness.

You're an intelligent person who knows rationally that there are actions you can take to clarify information, remedy situations, or at least shift your own perspective or ensure you don't lose track of responsibilities, but you may have felt like you lost your grip on all of that as your brain locked in on the intense emotions and every possible worst case scenario outcome — all fueled by a drive to protect yourself from that perceived threat. And the only thing that gave you even a moment of respite from those thoughts and feelings was an idea to do something dramatic in the context of the situation, like dump your fiancée, or give them full control of your finances while you profess how incapable and pathetic you are, or get very drunk, get online, and max out every one of your credit cards to show them what financial irresponsibility really looks like.

Hopefully those were just thoughts, but sometimes we actually take actions like that or do other things we end up really regretting. Both are reinforced by surges of dopamine and other brain chemicals that literally, physiologically reward our thoughts and actions that reduce the threat, even if it isn't actually a threat, and even if those thoughts and actions create far more painful and even dangerous situations. That's the influence of neurodivergent brain functioning differences on rejection sensitivity, but that's not all we're dealing with. Essentially, all neurodivergent adults had early experiences of rejection, or what felt to our young selves like being rejected, when just being ourselves caused us to be corrected, criticized, punished, teased, bullied, embarrassed, left out, or feeling like we're tolerated, not appreciated or chosen, by others.

Those experiences might support the healthy development of neurotypical children, largely because they're usually rare and don't repeat. Let me pause to make sure that's clear. Think of it like this: If you are in a new relationship and it's going amazingly, better than you ever dreamed, so you move in together, and your partner notices that you sometimes fold towels into squares, and other times you fold them in thirds. You tell them that you've never thought about it before and don't have any preference at all when it comes to how you fold towels, and they say that they have a strong preference for towels being folded into thirds, so you happily agree to fold them that way from here on out, and doing so really makes no difference to you at all, except that you feel good about doing it the way your partner prefers, which they appreciate, and it does prevent any distress or outcome that could arise from you folding them the way you used to.

Now let's take that same idea and apply it to neurotypical and neurodivergent children's experiences with, for example, talking a lot. Maybe their kindergarten class assigns one student each day for show-and-tell or sharing, which starts with a game of 20 Questions to see if the class can guess what the child brought from home before they reveal their item and tell the class what it is. We'll pretend a hypothetical neurotypical kid and a hypothetical neurodivergent kid have very similar experiences the first time it's their turn to share in that both of them got the same first question, "Is it alive?" and answered by saying exactly what their item was and what it does until the teacher gently reminded them that they were only supposed to answer "yes" or "no." We'll also pretend that they're in different classes because, if the neurotypical kid had witnessed the neurodivergent kid being corrected, the neurotypical kid probably wouldn't have done that when it was their turn.

That may have also been the case for the neurodivergent kid, but with an important difference. The hypothetical neurotypical kid didn't give all that information, instead of answering "yes" or "no," for any reason other than that they didn't know the rules of the game well enough yet, so they just answered the question the way they normally talk about anything. And the next time it was their turn, it was no problem at all for them to answer only "yes" or "no" until their item was guessed or the 20 questions were used up. Engaging in the activity that way, instead of the other way, made no real difference to them, except that they felt good about doing it the way their teacher and peers expected, which they all appreciated, and it prevented them from being embarrassed or getting in trouble, or losing friends had they repeatedly gone against the expectations and preferences of other people in this situation.

The hypothetical neurodivergent kid might also receive the teacher's correction as fairly neutral, just the rules they're learning for something new, but maybe this kid also gets corrected more and more often for talking to their classmates when they're supposed to be listening to the teacher, and for giving long, detailed answers when they're called on. And on top of that, their best neighbor friend tells them to "Be quiet" when they're watching cartoons together, and one day says matter-of-factly, "You talk too much." Plus this kid's big brother has a running joke with their dad that nobody really pays attention when that kid talks, because they'll keep talking about it no matter what. And their mom says to them, before they go in to visit their grandma in the hospital, "We all know you love to talk, but grandma doesn't feel good, so you can't be talking so much when we're in there. Plus there might be another person sharing the room and we don't want you to bother them."

That hypothetical neurodivergent kid is five years old, a kindergartner. And while none of those corrections were totally inappropriate or particularly harsh, every one of them, every time, came when that hypothetical neurodivergent kid was just being themself, and that really, really, really matters when it comes to development and wellness. When children are trying to learn a rule or expectation, or when they're deliberately ignoring or defying a rule or expectation, any kind of social consequence they experience makes some amount of sense, which means they can learn something from it—consciously or subconsciously—about what interactions lead to good or pleasurable results, and which result in difficulty or pain. But when children think they are meeting expectations, and have no intention of breaking a rule, and no idea any rule even applies to what they're doing, but they still experience social consequences, nothing makes sense. And if that happens frequently and repeatedly and in multiple situations, the main thing they learn is that any interaction they have could lead to good or pleasurable results just as easily as it could result in difficulty or pain.

You can see that, right? Our hypothetical neurodivergent kid lives in the same extroversion-emphasizing world we do, so they're expected to be friendly and outgoing and participatory, and they inherently are, but that makes the teacher they adore mad at them, and their neighbor friend hurt their feelings and eventually not want to hang out with them. It brings their dad and brother closer to each other, but they say they aren't even listening to them. And when they want to give love to grandma to help her get better, they're told they could somehow hurt her and disturb some person they don't even know by being themselves.

That hypothetical neurodivergent kid is five years old, a kindergartner. They can't make any sense of that because no one else around them can, and because it doesn't make sense. But their brain has it all figured out, thanks to the amygdala. Remember, the ancient brain structure that calls up intensely emotional memories of painful past experiences when a current experience is similar, so that we can protect ourselves without even expelling any mental energy? In other words, it volunteered to keep constant watch for any threats of harm we already experienced so we can avoid experiencing it again. That functioning is probably what's perpetuated the human race so far, and it serves us fundamentally, like when our ancestors learned which plants were poisonous after becoming violently ill. But in our modern world of social complexity, it rarely saves us from anything lethal like a poisonous plant, but it does make those of us who are neurodivergent exceedingly sensitive to rejection.

Without trying, or even knowing, we're on high alert for things that could bring us pain, and by "things," I mean people and interactions. If they're anything like any of the painful memories we might not even know we've kept, we avoid them without even thinking about it, which could mean literally staying away from certain people and interactions, but can also mean engaging in a detached, guarded way, or only after over-preparing then striving to be absolutely perfect so we at least increase our odds of dodging what is or feels like rejection.

It works sometimes, but not all the time, and it is fucking exhausting, and overwhelming and demoralizing, and it makes us tense and reactive and angry and vulnerable, so many of us struggle — sometimes a lot — with sadness, anxiousness, irritability, explosivity, impulsivity, addiction, pessimism, resentment, defensiveness, mood swings, "control" issues, perfectionism, people-pleasing, rumination, preoccupation, risk-aversion, withdrawal, and burnout. All of those experiences of being emotionally dysregulated are directly related to Rejection Sensitive Dysphoria, and to neurodivergence itself, both because of differences in the ways neurodivergent brains function and the early experiences common to most neurodivergent people.

Though neurodivergence isn't something we grow out of, many neurodivergent people report that, as they age, their lives are impacted far more by their emotional dysregulation than by the symptoms associated with their neurodivergence. But emotional dysregulation is not part of the diagnostic criteria for ADHD, autism, or any other neurodevelopmental difference, so when those experiences are reported to a therapist, psychologist, psychiatrist, or other physician, they're almost certainly going to be interpreted as symptoms of another disorder and result in misdiagnoses, most often of a depressive disorder and anxiety disorder, Borderline Personality Disorder, bipolar disorders, Obsessive-Compulsive Disorder, and sometimes Dissociative Identity Disorder, even though there are clear differences in the experiences of, for example, depression as meeting the diagnostic criteria for Major or Persistent Depressive Disorder versus in the context of rejection sensitivity.

This happens regardless of whether or not a person's neurodivergence has been formally diagnosed. Far too many neurodivergent people experiencing RSD are only ever misdiagnosed — usually with mood, anxiety, and personality disorders. But it's also common for people with confirmed diagnoses of ADHD, autism, and other neurodevelopmental differences to report their experiences of RSD to a clinician and, rather than informing them about RSD as part of their neurodivergence, their providers shift the focus of their care — sometimes completely — toward a different diagnosis. Many of my clients have had that kind of experience and described it as being incredibly disorienting, frustrating, and akin to being gaslit by someone whose job it was to help them.

On the other hand, some neurodivergent adults appreciate clinical attention — and even labels — being given to their emotional distress. In fact, with or without separate clinical diagnoses for their emotional experiences, many neurodivergent adults understand themselves as having one or more of those disorders, and get that feedback from friends and family members, and have found information about them online that seems to describe their struggles perfectly.

But wrong diagnoses are wrong, and it matters, because it's the wrong solution to the wrong problem — even if the solution is just your perception of what you need and are or aren't getting. I'll elaborate on that a little. Let's say you have ADHD, Predominantly Hyperactive/Inattentive Presentation. You've always been super social, very motivated to connect with people, and pretty impulsive, which has caused you to miss people's signals a lot, so the people you most want to be close to have often seen you as coming on way too strong and being kind of all over the place — so you lost them. That didn't change your nature, so you're still super social, very motivated to connect with people, and pretty impulsive, but on top of that, as time goes on, you are also experiencing more and more rejection sensitivity — and all the dysphoria that goes along with it — so you're hyper-focused on anything that suggests someone might reject you, which further damages the relationships and increases the likelihood that they do. And your responses to being rejected, even subtly, have become so intense, even you recognize that they don't make sense, so you talk to your primary care doctor about it. He doesn't talk to you about RSD or ADHD, or ask you about the effectiveness of the Adderall he's been prescribing for years. He refers you to a psychiatrist who tells you confidently at the end of your 45-minute intake session that you have Borderline Personality Disorder.

Or you can make this example like a choose-your-own-adventure and change that last part so you didn't talk to your doctor or see a psychiatrist, but you did some internet research and described the problems you're having in a couple of online communities you're in, and everything you find about Borderline Personality Disorder is spot on, like it was written about you personally. In either case, you feel like Borderline Personality Disorder is the thing that was missing from your understanding of yourself, so you lean completely into it, and start seeing all of your struggles through its lens, which is comforting because of the clarity it brings you. You finally know what's "wrong" with you, what caused it, and what you need to do to fix it. And everything does get better, but that's all they get: better. You still have the same problems, and though your understanding of yourself feels clearer, now it includes a layer of pathology you didn't have before — proof that something is wrong with you that is reinforced by your experience of working really hard to resolve it, but without success. It's the wrong solution for the wrong problem, because it's the wrong diagnosis.

That is not to say that neurodivergent people don't ever have Borderline Personality Disorder, or a mood or anxiety disorder, or other diagnoses, or that neurodivergent people don't ever benefit from treatments that target symptoms that are not associated with their neurodevelopmental differences. Both of these can be true, but what research is increasingly demonstrating is that neurodivergent adults' emotional distress and dysregulation are often best explained by differences in neurodivergent brain functioning and Rejection Sensitive Dysphoria that commonly results from neurodivergent children's experiences. Best explanations are really important, because anything else is technically the wrong explanation. In the example I just gave, being assigned a Borderline Personality Disorder diagnosis that really seemed to fit led to what felt like progress, but actually took you further away from really understanding yourself. That's because it did nothing to increase your understanding of your neurodivergence, which is an inherent part of who you are and how you experience every aspect of your life, and it's probably the actual cause of the problems you're having.

So for those of you whose lives are impacted by your emotions — maybe even more so than they are by the well-known features of your neurodivergence — and you felt, or are feeling, or someone who cares about you is telling you, that you need help or to deal with that right now — quick, fast, and in a hurry — because it's really getting in the way of your happiness, wellness, success, or relationships, what I'm suggesting is that you make sure — insomuch as you can — that RSD is not the best explanation for what you're experiencing before you accept anything else. That means that, if you want or need the support or services of a clinician, you'll have to find one who understands RSD and neurodivergence, and that may be difficult. With or without professional guidance, it will also require you to explore your patterns of automatic responses to certain things and their connections to your early experiences, which you may not remember clearly, or have realized are still impacting you — or even that they could.

No matter what it takes, doing that work will be worth the time and effort because, for most of us, it will spare us the experience of applying the wrong solution to the wrong problem — or bring clarity to those of us who are actively applying the wrong solution to the wrong problem right now, so we can begin to recognize that the reason it didn't fix us is not that we're beyond repair, but that we aren't broken. Should that exploration illuminate or lead to the confirmation of a new diagnosis, it will still have been worth it, because the more we understand our neurodivergence, the better we're able to accept ourselves, build lives that work for us as we are, and create a world in which differences are respected and valued. And if you do conclude that your struggles are best explained by RSD that was born out of your neurodivergence and the experiences you've had as a neurodivergent person, it will have been worth it, because the work you did to bear that out is exactly what reduces the impact of RSD the most: understanding it.

There's very little empirical research about RSD, and while some data suggests certain types of therapy help, those results may simply indicate that therapy, in general, is helpful. Experts like Dr. Dodson, who've worked with thousands of neurodivergent adults, report that therapy isn't useful for RSD overall due to its nature as an acute, automatic, and temporary response to specific situations. What seems to help the most is knowing why RSD happens — to yourself, specifically, and to most neurodivergent people — because that allows us to see RSD as the normal, common experience it is for people like us who've been through what we've been through. It's not just in our heads. It's not proof that we're doomed to be criticized, corrected, and rejected by everyone forever, or that being criticized, corrected, or rejected will always cause us immeasurable pain. We didn't cause it, and we don't have to fix it, because it's not a failing or a flaw. And it turns out that thinking of it and ourselves that way is a huge part of why it's impacted us so much, and why it doesn't have to anymore.

Until next time, remember: You don't have to change yourself to deserve happiness or success. Being who you are isn't the problem; it's the solution. I'm rooting for you — exactly as you are. I'll see you next week.