Rejection Sensitivity Dysphoria (RSD) is a term that was conceived to describe the intense emotional response and deep-seated fear individuals with Attention-Deficit/Hyperactivity Disorder (ADHD) often have regarding perceived or real rejection, criticism, or exclusion. Though it is not officially recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), it is widely accepted among clinicians who treat individuals with ADHD.
The construct of RSD can be traced back to various paradigms in psychology and psychiatry that explore emotional sensitivity, interpersonal rejection, and social anxiety. However, the term itself seems to have gained currency within the last decade, mainly due to the work of researchers and clinicians looking for a way to encapsulate the emotional dysregulation and intense emotional pain related to rejection that some individuals experience.
The current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), primarily tailors its diagnostic criteria for ADHD to children aged 6-12. These criteria have not been validated for individuals over the age of 16. The criteria focus solely on observable or quantifiable behavioral symptoms, intentionally neglecting elements related to emotional experience, cognitive patterns, interpersonal relationships, and sleep patterns. This limitation renders the DSM-5 criteria largely ineffective for clinicians who work with older adolescents and adults, as these criteria overlook crucial aspects of how individuals with ADHD experience their lives.
About five years ago, the research community began to explore the concepts of Rejection Sensitivity Dysphoria (RSD) and emotional dysregulation as integral components of ADHD. Patients and their families met this shift with enthusiasm, as it resonated closely with their lived experiences. However, the reception among clinicians and researchers was less welcoming. Many professionals were skeptical, partly because the concept seemed to lack a historical basis in the scientific literature. Additionally, at that time, most of the available research originated from the European Union, where the focus was on “emotional dysregulation” rather than RSD.
Fortunately, the landscape is evolving rapidly. Recent years have seen a surge in research on this subject, and the European Union has updated its definition of adult ADHD to include emotional self-regulation as a key diagnostic criterion. These developments collectively validate the concept of RSD and emotional dysregulation as significant, definable features of ADHD in adults, warranting attention and treatment.
Dr. Paul Wender stands as a seminal figure who, beginning in the 1960s, devoted over forty years to groundbreaking investigations into ADHD. He was the first to identify emotional dysregulation as a consistently observed, highly prevalent, and significantly debilitating aspect of what we presently refer to as ADHD.
Building upon this foundational understanding of the disorder, Dr. Fred Reimherr, another pioneer in the ADHD field, recently revisited his seminal work on diagnostic criteria. It is worth noting that Dr. Reimherr, in collaboration with Dr. Wender, had originally formulated what was then known as the Wender-Reimherr Criteria over five decades ago, which laid the groundwork for the contemporary criteria for diagnosing ADHD in children. His latest research reaffirms the diagnostic components and posits a radical shift in conceptualizing ADHD. According to his recent work, ADHD can be best understood as comprising two distinct subtypes: the well-recognized inattentive subtype and a newly emphasized emotional dysregulation subtype.
This conceptual shift marks a momentous change in the scholarly and clinical understanding of ADHD. Emotional dysregulation, a component that had been largely sidelined for half a century, is now rapidly ascending in prominence as one of the quintessential features defining ADHD. This shift is gaining traction in North America and across the European Union.
Further supporting this revised paradigm, a 2019 publication by Faraone in the Journal of Child Psychology and Psychiatry, entitled "Emotional dysregulation in attention deficit hyperactivity disorder – implications for clinical recognition and interventions," posits that there exists a "robust theoretical rationale" to consider emotional impulsivity and deficits in emotional self-regulation as core, defining symptoms of ADHD.
RSD arguably has its conceptual roots in various psychological theories and constructs, including:
Individuals with Attention-Deficit/Hyperactivity Disorder (ADHD) often lead lives marked by intense emotions and strong passions. Their focus is highly selective; if a particular subject or activity doesn't capture their interest, it virtually disappears from their awareness. On the flip side, they become deeply invested in the few matters that do resonate with them. This intense focus can perplex others, as it is not always clear why individuals with ADHD display heightened emotional reactions to issues that might seem inconsequential from an objective standpoint.