Rejection Sensitivity - ADHD fact or fiction

Rejection Sensitivity Disorder isn’t the same as ADHD and why that matters.

ADHD is a brain type and as such it can’t be cured. Many ADHDers report that a diagnosis of ADHD is empowering (Halleröd, 2015). Many experts view RSD in the same light, with a 2022 report by Cleveland clinic stating ‘For people who don’t grow out of ADHD, a condition like RSD is most likely a permanent, lifelong concern.’

I believe that RSD is significantly different to ADHD, that it is not an inevitable consequence of brain biology but an avoidable and curable response to environmental factors, which is made more likely by certain brain types. Through my experience of working with hundreds of individuals with ADHD, many of whom also suffer with RSD symptoms I now believe that RSD is an anxiety based disorder, specifically a type of phobia, similar to social phobia. Social phobia is defined as “A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others.” (DSM 5, 2016).

Fortunately there is extensive literature on how phobias develop and are maintained. By applying that knowledge to RSD we can see the mechanisms by which ADHD increases a persons chance of developing RSD and understand how environments such as schools and workplaces can be adapted to reduced that risk. Applying the two process model (Mowrer, 1947) suggests that RSD forms when rejection is associated with a negative experience, which it often will be for ADHDers who struggle with emotional regulation (Retz, 2012). RSD often develops during adolescence, and increases the risk of developing social anxiety in adolescence(Zimmer-Gembeck, 2021). Schools and parents should be gentle with rejection, ensuring that rejection is not associated with isolation or shame. Preventative programs could role play rejection with young people in a low anxiety environment, helping them to learn how to give and receive rejection without developing RSD. It’s important that any such program feels positive to the young people involved to avoid creating a negative association. Therefore the program must be optional, with participants free to leave without stigma at any point.

Having developed, RSD is then maintained by avoidance, as long as someone avoids situations that might lead to any form of rejection they are denied the opportunity to learn that such rejection can be survived. The feeling of relief after successfully avoiding possible rejection reinforces the phobia. To overcome this, clients should have regular opportunities to experience safe rejection, that is, rejection that doesn’t lead to isolation or shame. Additionally, brain mechanisms act to protect our previous beliefs (e.g. rejection is painful, I’m a person who can’t handle rejection) and so evidence that rejection is safe can be discounted by someone with RSD. To counter this, the client should keep a written record of their experiments with rejection, noting when rejection happens and what the result is. This will help them ‘hold onto’ the evidence that rejection is safe, allowing their brain to change the beliefs that are maintaining RSD.

Additionally there is a wealth of research into how to cure phobias and we can draw on this to identify likely methods of curing RSD. Psychological interventions can be used to successfully treat social phobias, such as fear of public speaking (Ebahimi, 2019), including cheap email based self help programs (Tillfors, 2008), graded self exposure and cognitive based therapies (Veale, 2003). Common medications, such as SSRIs, can also be effective, either alone or in combination with psychological interventions (Canton, 2012). Further research into how best to adapt these treatments for ADHDers who suffer with RSD would be valuable, but this should not delay treatment as there is already sufficient research to support and treat RSD.

A word of warning. If a person formulates a phobia as part of their identity it becomes harder to successfully treat, as identity change is hard. Therefore there is an urgent need to curb the many ADHD influencers who share the message that RSD is a component of ADHD or of someones identity. Viewing ADHD as part of ones identity seems to be helpful and increase positive outcomes, however viewing RSD as identity is dangerous as it maintains the beliefs underlying the phobia and makes it more resistant to treatment. RSD, if left untreated, is associated with increased risk of depression, anxiety and other disorders (Gao, 2017).

Acknowledgements

The insights in this white paper owe a big debt of thanks to the work of Maggie Johnson and Alison Wintgens on Selective Mutism, their insight that SM is best viewed and treated as a phobia crystallised my understanding of RSD. The compassionate, practical and effective methods they lay out in The Selective Mutism Resource Manual are a treasure trove for researchers and practitioners in this area.

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Retz, W., Stieglitz, R.-D., Corbisiero, S., Retz-Junginger, P., & Rösler, M. (2012). Emotional dysregulation in adult ADHD: What is the empirical evidence? Expert Review of Neurotherapeutics, 12(10), 1241–1251. https://doi.org/10.1586/ern.12.109

Substance Abuse and Mental Health Services Administration. DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 16, DSM-IV to DSM-5 Social Phobia/Social Anxiety Disorder Comparison. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t12/

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Zimmer-Gembeck, M. J., Gardner, A. A., Hawes, T., Masters, M. R., Waters, A. M., & Farrell, L. J. (2021). Rejection sensitivity and the development of social anxiety symptoms during adolescence: A five-year longitudinal study. International Journal of Behavioral Development, 45(3), 204–215. https://doi.org/10.1177/0165025421995921