RSD + Me: Rejection Sensitive Dysphoria (RSD) and the Subtle Ways it Often Manifests in Women...

Part 1 of my new learning to live well with ADHD series

Over the years, I've seen many women in my therapy practice who came to me for help with Social Anxiety. Now, knowing what I know about ADHD and Rejection Sensitivity Dysphoria (RSD), I wonder if, in some cases, I missed the mark. Before I allow myself to feel too badly about this, I try to remember that many of the same tools we use in our field to help people with Social Anxiety (like CBT, Exposure Therapy, Reality Testing, etc.) are also helpful for people who struggle with RSD. So, while I may have missed some ADHD, I'm hopeful that our work together was still helpful. There is a lot of crossover between Social Anxiety, which is a common type of Anxiety Disorder, and RSD, which isn't considered its own diagnosis but instead a set of symptoms. The more we, collectively speaking, are learning about how ADHD manifests in women, the more we are developing new ways to talk about the experience of living with it. While I've come to understand what RSD is now, it wasn't until 2022 (ish) that I had even heard the term, and we most certainly didn't learn about it in grad school or training.

A Few Key Differences…

Social Anxiety is marked by a fear of being judged, embarrassed, or rejected in social situations, which often leads to high levels of distress and people avoiding social outings, public places, etc. RSD is an extreme sensitivity to real or perceived rejection, criticism, or failure, spanning beyond social situations (work, home, school, etc.), and it often causes sudden, intense feelings of shame or anger. RSD develops more commonly in people with ADHD, both because of our struggle with emotional regulation AND because we usually have a history of receiving feedback and criticism more often than our peers. I highlighted the word “perceived” in the previous sentence because, to me, this is the worst part of RSD. Can't we just struggle with actual rejection without adding the perceived category? It's messy, but both because we tend to feel things deeper and because of that history of being criticized or rejected, we often write the story before it's written, so to speak. In other words, we assume that somebody is upset, disappointed, or doesn't like us before we have any evidence to support our belief. Fun, right?

Common Tenants of RSD:

Heightened Emotional Reactivity: ADHD affects the brain’s ability to regulate emotions, making negative feedback feel intensely painful. (Did you know that the brain doesn't differentiate between physical and emotional pain?)

Chronic Feelings of Not Measuring Up: Many women with ADHD spend their lives feeling like they’re “falling behind” or “too much,” especially if they were misdiagnosed or overlooked. This can lead to deep fears of rejection and a tendency to take criticism personally.

Masking and People Pleasing: Because ADHD in women is often underdiagnosed, many learn to mask their symptoms to fit in. This can make them hyper-aware of how others perceive them, leading to perfectionism, over-apologizing, and avoiding conflict—all ways to prevent rejection.

But RSD Doesn’t Always Look So Obvious…

When I was first diagnosed, I started seeing a therapist who specialized in ADHD because, while clinically speaking, I knew a fair amount about the disorder, I wanted to see more clearly how it affects me in my day-to-day life and, of course, see if there were some helpful tools (beyond just my medication) to help me function and feel better. My inner monologue was, “Okay, so I know I lose things, spill things, get lost a lot, and feel overwhelmed with admin tasks (and life in general)…but how else does this affect me?” During one session, my therapist introduced me to the term RSD, and I immediately wanted to dismiss it because I couldn’t find myself in the picture she described: women who are “quick to anger” or become “irrationally angry” and fly off the handle at seemingly benign things. To be fully honest, my first thought was, “Lady, I’m not Bipolar!” Which, clearly, I can now see was a highly defensive reaction that IS maybe indicative of RSD.

If you could take a deeper dive into my inner monologue in that moment, as I scanned for any signs of RSD in my history, it would have sounded something like this: Nope, I don’t have that…I have thick skin! Remember that time the publicist you worked for in LA told you that you were pretty but you’d look skinnier if you wore tighter clothing? You hated it, but you kept working for her. In fact, it wasn’t until she had you risk your life by driving hundreds of thousands of dollars of jewels to a Beverly Hills Hotel without security, asked you to return expensive items of clothing to Bloomingdale's that weren’t actually purchased there, and then proceeded to not pay you for a few months that you actually quit.

Once we started digging a little deeper, what I came to realize was not that I had “thick skin” (whatever the hell that really means anyway) but instead that I am highly adaptive and, over the years, have gotten good at masking the feelings of inadequacy or shame that would surface when I received feedback or perceived that people weren’t happy with my performance. I may have looked like I had it all handled on the outside by laughing it off or continuing to forge on…but on the inside, it felt like I was crumbling, and nobody even knew. I was grinning and bearing it, but all the while, I was formulating harmful beliefs about my identity and worth, which then impacted the choices I made. As it turns out, “stuffing it all down” doesn’t lead us down a path of health and wellness. Side note: Is this why I (and millions of other women) deemed I Can Do It With a Broken Heart by T Swift their theme song? “I’m so depressed, but I act like it’s my birthday…everyday!” Yep, that tracks. Both because of social conditioning and because I worried that if I showed people my real hurt, I’d be further rejected, I mostly kept my feelings of shame and inadequacy locked up—like a “good girl.”

What do we do about it?

To be clear, you don’t have to struggle with RSD to have ADHD (it’s not in the DSM 5 and isn’t an official part of the diagnosis), but most healthcare professionals and psychologists who specialize in ADHD and neurodiversity recognize it as one of the key features. What we do about RSD really depends on how much it’s impacting us—and we can’t actually know that if we don’t do the deeper work of recognizing how it may be showing up in our lives…or, in my case, “hiding in plain sight.” A few questions that might be helpful to ask yourself regarding you and RSD: What do I feel especially sensitive to that other people seemingly don’t? How do I tend to handle feedback or constructive criticism? Do I make assumptions about how people perceive me before I even know? What emotions come up for me when I think about trying or doing something new before I’m good at it? Do I get angry quickly (even if I don’t show it on the outside) if I am confronted and it seems unfair? When do I feel the most shame?

Both clinically speaking (the work I do with my clients) and personally speaking (the work I do in my own life), here are the things that I’ve found to be most helpful in not allowing RSD to take the wheel, hijack my emotions, and steer me away from my values and towards shame:

Get to know it: I shared some tools for how you can do that above, but we can’t accept what we don’t understand.

Accept it: This doesn’t mean we use RSD as an “excuse” to lash out, avoid, or treat ourselves or others poorly. Instead, it means we accept that, due to valid reasons, we are often more sensitive than the people we are surrounded by…and this isn’t “good” or “bad,” it just is what it is.

Learn to challenge it: When we understand and accept our sensitivity, we are more free to challenge it and consider alternatives. I always find it helpful to use real-life examples—so let me give this one a try. Remember the publicist/body-shaming story I shared earlier in the newsletter? Well, I’d be lying if I said that her comments about my body haven’t lived in my head, rent-free, for years after the fact (your girl knows how to hold a grudge). In certain seasons, I’ve allowed her to impact the way I dress, how I feel about my body, and the way I perceive other people are judging my body—I’m STILL working on undoing the shame, and part of the way I do that is by telling the story, because shame can’t live where stories are told. In addition to talking about the way that moment impacted me, I’ve also gotten into the habit of noticing when I’m making an assumption about what people might be thinking about my body, and I try to take a deep breath, give myself grace, remind myself not to mind-read, and do my best to move on.

Embrace the cool-down: Some people with ADHD do tend to be highly emotionaly reactive- meaning they speak before they think…and so learning to embrace the cool down can feel especially hard. As for me, due to my own personal growth and evolution, I’ve let go of the “good girl” part of me and have gotten better about externalizing my feelings- which is a double-edge sword. While feeling and dealing with our feelings is a healthier route to take than stuffing then down, reacting without thought is problematic. So, instead of staring down the guy in line at Starbucks who looked just a little too long, I’m learning to take a deep breath and pause before I make an assumption or react.

I’d love to hear more about how this landed for you- and I will open up a thread on here (Substack) where we can chat more about RSD + I can answer your questions!

If this post resonated, please share with a friend - and thanks for being here to continue to explore the topics I care deeply about like ADHD, parenting, and how the modern political landscape impacts our mental health and well-being.

Until next week,

Kaitlin