Managing Rejection Sensitivity Dysphoria

... Part 8 of the Fundamentals of CBT series

May 30, 2025

Photo by Cristina Anne Costello on Unsplash

🧠 TL;DR: what this article covers

Rejection Sensitivity Dysphoria (RSD) is more than disliking criticism - it’s a reactive, overwhelming emotional pain triggered by real or perceived rejection.
RSD reactions are neurological, but what happens next - the rumination, the self-attack, the spiralling - can be changed.
Medication, therapy, self-regulation strategies, and compassion-based tools can make a real difference.
You don’t have to fix every RSD maintaining process. Just shifting one or two patterns - avoidance, perfectionism, harsh self-talk - can loosen its grip.
You don’t need to stop caring what people think. You just need to stop losing yourself every time it hurts.

And now onto the full article!

What is RSD?

Everyone hates rejection. No one enjoys being criticised.
But Rejection Sensitivity Dysphoria - or RSD - is something else entirely.

It’s not just “taking things personally.” It’s not “being a bit thin-skinned.”

It’s an intense emotional and physically felt pain - sudden, overwhelming, and often out of proportion to the trigger. It hijacks the whole system.

“Rejection sensitive dysphoria is a triggered, wordless emotional pain that occurs after a real or perceived loss of approval, love, or respect.”
Dr William Dodson

It can also be triggered by criticism, teasing, humiliation - or the awful sense that you’ve let someone down. Sometimes even yourself.

When RSD hits, there’s no rational filtering, just a visceral, bottom-drops-out dread.

RSD is not a formal diagnosis. You won’t find it in the textbooks, but if you speak to any clinician who works with ADHDers - and more importantly, speak to those who live it — and they’ll tell you it’s very, very real.

What RSD feels like, from the inside

Photo by Yuris Alhumaydy on Unsplash

People with RSD don’t just feel things deeply - they feel them violently.

They’re constantly on alert, scanning for micro-signals of disapproval. A pause in someone’s reply. A flat tone. A joke that might not have landed. The world feels full of traps.
Their brains are wired with the volume turned way up. That’s not dysfunction. It’s the ADHD nervous system - fast, loud, and exquisitely reactive - turned inward.
When rejection hits (or might), the reaction is immediate. Rage. Tears. Collapse. It’s not a tantrum. It’s a survival response.
Some people don’t explode, they implode. One tiny moment spirals into shame or despair. It looks like a mood disorder. But often, it’s not. It’s rejection pain, flooding the system like a broken dam.
Underneath are beliefs tattooed onto the nervous system: “I’m too much.” “I’m not enough.” “I don’t belong.”
So they shrink, withdraw and avoid. Don’t post the thing. Don’t speak up. If you don’t try, you can’t fail. If you don’t connect, you can’t be rejected.
Others go the opposite way: perfection, performance, praise-chasing and people-pleasing. Masking becomes survival. But inside is exhaustion and fear.
Their inner voice is brutal. “You idiot.” “Why did you say that?” “They were just being polite.” It’s not that self-compassion is missing in action - it was literally never learned.
When they’re triggered, regulation feels impossible. The nervous system locks up or spirals out. They lash out, shut down, disappear into numbing habits. They’re not overreacting - they’re overwhelmed.
Anxiety and depression often sneak in too but they’re not the cause.
Mood symptoms are the smoke. RSD is the fire.
That fire often started early, during childhood. Not a single big trauma - but a thousand small ones. Being left out, misunderstood, or ‘too much’ for the room.
And society? It adds fuel. The world still treats neurotypical people as the norm and tells ADHDers to shape up or shrink down.

What keeps RSD going? Introducing the vicious flower

So why doesn’t RSD just flare up and then fade like a normal emotional reaction?

It’s not just the intensity of the emotion. It’s the entire system that forms around it.

RSD becomes self-reinforcing, with each part of the experience feeding itself and the others. Over time, a whole ecosystem forms - a vicious flower of pain, distortion, and defence.

RSD isn’t one feeling - it’s a whole architecture of threat, reaction, and fallout.

In CBT, we often capture ideas in metaphors and diagrams. Here's what’s called the vicious flower of RSD:

Each petal is a process that maintains the RSD and stops it from going away:

Neurobiological susceptibility - the instant neurological reactivity
ADHD-related trauma - childhood exclusion, misunderstanding, bullying
Hypervigilance and anticipatory dread of rejection - always scanning for rejection cues
Cognitive distortions - black-and-white thinking that categorises experiences as either/or instead of a bit of this and a bit of that. And catastrophic assumptions
Difficulties with emotion regulation - no easy way to return to calm
Low self-compassion and shame - the inner critic kicks you while you’re down
Negative core beliefs - “I’m unlikeable”, “I always mess up”
Somatic pain - rejection isn’t just felt emotionally; it lands in the body
Avoidance - steering clear of anything risky or exposing
Maladaptive coping - lashing out, masking, people-pleasing, perfectionism
Co-existing anxiety or depression - mood disorders or low self esteem turn up the volume of distress even further
Social invalidation - judged by neurotypical standards

It’s important to note that the arrows are double-headed - showing how each petal and RSD reinforce each other.

For example, the more you avoid situations where rejection might happen, the more intense your sensitivity to rejection becomes - and the more intense the sensitivity, the more you avoid.

Of course, avoidance makes sense in the short term. It feels protective. It is protective, but only temporarily.

But the trouble is, when you keep relying on any of these maintaining processes, you never get the chance to learn other, more effective ways to manage your RSD in the long term.

The good news is that you can learn more adaptive skills.

And you don’t need to pull off every petal to dismantle the flower. Even breaking off one or two can weaken the whole .

RSD can coexist with alexithymia

Alexithymia is the difficulty identifying, naming, and expressing emotions. It’s not a lack of feeling - the emotions are there - but recognising and describing them is hard.
Some studies suggest that nearly half of ADHDers may experience alexithymia to some degree.

Pairing alexithymia with RSD may mean you’re hit by a tsunami wave of shame, hurt, or rage… but you can’t quite name what you’re feeling. You just know something’s wrong.

Overwhelmingly, viscerally wrong.

🧠 It’s like being stabbed by an emotion you can’t locate.

This combination is especially tough because:

You might feel dysregulated but not know why.
You might lash out or shut down without understanding the trigger.
You might struggle to soothe yourself, because the emotional signal is so fuzzy, it’s hard to respond to.

There’s very little direct research into the co-occurrence of RSD and alexithymia, but early evidence - and lived experience - suggest they may be linked.

Theoretically, it makes sense: the more emotionally sensitive you are to rejection, the more alexithymia might “protect” you from feeling the full intensity of RSD. But that very protection keeps you disconnected from the emotional signals you need to regulate. A truly vicious cycle.

What helps when RSD hits?

Medications

There is sadly no RSD pill. It’s not a formal diagnosis, so there’s no treatment that’s specifically licensed to treat it. But doctors can do what’s called off-label prescribing of ADHD medications, particularly for RSD symptoms.

Alpha-2 agonists (e.g. guanfacine, clonidine) directly lower baseline arousal. Dr William Dodson, a psychiatrist who has been researching and treating ADHD for decades, says up to 60% of ADHDers get some RSD symptom reduction from them, describing it as though “putting on emotional armour.”
Stimulants - these are the amphetamine-related medications, like methylphenidate (also known as Medikinet, Concerta and Xaggitin), dexamphetamine (also known as Adderall, Dexedrine or Amfexa) and lisdexamphetamine (also known as Elvanse or Vyvanse). They boost brain dopamine levels, helping with focus and impulse control. For some, they quieten the storm enough for emotional regulation to be accessible. For others, they can increase their anxiety.

Non-medication approaches

Some clinicians, like Dr Dodson, believe psychotherapy doesn't help, because the reaction is neurological and fast, beyond the reach of reason.

But others - myself included - see it differently.

The sting may be neurological. But the spiral is psychological. And spirals can be softened.

Therapy doesn’t erase sensitivity. It helps you interrupt the cascade - the rumination, the self-attack, the retreat. And that can make a huge difference.

🌬 Regulate your body first (self-regulation approach)

You can’t think clearly when your nervous system is on fire.

Before you untangle thoughts, soothe your body:

Breathe out longer than you breathe in. Or try a breathing with visualisation exercise.
Go to your inner sanctuary by practicing a Safe Place visualisation.
Try PMR - tense and release each muscle group.
Move. Let the charge discharge.
Use sensory grounding - water, scent, texture. Anchor in the now.
Or use my emergency soothing with a tennis ball technique.

🧠 Before you challenge your thoughts, help your body feel safe enough to hear them.

🎧 Distract (respite approach)

If it’s all too much - pause.

Watch something silly. Play your comfort playlist. Cuddle your pet.

There’s an important distinction here: distraction isn’t avoidance — if you understand that you’re using it deliberately, just for a short time, to buy space until your brain comes back online.

But if it’s your only strategy? Then yes - it risks becoming avoidance. And as the vicious flower shows us, avoidance is one of the things that keeps RSD going.

🧠 Judicious and limited distraction isn’t denial - it’s a nervous system timeout.

🎭 Catch the story mid-performance (mindfulness approach)

When rejection hits, the mind scripts catastrophe.

“Everyone hates me.”
“I’ve ruined everything.”
“I’ll never be okay.”

Name the story instead of getting swept into it.

“Ah, the ‘Unlovable Me’ episode is airing again.”
“Looks like ‘Total Social Ruin’ has arrived now.”

🧠 Narratives lose power when you stop starring in them and start naming them.

✍🏽 Write it out (externalisation approach)

Can’t make sense of it? Write it down. Not for wisdom. Just containment.

Try:

What just happened?
What story did I tell myself?
What do I need?

🧠 Seeing it on paper can help it feel less like everything and more like something.

🪞 Talk to yourself like you would to a friend (compassionate approach)

When the inner critic attacks, respond with gentleness.

“That hurt. But it doesn’t mean I’m worthless.”
“I’m allowed to care. I’m allowed to mess up.”
“I’m still here. Still worthy.”

🧠 Compassion isn’t letting yourself off the hook - it’s letting yourself back into the room.

A final word

You don’t have to “cure” your RSD. You don’t need to become unbothered, impenetrable, or stoic. You just need tools. And practice. And tenderness. You need to remember - in the thick of the pain - that this doesn’t mean you’re broken. It means you’re wired for connection. That’s not weakness. That’s humanness.

Call to action

If this article resonated with you, you’re not alone - and you don’t have to figure it out alone either.

📌 Save this post to come back to when RSD strikes.

🧠 Try one tool next time it hits - just one. See what shifts.

📓 Journal your own vicious flower - what are your petals?

🧡 Share this with someone who doesn’t get why rejection hits you so hard.

🎥 Want to try these self-regulation tools with me? Click on the links in the ‘Regulate your body first’ section above, where I talk you through a few of them, step by step.

🔍 Curious about alexithymia? - read my previous alexithymia article.

And if you’re experimenting with any of these tools, I’d love to hear what’s working. Comment below or just hit reply.

Click on the links in the ‘Regulate your body first’ section above.

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