Rejection sensitive dysphoria: causes and treatment

Let’s face it: rejection is tough. Whether it’s being passed over for a promotion or going through a painful breakup, we’ve all experienced the sting of being told “no.” 

But for people with rejection sensitive dysphoria (RSD), that sting develops into something much more overwhelming that can make it difficult for a person to function.

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People with rejection sensitive dysphoria (RSD) are extremely sensitive to social rejection (Gao, 2017). They experience intense emotional pain whenever they encounter rejection or criticism, whether real or perceived. The potential for rejection itself can be triggering, and even the smallest comment may feel catastrophic (Berenson, 2009).

People with RSD live in a vicious cycle of emotional turmoil. Not only do they anxiously expect rejection, but they’re also quick to notice any type of dismissal. The response to this includes intense emotional reactions that can disrupt their life and the lives of others around them (Berenson, 2009). 

RSD symptoms share similarities with many other mental health conditions. 

Because of this, RSD can be difficult to diagnose and may be mistaken for other conditions, including anxiety, bipolar disorder, depression, body dysmorphia, borderline personality disorder, and social phobias (Gao, 2017; Shaw, 2014). 

Symptoms of RSD may include (Bondü, 2015; Gao, 2017):

• Anxiety

• Avoidance of social situations that may lead to rejection

• Fear of rejection or failure

• Feelings of not being accepted or liked by others

• Low self-esteem

• Negative self-talk

• Outbursts of anger or emotion in response to rejection

• People-pleasing tendencies

• Perfectionism

• Rumination over experiences of rejection

RSD can significantly interfere with someone’s overall well-being and affect their personal and romantic relationships. People who experience it can become so fearful of the possibility of rejection that they withdraw socially to protect themselves. This further weakens their relationships and heightens the perception of being rejected (Berenson, 2009).

People with RSD are also more likely to ruminate or obsess over any perceived rebuff, which leaves them feeling even worse (Pearson, 2011).

There are several proposed causes for RSD, ranging from personal experiences to a genetic predisposition. A person may develop RSD after being teased, bullied, romantically rejected, or as a result of parental neglect. 

RSD can develop in childhood if a person lived with a hyper-critical parent or was teased at school. It can also crop up later in life if, for example, someone is bullied at work or criticized by a romantic partner. Some people may have a genetic predisposition to RSD if there’s a family history of it (Berenson, 2009). 

People with attention deficit hyperactivity disorder (ADHD) or autism may also be more likely to develop RSD, though the two conditions don’t always co-exist (Mazefsky, 2015; Surman, 2013).

Impulsivity and extreme emotional sensitivity are two symptoms of ADHD, a disorder that affects 10% of children and 5% of adults. ADHD symptoms may worsen RSD and intensify feelings of rejection. Over 60% of people with ADHD report RSD symptoms—like being quick to anger or emotionally overreacting—compared with less than 15% without ADHD (Surman, 2013). 

People with autism also experience extreme emotional sensitivity. They may have trouble regulating emotions and communicating, leading to a more intense perception of rejection or misinterpretation of neutral feedback as rejection. Due to their increased rejection sensitivity, individuals with autism may be more prone to thoughts of self-harm and symptoms of anxiety and depression (Mazefsky, 2015).

If you or someone you know is contemplating suicide, know that help is available. Call the National Suicide Prevention Lifeline, available 24 hours a day, 7 days a week at 1-800-273-8255.

RSD does not appear in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5), so there are no official diagnostic criteria for this condition (Shaw, 2014). 

Because RSD shares similarities with other mental health conditions, a healthcare professional will usually first try to figure out if your symptoms are due to another condition before investigating RSD. You may also be asked questions to better understand how you react and feel in certain situations. Some questions you can expect include:

• How do you feel after experiencing rejection or criticism?

• Do you ever perceive neutral feedback as rejection?

• Are you a people-pleaser?

• Would people say you have overly high standards for yourself?

• How would you rate your self-esteem?

• Do you worry about failure?

• Do people say you’re too sensitive?

• Do you worry about people judging you for your shortcomings or true feelings?

Based on your answers, a healthcare provider may ask additional screening questions to evaluate what might be causing rejection sensitivity.

Treatment options for RSD typically focus on addressing any underlying conditions first. 

For instance, medication is often the first line of treatment for the core symptoms of ADHD. Prescribed drugs also tend to relieve other symptoms, including extreme rejection sensitivity (Shaw, 2014). 

Depending on your diagnosis, you may be prescribed ADHD medication, mood stabilizers, or antidepressants (Shaw, 2014). Alongside medication, psychotherapy and healthy lifestyle changes are also recommended.  

Cognitive behavioral therapy (CBT) is one type of therapy shown to be effective. In CBT, therapists work with people to help them identify destructive or unhelpful patterns in their thoughts and behaviors. They also teach effective tactics for managing things like stress, rejection, and trauma. CBT can help individuals with RSD accurately recognize their emotions, consider if they’re overreacting, and process negative emotions in a healthy way (Shaw, 2014).

Lifestyle changes may also make it easier for you to control your emotions when facing rejection and criticism. Following a healthy diet, exercising daily, enjoying hobbies, and getting plenty of sleep can all lower stress levels. With less stress, it’s easier to take a breath and react more calmly (Choi, 2018; Childs, 2014). 

Parents of children with RSD can minimize negative experiences at home and connect the child with friends who are more emotionally stable (Shaw, 2014). 

Rejection is painful, and it’s normal to feel completely devastated once in a while. But if you notice that you’re having overwhelming emotional reactions anytime you experience rejection—to the extent that it interferes with relationships and your wellbeing—it may be time to talk to a healthcare provider or mental health professional. 

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Current version

June 03, 2021

Written by

Amelia Willson

Fact checked by

Yael Cooperman, MD

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About the medical reviewer

Yael Cooperman, MD, Ro

Yael Cooperman is a physician and works as a Senior Manager, Medical Content & Education at Ro.