RSD & ADHD Emotionality
RSD shows up in unpredictable ways. From obvious moments of rejection by someone we care about to more subtle forms of invalidation – like being told how to do something when we already know how to do it.
Understanding the patterns that make RSD unique
Recognizing RSD
in your life
For more than three decades of clinical practice, Dr. William Dodson listened to countless ADHD patients describe their experiences of severe emotional pain. While other clinicians viewed these self-reports through a neurotypical lens and often dismissed them, Dr. Dodson did something different—he believed his patients. His careful documentation revealed clear patterns that help us understand why Rejection Sensitive Dysphoria (RSD) is so different from ordinary emotional sensitivity and mood disorders.
RSD is often misdiagnosed as a mood disorder—it's more than just exaggerated or irrational emotion.
RSD is a deeply physical, neurological, and emotional response to the threat of rejection, correction, or dismissal of our self-worth. Unlike mood disorders like anxiety, depression, bipolar, or borderline personality disorder, RSD stems from the unique way our ADHD brains process threats to an underdeveloped self-worth.
This doesn’t mean a mood disorder couldn’t also be part of what’s going on, but some ADHD and RSD symptoms mimic these conditions. If ADHD and RSD are present, screening for them first can get you treatment and relief faster because ADHD meds often work within hours—treatments for mood disorders can take weeks to show results.
Let’s look at how RSD shows up in our lives and what works to make it better.
What is RSD
Understanding
Rejection Sensitive Dysphoria
Rejection Sensitive Dysphoria (RSD) is intense, overwhelming emotional pain related to real or perceived rejection or criticism from others. It may also be caused by a sense of falling short of others’ expectations or not measuring up to one’s own high standards.
People with RSD don’t handle rejection or criticism well. In fact, those with RSD may even experience actual physical pain from feelings of rejection or failure.
RSD is linked to emotional dysregulation, which is often a symptom of ADHD in adults. While the pain experienced with RSD can be traumatic, it is not caused by trauma. It’s important to remember that it is not a sign of weakness – it’s simply a condition that’s linked to ADHD, and experts believe it is the result of differences in brain structure and function.
The emotional connection
RSD isn't the only type of
ADHD emotionality
ADHD-related emotional dysregulation—such as irritability and distress sensitivity—can be improved with first-line stimulant meds for ADHD.
General Rejection Sensitivity (without Dysphoria) can develop in anyone because it comes from early adverse life experiences that happen to us, not from our neurology.
Rejection Sensitive Dysphoria is vastly different. It’s a specific neurological response pattern that Dr. Dodson documented in his ADHD patients with 12 unique characteristics that set RSD uniquely apart.
What makes RSD distinct isn’t just how it feels, but how consistently it follows specific patterns. There’s always a trigger, even if others can’t see it. These triggers aren’t random – they fall into clear categories: rejection, teasing, criticism, or feeling like we’ve failed. What’s remarkable is how the intensity of our response exactly matches the trigger’s level of rejection of our worth.
An RSD shift happens
in an instant -
One moment we're fine, the next we're pulled under by a powerful wave of
emotional and physical intensity.
The impact is immediate.
The pain of RSD shame sinks right through you—like a deep feeling of depression.
Other times the instantaneous pain of RSD erupts as a hot, fast temper—it’s not anger—it’s a hardwired, protective shield from overwhelming distress. It’s driven by a disbelief (“How could this happen?“) and an instinct to push back against the hurt.
RSD responses are often mislabeled as ‘anger issues,’ but RSD reactions stem from extreme emotional pain, not uncontrolled or hostile rage. The sudden, intense temper isn’t about aggression toward others. Unlike chronic anger struggles with frustration and impulse control, RSD reactions are immediate, intense, and deeply tied to severe emotional sensitivity.
RSD pain goes beyond emotional—it’s physically overwhelming and primal—impossible to put into words.
For many of us, these vividly intense responses are etched into our psyche—a wound that never fully heals, always there as a reminder of our inadequacy and the pain of that moment.
The heaviness of RSD episodes lingers and leaves a trail of self-recrimination in its wake. Each time, we flood with intense shame over our inability to control reactions, no matter how justified they may be. This isn’t weakness or mere impulsivity—it’s a consistent neurological response—one that Dr. Dodson observed in patient after patient.
Patterns developed from a
lifetime of RSD
- Intense, fast emotional responses
- Critical self-image and self-talk
- Intense unease and deep anxiety
- Paralyzing avoidance of difficult situations
- People pleasing that devalues our own needs
- Fragile self-trust leads to weak boundaries
- Perfectionism to avoid rejection and criticism
- Strained relationships at home and work
Awareness of these patterns is the first step—but what exactly happens during an RSD episode? Let’s break down the experience phase by phase—because knowing what’s happening in your brain and body during each stage can help you start building skills to manage RSD more effectively.
We do not rise to the
level of our expectations.
We fall to the
level of our training.
-Archilochus
Signs & Symptoms
Recognizing the
patterns of RSD
Since RSD isn’t an official medical condition and there’s limited research on it, your doctor, counselor, or licensed therapist might not know much about it or they may mistake it for another condition, such as bipolar disorder or social anxiety disorder.
Strong, immediate responses to real or perceived rejection can manifest as sudden outbursts of anger, rage, or crying. These reactions often feel overwhelming and may seem disproportionate to others.
A persistent pattern of negative self-perception impacts daily confidence and self-worth. Individuals often struggle with feeling fundamentally “not good enough,” leading to harsh self-judgment.
Social situations trigger intense self-consciousness and heightened awareness of potential criticism. This can lead to frequent anxiety and depression symptoms, especially in situations involving evaluation or judgment.
Fear of potential rejection often leads to avoiding new opportunities or situations where criticism might occur. When faced with such situations, many experience “paralysis” or inability to take action, even with tasks they’re capable of completing.
An intense drive to meet impossibly high standards becomes a shield against potential criticism. This manifests as meticulousness in work and personal life, often at the cost of time, energy, and wellbeing.
Relationships become emotionally draining due to constant vigilance against perceived rejection. People-pleasing behaviors dominate social interactions, while individuals feel perpetually scrutinized and misunderstood by others.
Understanding RSD Episodes
What happens during an
RSD episode
Let’s break down exactly what happens during an RSD episode – understanding these phases helps us recognize them when they start and begin developing better ways to manage them.
There’s always a trigger—even if no one else sees it. Your body knows first.
RSD isn’t just emotional sensitivity—it physically hijacks you in an instant with a punch in the gut, a kick in the teeth, a skipped heartbeat.
The trigger hits like a water drop breaking a pond’s surface, pulling you under. Time stands still.
The pain isn’t just emotional—it’s physical, beyond words. Voices fade as you sink into disbelief.
Now you’re face to face with someone who has no idea what just happened.
Was it true disrespect? Or unsolicited advice on how to load the dishwasher? Thinking about boundaries or explaining? —it’s pointless. They don’t see the weight of everything that came before this moment. You’ve spent the day—your whole life—trying your best and ignoring your needs just to get along.
Your reaction seems overblown—is overblown. But the physical distress is unbearable, crushing, and overwhelming.
Fight or flight kicks in—no time to think, only react. Were they intentionally criticizing, or just oblivious? If they say you’re overreacting, frustration surges; if they apologize, shame deepens.
From the outside, nothing of consequence has happened. But inside, it’s like being cornered—your body floods with distress and the urge to escape takes over.
You leave. You walk. You breathe. The urgency fades, but your body is still wrung out, adrenaline slowly draining. Your heart pounds less. Muscles unclench. The world is no longer closing in.
Step by step, breath by breath, the intensity eases—not gone, but shifting, settling, processing.
The next several moments, hours, and the rest of the day are spent in ruminating reflection: What part of me was being rejected? How could they be so insensitive?
Then harsh self-judgment ‘What is wrong with me?‘ This isn’t just overthinking- it’s your brain desperately trying to figure out how to prevent this pain in the future.
As the intensity fades, the episode’s impact lingers—sometimes for a while, sometimes for years.
It’s in this phase that we can find ways to make RSD better. Medication can make it easier to build skills to keep episodes away. These skills come from support groups, ADHD coaching, therapy, and lifestyle changes that build resilience, so while triggers still happen, they’ll no longer trigger you.
RSD care works like emotional armor—you have to put it on every day to move forward with confidence.
Understanding RSD Episodes
What happens during an
RSD episode
Let’s break down exactly what happens during an RSD episode – understanding these phases helps us recognize them when they start and begin developing better ways to manage them.
There’s always a trigger—even if no one else sees it. Your body knows first.
RSD isn’t just emotional sensitivity—it physically hijacks you in an instant with a punch in the gut, a kick in the teeth, a skipped heartbeat.
The trigger hits like a water drop breaking a pond’s surface, pulling you under. Time stands still.
The pain isn’t just emotional—it’s physical, beyond words. Voices fade as you sink into disbelief.
Now you’re face to face with someone who has no idea what just happened.
Was it true disrespect? Or unsolicited advice on how to load the dishwasher? Thinking about boundaries or explaining? —it’s pointless. They don’t see the weight of everything that came before this moment. You’ve spent the day—your whole life—trying your best and ignoring your needs just to get along.
Your reaction seems overblown—is overblown. But the physical distress is unbearable, crushing, and overwhelming.
Fight or flight kicks in—no time to think, only react. Were they intentionally criticizing, or just oblivious? If they say you’re overreacting, frustration surges; if they apologize, shame deepens.
From the outside, nothing of consequence has happened. But inside, it’s like being cornered—your body floods with distress and the urge to escape takes over.
You leave. You walk. You breathe. The urgency fades, but your body is still wrung out, adrenaline slowly draining. Your heart pounds less. Muscles unclench. The world is no longer closing in.
Step by step, breath by breath, the intensity eases—not gone, but shifting, settling, processing.
The next several moments, hours, and the rest of the day are spent in ruminating reflection: What part of me was being rejected? How could they be so insensitive?
Then harsh self-judgment ‘What is wrong with me?‘ This isn’t just overthinking- it’s your brain desperately trying to figure out how to prevent this pain in the future.
As the intensity fades, the episode’s impact lingers—sometimes for a while, sometimes for years.
It’s in this phase that we can find ways to make RSD better. Medication can make it easier to build skills to keep episodes away. These skills come from support groups, ADHD coaching, therapy, and lifestyle changes that build resilience, so while triggers still happen, they’ll no longer trigger you.
RSD care works like emotional armor—you have to put it on every day to move forward with confidence.
You can't prevent the raindrops
from falling -
but you can steady yourself in the
ripples they create.
Clinical options
Find what works best
for you
RSD is deeply tied to how our brains are wired to the rest of us. There are non-stimulant medications that target the neurological and physiological roots of RSD. These aren’t typical mental health meds used for mood disorders; instead, they address the unique way RSD impacts the brain and body. Paired with therapy and ADHD coaching, these non-stimulant meds can make a real difference.
Just as we looked at RSD step by step, let’s explore ways that can help those who live with it.
Important note: I’m not a doctor or medical professional and I strongly advocate for you to work with an ADHD medical specialist. They are in short supply, but worth the time to find. Start with provider directories at CHADD.org, and Psychology Today, and groups like your local CHADD chapter.
RSD isn't in the DSM -
and that's a big problem.
Most primary care and family practice clinicians haven’t heard of RSD. They also aren’t aware that the FDA approved Alpha Agonists Guanfacine (2009) and Clonidine (2009-10) for ADHD. These medications were originally developed for blood pressure control, but research and clinical experience have shown they can be incredibly helpful for ADHD.
Both are FDA-approved for ADHD but not specifically for RSD because RSD isn’t an official diagnosis yet. ADHD criteria used to include emotionality, but in 1980, the DSM-III changed the definition to only attention and hyperactivity. Emotions were left out because they were hard to measure. Though many experts see emotional sensitivity as a big part of ADHD, treatments are approved for ADHD as a whole.
Links provided in blue so you can do your own research to make informed decisions with your ADHD providers.
For many people with RSD, Guanfacine and Clonidine have been life changing. Unlike typical ADHD meds—they help with the intense sensitivity that makes RSD so overwhelming.
What makes these medications unique?
Many say it’s like wearing an emotional armor—not just to soften the blow but stop a wound before it happens. Without it, every trigger is a wounding threat, forcing an instant reaction. With the armor, a trigger’s blade bounces off—fight-or-flight is held back. Now you have an extra beat of clarity that lets you stand your ground and respond with intention and control.
How you know it's working:
- Freedom from the sting of rejection – Imagine feeling steady in the face of criticism, instead of crushed by it.
- A deep sense of calm – Not just in your mind, but in your body. Like exhaling after holding your breath for years.
- Mental clarity that cuts through the noise – Racing thoughts quiet, making space for focus and intention.
- Restful sleep without dependence on sleep aids – Finally, wake up feeling rested instead of drained.
- Relief without sedation – After the first week, you’ll feel balanced—not zoned out or dulled.
For many, the Alpha-2A Agonists Guanfacine and Clonidine are a game-changer. Around 60% of people experience profound relief—but finding the right one, at the right dose, is key. Your prescriber will help you know what to expect.
It typically takes 5-7 days each to see if either medication is working for you. Some people need to try both—separately to compare their effects and determine the best fit. If, after giving each a fair trial, you’re not experiencing the benefits listed above, it’s a sign that these medications may not be the right match for you.
Adjusting to the New Normal
Like many medications, there’s a short adjustment phase. The first week may bring minor side effects—like a dry mouth (sip water or try xylitol mints), sleepiness (take it at bedtime), mild headaches (carry a water bottle), or lightheadedness (wiggle your toes before standing). But here’s the good news: these usually fade in 5–7 days.
Many people say the first week was absolutely worth it for the peace and clarity they gained
Disclaimer: This is not medical advice. What I’m sharing comes from my personal experience with Guanfacine, along with insights from Dr. William Dodson’s published work in ADDitude Magazine on trial protocols for Alpha-2A Agonists (Guanfacine and Clonidine). Dr. Dodson is also not providing medical advice but rather sharing what he has learned from his clinical experience treating patients. It is essential to work with an ADHD specialist or a medical provider who is willing to take the time to review the publicly available evidence and tailor a plan that fits you.
Growth Strategies & Lifestyle Options
Practical Approaches for
more control
Managing RSD isn’t just about finding the right medication—it’s building the skills we never had the chance to learn. Pills don’t drive skills—they clear a path in your brain and body so you can take the next step. But what is the next step? Task initiation impairment is often called procrastination (it’s not, but that’s a different article)—task issues start in the pre-frontal cortex—and are a big ADHD challenge. Too many steps and stuck making a decision cause us to feel paralyzed, even when we want to move forward.
This is why handling RSD needs clear, actionable steps—not just ideas, but a really simple plan. Start here (or anywhere). Seriously—grab a sticky note and pen and start.
Step 1 | Build Your Support Network First
Start with local, virtual, and workplace ADHD groups for a safe place to learn quickly. Then, encourage friends, family, and co-workers to also join a group for their own support, and seek evidence-based info together with you. Next, work with an ADHD coach like an athlete does to improve their skills.
Step 2 | Become a Detective—Learn What Works for You
While medical treatment can be a transformative foundation for managing RSD, there are additional strategies that can help you navigate daily challenges. Think of these as tools in your toolkit - they work best when combined with medically supervised medication. Don’t forget the basics of balance like increasing your reserves with improved sleep, healthy food, walking in nature, and fitness strength + movement.
Step 3 | Map Your Triggers Before They Surprise You
Getting to know your specific triggers is all about being prepared. Keep track of the situations, interactions, and environments that tend to spark RSD responses. This awareness gives you time to build new skills before you need them.
Step 4 | Recognize Early Warning Signs
Learn to recognize your early warning signs. Low reserves from stress, hunger, or fatigue make it harder to navigate an incoming trigger with the new skills you’ve learned. You will also start to recognize telltale physical signs like tensing, your stomach tightens, your heart or thoughts start to race, or your breathing quickens. Spotting these signals early gives you more options for managing your response.
Step 5 | Learn Distractions & Grounding Techniques
When you feel an episode starting, having go-to distractions like music, humor, and other grounding practices can help you soften an episode. They may not stop an episode, but they can help you ride it out more effectively. Each time we get better at it. Fill your reserves w/improved sleep, food, walking in nature, and fitness strength + movement. Learn how to lead a life in balance. Become a detective to learn what this balance is for you.
Taking the Next Step
Resources for
RSD support
Want to understand RSD better? Let’s spend an hour together exploring how it works from the inside out. We’ll break down the experience, review RSD’s patterns and answer questions about resources.
2023 Joint Conference Presentation
View the slides from Dr Dodson’s and my joint conference presentation with Dr. Dodson, exploring RSD from both clinical and lived experience perspectives.
The RSD Support Guide
Download my detailed RSD Support Guide that outlines the steps to finding help and creating a plan to manage your RSD.
From Experience to Research to Working with Dodson
Read how living with RSD led me to learning about Dr. Dodson’s work, to studying it, to co-presenting with him at the 2023 International ADHD Conference, combining clinical expertise with real-world understanding.
Expert Interview
Listen to an in-depth interview by Melissa Reskoff with Dr. Dodson and myself, where we discuss unique insights into RSD.
View the slides from Dr. Dodson and my joint conference presentation, where we explore RSD from both clinical and lived experience perspectives.
Download my detailed RSD Support Guide for a structured guide that outlines the steps to finding help and creating a plan to manage your RSD.
Discover how my personal experience with RSD led to collaboration with Dr. Dodson and groundbreaking research in the RSD and emotionality field.
Listen to our in-depth conversation with Melissa Reskoff, where Dr. Dodson and I share insights from both clinical and personal perspectives on RSD.
There's always a trigger - even if others can't see it. Your body knows before your mind does: time slows as you rapidly assess what's happening. Maybe it's criticism in a work email, sensing you've disappointed someone, or downright rejection. These triggers might seem minor to others, but your brain and body are already launching a protective response. This isn't random emotional sensitivity - RSD triggers consistently fall into specific categories: rejection, criticism, teasing, or a sense of falling short. The shift from feeling okay to feeling hijacked happens in an instant, and physical symptoms start immediately: stomach dropping, chest tightening, muscles tensing.
The impact of the trigger pulls you down fast, like a water drop breaking the surface of a pond. Time freezes as you disconnect from your surroundings. The pain isn't just emotional - it's physical, and so intense it defies description. People around you might still be talking, but their voices are far away as you sink into a state of disbelief. This isn't just feeling bad - it's a total mind-body response that temporarily cuts you off from the world around you.
As you start to resurface into the present moment, you might find yourself face-to-face with someone who has no idea what just happened. Trying to explain feels impossible - how do you put words to something this intense? Your attempts to describe the issue, your reaction, and why it matters can come out sounding scattered and desperate.
Now comes a critical moment - how others respond can dramatically affect what happens next. The person who triggered the episode might have meant to hurt you, been carelessly unempathetic, or simply stumbled into it without realizing. If they dismiss your reaction or try to comfort you with phrases like 'you're just being too sensitive,' your fight-or-flight response kicks in hard. This is when you feel the urgent need to Get. Away. Now. Your body and brain are screaming for escape, and there's virtually no stopping this protective response once it starts.
Finally alone, you can breathe again. Your thoughts start to race between two extremes - outward blame ('How could they be so insensitive?') and harsh self-judgment ('What's wrong with me?'). As your thinking clears, you’ll find yourself analyzing every detail of what happened. This isn't just replay - it's your brain desperately trying to figure out how to prevent this pain in the future. Questions flood in: Could you have done something differently? Should you have seen it coming?
Hours or even days might be spent in deep reflection. Your mind keeps circling back: What was your part in this? Was there really a threat of rejection, or were your emotional reserves running low that day? This isn't just overthinking - it's your brain trying to recalibrate its threat detection system. Gradually, your sense of control starts to return. You begin to find solid ground again, opening the possibility to reconnect and heal.
The intensity finally begins to fade, like ripples settling after the initial drop. With therapeutic and medical support, each episode can become more manageable - not because they hurt less, but because you understand them better. People who find the right treatment often describe it as putting on emotional armor: the triggers are still there, but they don't wound as deeply. You start to recognize that while you can't always prevent the drops, you can learn to navigate the ripples they create.
