American media personality Paris Hilton recently shared on a podcast that she suffers from rejection sensitivity dysphoria, or RSD. Hilton, who has been diagnosed with ADHD, says the condition is common in people with the disorder. She also spoke of the impact RSD has had on her mental health over the years, describing it as being “like a demon in your mind” and saying that has been “extremely painful”.
It’s important to note here that RSD is not actually a clinical condition recognised in diagnostic manuals. What Hilton might actually be referring to when she talks about RSD are two separate but closely related psychological concepts: emotional regulation and rejection sensitivity.
Emotion regulation is an umbrella term. This refers to a person’s overall ability to manage emotional reactions in any given situation. Rejection sensitivity falls under this umbrella. It is when a person has a strong emotional reaction to rejection, even perceived rejection by other people. They may experience anger, shame, shutting down and becoming defensive following criticism by others.
People who have healthy emotional regulation skills are able to keep their emotions under control, even if a situation becomes stressful or tense. They’re also less likely to develop rejection sensitivity.
While difficulties in regulating our emotions is part of being human, our life experiences can shape how each of us perceives and regulates emotions in a given situation.
For example, if growing up you had a parent who repeatedly criticised you, you may be more likely to develop low self-worth. This is because we internalise the negative things people say about us and to us. It also means that, in the future, you may be more sensitive to criticism.
How is rejection sensitivity related to ADHD?
Between 25% and 45% of children with ADHD, and 30% to 70% of adults with ADHD, have difficulties with emotion regulation.
These difficulties often manifest as catastrophising (assuming the worst outcome will happen), blaming others and feeling vulnerable to perceived rejection by others.
Perceived rejection or criticism often causes emotional discomfort, too. While some people with ADHD will try to hide their emotions when feeling rejected, others may become overwhelmed and may lash out or become disengaged. These difficulties can contribute to emotional distress and affect relationships, education and employment.
Although the causes of emotion regulation difficulties in ADHD are not fully understood, research has explored several possible mechanisms.
For instance, research my colleagues and I previously published compared the brain waves of 6- to 11-year-old boys with and without ADHD. Both groups listened to a series of angry, happy or neutral voices through headphones.
The study showed that in boys with ADHD, their brains were extra active when listening to threatening (angry) voices. These results suggested an automatic, hyper-vigilance to threat in people with ADHD.
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A similar study showed that not only did young people with ADHD exhibit a larger brain reaction when rejected by their peers, they also had a smaller brain reaction when they were accepted by their peers.
Past experiences of being threatened or rejected can affect you deeply and may change how your brain develops. Although the exact mechanisms are not fully understood, research has also shown that experiences of rejection can shape how the brain develops in ADHD. For example, research found that in 9- to 13-year-olds, experiencing a greater number of stressful life events (such as being threatened) was linked with higher ADHD symptoms. In addition, children with high ADHD symptoms had differences in certain regions of their brain compared to children with low ADHD symptoms.
ADHD is not the only condition linked to rejection sensitivity. Conditions, such as autism, borderline personality disorder, depression and anxiety are also linked to rejection sensitivity.
However, the way rejection sensitivity manifests in these conditions differs. For example, people with ADHD who have rejection sensitivity may be very emotionally reactive when facing a difficult situation. But autistic people may tend to withdraw.
Managing rejection sensitivity
Some of the prescription treatments used to manage ADHD symptoms can offer some temporary relief from the emotional distress linked to rejection sensitivity. But they do not cure it.
A better strategy may be to focus instead on building environments that support wellbeing in people with ADHD rather than trying to resolve biological differences. Directing people with ADHD into areas where their strengths and interests lie may better equip them to deal with difficult situations or challenges.
Person-centred therapeutic approaches do exactly this. They aim to offer an environment, via a safe therapeutic relationship, where a person feels seen as a whole person – rather than for the problems they may have. The experience of being seen and accepted strengthens self-worth, and offers a corrective emotional experience to people who have felt criticised or judged in the past.
When people feel accepted, they start to feel more confident and rely less on negative self-talk. Recent research shows this approach can be effective for people with ADHD.
Treatments such as child-centred play therapy may be effective for children with ADHD in reducing emotion regulation difficulties – including rejection sensitivity. This therapy uses play to allow children to express their thoughts and feelings. Recent research has shown that this type of therapy is effective for improving emotional wellbeing in childhood ADHD.
In contrast, cognitive behavioural therapy focuses more on teaching you coping skills to alter so-called problem behaviours. This type of treatment can be effective for reducing ADHD symptoms but not necessarily for improving emotion regulation in ADHD.
Thanks to people like Paris Hilton, rejection sensitivity is now being talked about. This might help reduce stigma and hopefully pave the way to a more accepting, compassionate world for people with ADHD.
Georgia Chronaki does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
