Episode 4: Deep Dive into Rejection Sensitivity Dysphoria with Henry Shelford and Dr. Shyamal Mashru

Henry and Dr. Shyamal talking about Rejection Sensitivity Dysphoria (definition, triggers, and treatment). Dr. Shyamal is a consultant psychiatrist practicing both in the NHS in Adult ADHD service and in his private clinic, ADHDHealthClinic. You can contact him through his website: adhdhealthclinic.co.uk. The clinic also has its own page on RSD.

You can watch the video interview on YouTube here. 

TRANSCRIPT:

Henry Shelford: Hi. It’s Henry Shelford, co-founder of ADHD UK, here for our next deep dive, which is rejection sensitivity dysphoria. And I will have Dr. Shyamal Mashru, psychiatrist, here.

Dr. Shyamal Mashru: Hello.

Henry Shelford: Hi, Henry.

Dr. Shyamal Mashru: How are you doing?

Henry Shelford: I’m doing great. And you?

Dr. Shyamal Mashru: Yeah. No, no. Well, thanks for having me again. I think we’ve got quite an interesting topic, which is going to resonate with many, many people here who either have diagnosed or undiagnosed ADHD. This topic, when I bring it up in consultations with patients who’ve come for an assessment, they often break down in tears with this one, actually.

Henry Shelford: OK, well, try not to make anyone cry. And so it’s rejection sensitivity dysphoria. What is it?

Dr. Shyamal Mashru: OK, so in a nutshell, it is described as a complex and intense—and underline the word intense here—emotional response that occurs when someone feels a perceived or real rejection or criticism. The driving force behind this is an intense fear of failure or rejection. And this is seen in almost all patients with ADHD.

There’s been so—it was a term that was originally coined by Dr. Paul Wender in the 1960s. And at that time, Dr. Wender was looking actually at children with diagnoses of what would now be ADHD—it wasn’t called ADHD at that time. And what he was noticing was the intense emotional dysregulation, which we’ve discussed in a previous episode, actually, of these children who would be looked at as potentially overly sensitive children who are having lots of tantrums.

And then there was more research done by a chap who’s still around now, actually, who talks about this subject, called Dr. William Dodson. The interesting element of rejection sensitivity—well, there are a lot of interesting elements—but one of the big ones for us as clinicians is that this is not even called a symptom. It’s an experience that’s seen in almost all patients with ADHD.

In one-third of those patients, Dr. Dodson’s data shows—and I would agree with this, actually, in my own experience; I’ve probably seen 6,000 odd patients—it’s the most crippling experience in ADHD in at least one-third of patients. And yet it is not part of the current diagnostic criterion for ADHD. And as the talk progresses, it can look like other conditions, and this might be one of the reasons where ADHD is missed for other conditions.

Henry Shelford: So what’s it looking like? Like, what are you actually—actually, to start, pull back slightly. So, intense fear of rejection. How is that different from a response when I was in dating?

Dr. Shyamal Mashru: Good question, Henry. I mean, essentially, it is all a matter of degree with rejection-sensitive dysphoria. So dysphoria comes from the Greek word, which means unbearable pain or suffering. OK, so no one likes to be rejected or criticized, right? No one really likes to, you know, fail at things, right? That’s not an enjoyable experience by anyone.

But RSD—rejection-sensitive dysphoria—is much more than that universal discomfort of rejection and failure. Patients will describe this almost as a physical pain, and it can destroy them for quite a long period of time. It comes on all of a sudden. That’s how it’s described. They can’t control it at all, and it’s instantaneous. Many patients can actually describe themselves feeling things like chest pain, breathlessness. It’s physical, almost. They find that they can’t control it. They find this hard to describe until I describe it to them a lot of the time.

And that it must run its course. It’s very hard for them to control this until they start to understand what this is. And it can last anything from minutes to months in duration. And it has, then, sort of—I would categorize it as two types of effects. If it’s internalized, it can look like major depression, complete with suicidal ideation, and I’ve seen that in some patients. If it’s externalized, it can present as rage directed at the person or situation that they have deemed as wounding them. And that can cause a lot of breakdowns in relationships—work relationships, personal relationships, etc. So, it’s the intensity of that response.

Henry Shelford: How, like—you talked about lasting for months. How’s that—and it being confused with depression? How is it different from depression?

Dr. Shyamal Mashru: So, let’s talk about the different conditions it gets confused for, first of all, right? Because there are—

Henry Shelford: If we’re doing that, I want to throw in anxiety as well because, like, when you talked about the feeling of chest pain, that sounded a lot like my understanding of a panic attack. So, OK, back to you.

Dr. Shyamal Mashru: So, there are a number of different conditions I’ve seen this get potentially misdiagnosed for or look like. One: generalized anxiety disorder with panic attacks. I would say the key difference here between RSD and that is in the name. So, generalized anxiety disorder is when a person is in a general state of anxiety and what’s called catastrophic thinking all the time. They always are jumping to the worst scenario continuously. So, there’s a constant state of anxiety all the time, not necessarily in response to a particular situation.

RSD, when you talk to the patient about it, they’ll often exactly be able to pinpoint: “It was when my partner said this that triggered me.” Or, “It was when this happened, when my boss was going to call me in for a chat that triggered me, and I started worrying about losing my job. I’m going to get found out.” So, there’s often a trigger.

Where else can it get confused for? Social anxiety. Logically, if you have an intense fear of failure or rejection, you might, as a protective response, start to avoid or withdraw yourself from social situations where you know you need to meet new people. So, I’ve had patients tell me, “I think it was really embarrassing because I started this new job. It was a Christmas party. I had to make an excuse not to go because they are worried about being judged or even found out.” So, they might avoid social situations. They’ll go and talk to their—potentially, you know, their family doctor about this. That can look a lot like social phobia.

The third one is something known as borderline personality disorder, or emotionally unstable personality disorder. If you remember, I said if RSD responses get externalized, it looks like rage directed at the person that caused them that wound. What starts to happen is they can start lashing out at their partners, for example, lashing out at children, lashing out at work colleagues. If you have a person who’s presenting on the outset as being potentially difficult and breaking down their relationships or sabotaging them, that can look like borderline personality disorder.

Another comparison is depression with suicidal ideation. I’ve had patients who told me that even in their teenage years, they might have had a first love, and when that relationship ended, they responded in ways like attempting overdoses. On the outside, they were very low in their mood, and that can look like a major depressive episode with suicidal attempts.

Another one is bipolar disorder. If in the day your emotions are going up and down in relation to situations—experiencing your high highs and low lows—you could talk to someone who might not have knowledge of this and be diagnosed with bipolar disorder. The key difference with bipolar disorder is you have clear time periods of low mood and hypomania. You might have weeks or months of depression, followed by several weeks of a manic episode. With RSD, however, there is always a clear trigger that the patient will point to. In other mood disorders, the cause of feelings is often unclear.

Henry Shelford: That’s an important takeaway—the difference is that there’s a clear trigger driving those responses. So, what do you do then? How do you help deal with this?

Dr. Shyamal Mashru: Before we go into that, Henry, I want to answer why people might develop rejection-sensitive dysphoria. Why does this happen?

Henry Shelford: Yes, why is it that for one-third of people with ADHD, this is the most crippling experience?

Dr. Shyamal Mashru: The underlying core belief or “hot thought,” in psychological terms, is the feeling of “I’m not good enough.” If you’ve gone through life and no one knew you had ADHD, including yourself, you’ve likely struggled in multiple areas. You’ve gone through an education system where you probably felt you didn’t meet your academic potential. Teachers might have called you lazy, and you might have started believing that yourself because your parents said it too.

You may have entered a work environment where you felt you had to work harder than your peers just to keep up, working after hours but still not getting the promotions your colleagues got. Socially, you might have avoided interactions, which held you back from opportunities like moving up the corporate ladder. Over time, your partner might feel they are carrying you in the marriage, or you might feel like you’re snapping at your children and letting them down. All of this compounds into questioning your self-worth.

Dr. William Dodson suggests that RSD is neurological or biological, and that may be part of it. However, I believe the natural course of someone’s life with undiagnosed ADHD leads to these feelings—it’s no surprise they feel this way about themselves.

Henry Shelford: Honestly, we agreed you wouldn’t make me cry, but this is tough to hear.

Dr. Shyamal Mashru: Yes, but it’s critical to understand. Let’s talk about treatments now. Neurologically, there are medications, though in the UK, they’re not licensed for RSD. In the US and Canada, there’s emerging evidence for alpha agonists like guanfacine or clonidine. These were originally blood pressure medications but have shown promise for ADHD. Patients describe feeling like they have “protective armor” with these medications, allowing them to experience rejection without the extreme emotional response.

However, I believe the first-line treatment should be talking therapy. Emotional responses in ADHD are fast and intense, and the goal of therapy is to help patients step back and introduce a pause. This involves mindfulness and building awareness of what triggers RSD. A good therapist can help a patient understand their past triggers, recognize patterns, and develop strategies to manage their reactions.

Henry Shelford: That sounds challenging but transformative.

Dr. Shyamal Mashru: It is. Beyond that, building self-esteem is critical. People with ADHD often excel in high-pressure situations or when doing something they love. Strength-based training helps them focus on their skills, which improves their self-esteem and changes how they perceive themselves.

Henry Shelford: You mentioned earlier that RSD isn’t part of the diagnostic criteria for ADHD. Should it be?

Dr. Shyamal Mashru: Yes. Current diagnostic criteria focus on children and were based on research with boys. Emotional dysregulation, like RSD, is overlooked, which leads to misdiagnoses. Including it would help clinicians better identify and treat ADHD, particularly in adults and women.

Henry Shelford: That makes sense. To wrap up, what’s the key takeaway about RSD?

Dr. Shyamal Mashru: RSD is nearly universal in ADHD. Recognizing it and addressing it through therapy, coaching, or medication can transform lives. It’s about understanding yourself, reframing your narrative, and building resilience.

Henry Shelford: That’s a hopeful note to end on. Thank you, Shyamal, for sharing your expertise. This has been a tough but enlightening discussion. I’m looking forward to our next deep dive.

Dr. Shyamal Mashru: Thank you, Henry. It’s always a pleasure. For those interested, I see patients in the NHS and privately. You can book through my website, www.adhdhealthclinic.co.uk.

Henry Shelford: Brilliant. Thank you, Shyamal. And thank you to everyone watching. Stay tuned for our next session!