Car metaphors are a pretty popular way to explain certain things, so let’s start there, eh?
Let’s say an electrical issue in your car is causing an avalanche of problems. The power brakes are slow to respond (anxiety). The starter just doesn’t start at all sometimes (depression). The mechanics haven’t found the source causing these problems, but each individual issue is fixed repeatedly. In this analogy, the fictional electrical issue is ADHD. Just the bad parts. As far as I know there isn’t a way to make your car more creative.
Oh! A very important detail I left out- you may not have noticed that your temperature warning light is dead. This car doesn’t have a temp gauge, just that light, and the light only turns on when the engine is overheating. So as you drive in the summer heat, you crank up the AC, and the more you drive, the hotter the car gets. The AC is definitely running, the heat outside is fairly normal, you’ve already checked the air filter, and you can’t figure out why the car keeps getting hotter. Meanwhile, the spark plugs are starting to melt.
That part actually happened on the return trip from a hurricane evacuation. I took it to the dealership with a check engine light and was told to avoid driving it at all because it had become a fire hazard.
The point of all this: ADHD, left untreated, causes a barrage of life problems, and those problems can keep coming back. Anxiety and depression are two. Crippling self confidence issues, certainly. And for 99% of ADHDers, as well as many with borderline personality disorder and many on the autism spectrum, there is also Rejection Sensitive Dysphoria, or RSD. It is a very new concept with little in the way of data, and in my case it has made the single greatest measurable impact on my life out of all of these issues. On multiple occasions over the past two decades it has caused or fueled breakdowns with the potential for self-harm or self-endangerment.
As with the car analogy, the problem compounds itself. Rejection Sensitive Dysphoria is a severe aversion to rejection, a fear so great that the afflicted will likely base significant life choices around avoiding it- both real and perceived rejection in equal measure. When facing rejection they will compulsively or obsessively try to resolve the problem, usually making things worse. This becomes so overwhelming for the recipient that the rejection becomes real or reinforced. Coupled with the emotional severity caused by ADHD along with other coorbidities, this can even lead RSD to generate a risk of suicide by way of a snowball effect. All of this is caused by something that was only recently given a name, and isn’t even its own disorder or comorbidity like anxiety and depression are.
An important feature of RSD, like many emotional difficulties, is that negative reactions are either faced inwards, towards the self, or outwards to others. In my case everything has been intensely inward-facing, which is why the struggle against self-harm and suicidal ideation could be so great at times. If those sensations are pointed outwards, they can manifest as aggression, forms of abuse, or the potential for violence.
If anything, from my experience, the most defining trait of RSD is severity. I’ve found it can be incredibly overpowering, especially today due to social media, smartphones, and the addictive reward cycles those can cause. People who experience it often struggle to describe how it feels, as if no description is hyperbolic enough to describe it. There’s a point somewhere between a fictional traumatic event that isn’t severe enough, and another event that fits but is too outlandish of a comparison to be believable to anyone. It’s a very deep-seeded and extreme fear of rejection that is incredibly difficult to control, even for those who know about it. Of course, many don’t, so they can’t see the gap between how they feel and how someone else feels. They don’t realize certain forms of rejection are even possible because they can’t comprehend why someone would do that to someone they care about. Things that, to everyone else, are just unpleasant facts of life that, for some, are necessary to move on. Since it was totally unknown until recently, even the few of us that are lucky enough to recognize it went through life prior to this making decisions with a flawed perspective on how others perceive relationships, and a risk of severe overreaction at the threat of perceived abandonment. It can be very difficult to avoid any kind of snowball effect because the behaviors RSD causes can drive away anyone who witnesses them. They can make you possessive, manipulative, neurotic, and so on.
I realized recently that when a friend abruptly cuts ties, especially if I got blocked, it registered in my mind as being told to end my life. That is not an exaggeration, but is almost verbatim what was going on subconsciously. The line of thought repeatedly went to “What are they doing? Do they just want me to disappear?” or something worse. It’s an escalation so extreme that it’s best explained by a deep and severe trauma. In the case of RSD, it’s believed to be caused by a pattern of rejection in childhood, one that lasts years- something neurodivergent children face almost uniformly. In some cases sufficient treatment did not exist until sometime in the past fifteen years, and what little did exist was marred by side effects and intense social stigma, even rumors in some circles. In my case, I was kept off medication until middle school, when it actually became a problem. In 2000 (and 2020), stimulants didn’t appear to work because they made my anxiety worse. Prior to adulthood there was very little in the way of known coping skills, and what little was known was exclusively focused on productivity, as is the DSM to this very day for a number of reasons.
Emotion is the half of ADHD that actually mattered throughout my life and simply was not treated beyond anxiety, depression, aside from the crossover benefits coming from certain medications and in particular, CBT and DBT. Because of the lack of existing non-stimulant ADHD treatment I barely graduated high school, however today I have three college degrees, and got better grades in each subsequent degree program. I made it work, even if I did it in ways that made it hard to find work in the field. But on the emotional end of ADHD, my life and those around me have been plagued by emotional severity and unrecognized rejection sensitivity going as far back as age 13. I was totally unaware of the emotional effects of ADHD until a quarter-century after my diagnosis. I’m thirty-four, and it took the implosion of multiple friendships and a relationship I had bet everything on, plus a series of close calls with self-endangerment, intensive outpatient therapy, and exploring different treatment options over the course of nine months for me to find this out. Greater public knowledge of ADHD and RSD would have spared people in my life a lot of strain, heartbreak, and in at least one case, therapy. This is the point at which you have to look at everyone that came before you who never found out what was “wrong” with them, and say “at least I got some answers”.
In 2003 or 2004 I was considered a candidate for asperger’s syndrome, which I believe now was due to my social withdrawal and ADHD symptoms. Although understandable, this of course was inaccurate, and asperger’s syndrome itself isn’t even used in psychiatry anymore. It was replaced by the more general autism spectrum disorder. All of these are reminders of just how significantly the progress of psychological health may be hindered by how young the field is. It’s important to remember how many of these oversights are not the fault of any medical professional, but in fact that we are only aware of them because of the commitment of those in the field.
Along with its severity, its newness and lack of data is the most detrimental characteristic of RSD in my opinion. Specifically, I decided to return to this topic and focus on it not necessarily because of my own experiences (although expanding upon that had been a long-term goal) but because of a pattern I discovered and wanted to research. The impetus for this article was recognizing the traits of RSD in true crime stories from recent years. This, as well as abuse, seemed at the time to be two possibilities of the external form of RSD. As referenced earlier, the internal form can build into the risk for self-harm or suicide, and at times prior to effective treatment I’ve dealt with intrusive thoughts (in visual and spoken forms) about self-harm and endangerment so extreme that I have not yet been comfortable describing them anywhere. As you can imagine, someone projecting that same mentality at someone else instead of inward towards themselves opens up the possibility for disaster.
Because of how new RSD is to us, there is no simple answer for what to do to manage it for the time being. More studies are needed, which thankfully will likely occur over the coming years even if it’s as a secondary result of studies on other disorders. For now all we can do is make it better known so that those experiencing it understand it, and perhaps mental health professionals can better differentiate it from various forms of anxiety- and as we’ve seen with ADHD and the autism spectrum over the years, that’s no easy feat.
Do you or someone you know suffer from symptoms of RSD? If so, tell us your story in the comments.
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