It’s a relief to see how discussion and visibility of ADHD has grown over time, however after spending a lot of time reading articles, watching videos, and catching general discourse around it, something is severely understated. Personally, this one aspect of ADHD has had a greater impact on my life than anything else- to such an extent that its omission from not only common knowledge of ADHD but from the very diagnostic criteria used in psychiatry is incredibly damaging.
ADHD is known primarily for the effect it has on attention, and how that interferes with learning and the ability to perform at work. This is how most seem to experience it, but the same forces that make attention work differently have a powerful effect on emotion regulation, which can cause a wide array of other problems.
Not only is emotion regulation more difficult with ADHD, the emotions themselves can be far more extreme- even painful. Considering how depression and anxiety are common comorbidities of ADHD, this isn’t a small detail. What’s worse is how ADHD symptoms can actually become more difficult due to stress or emotional difficulty.
What is emotion dysregulation?
As Joseph Nigg, Phd. explains, when an emotional trigger hits a neurotypical brain, the amygdala will send a message to the cerebral cortex about the flood of emotion coming in. The cerebral cortex then inhibits the emotional response so the person can take a breath and think things through. In an ADHD brain, the link between the amygdala and the cerebral cortex is weak, and the cerebral cortex fails to act as a safety valve to release that pressure. As a result, those with ADHD may seem to flip out at insignificant things, have tremendous difficulty recovering from powerful emotions, and can also have difficulty understanding the emotions of others and appear insensitive.
What is Rejection-Sensitive Dysphoria?
RSD, or Rejection-Sensitive Dysphoria, is extreme emotional sensitivity caused by perceived disapproval or criticism from loved ones and other respected peers and authority figures. This is tied to ADHD, because children with ADHD receive thousands more criticisms than neurotypical children. RSD essentially looks like what is described above; it’s an emotional vocabulary much more extreme, painful, and reactive than is considered normal, and often precludes mood disorders. Those with RSD are fearful of situations that may be emotionally challenging, or that make them feel vulnerable. They often become people pleasers, to the point that they start to give away part of their identity and individuality, and are quicker to give up at the sign of possible rejection. Perhaps most significant is what’s best expressed in this line from ADDitude Magazine: When this emotional response is internalized (and it often is for people with RSD), it can imitate a full, major mood disorder complete with suicidal ideation. However, some are able to harness the emotional potency of RSD and adapt it to overachieve, often with a perfectionist approach. I personally have experienced all of these. No other ADHD symptom has had a more significant impact on my life. One of the telltale signs of RSD is emotion that can become so overpowering and painful that it becomes impossible to describe. This sensation is what causes the most damage, in my experience- someone with RSD may react to something emotionally harrowing as if it’s a literal life or death scenario, because their emotions are treating it as such.
While my childhood was fairly smooth and I stayed on the honor roll, in middle school I found myself struggling to pass, which led to severe emotional dysregulation. While there was some improvement, it was never enough to get back to where I had been, and I began suffering from depression, which further impaired my schoolwork. Emotional fallout, self-harm and thoughts of suicide were a regular part of life throughout my teen years until my early 20’s, and again in my late 20’s and mid-30’s. While I had been diagnosed in 2nd grade, I wasn’t medicated for it until middle school, and almost nobody was aware of many forms ADHD can take. ADHD was only a few years old when I was diagnosed, it had been added to the DSM when I was a year old. When Ritalin and Adderall didn’t seem to work, there were no other options. There would be no nonstimulant option until I was in college, and I wouldn’t try it until 2021. By my early 20’s my assumption was that the ADHD was gone, or a non-issue. However, that was only because I found a field I loved and had no problem paying attention to. I worsened in my late 20’s after trying to start a career, and for several years, depression and anxiety were treated as the sole issues. Those two were directly caused by my ADHD, and catastrophes in my early teens and mid-30’s were essentially RSD and emotional dysregulation on a rampage in my mind. Somehow it took years to realize I wasn’t just sensitive or quirky. My emotions were extremely volatile, incendiary, crushing and debilitating depending on the event. I made important decisions based on how my hair-trigger emotions would torture me if I got it wrong.
Now that I know the truth, I look back at all the times I hurt others because many emotions were like deeply internal panic attacks. That part of the healing process feels similar to entering AA, because I’m only now seeing the path of destruction behind me… Despite the fact that my emotions were turned inward towards myself, as opposed to outward, which can happen with others. In fact, as much as 50% of those in anger management are believed to have RSD.
A neurotypical person only has their own, normal emotions as a frame of reference, and you simply can’t make people feel an emotion their brain is designed to protect them from, so it’s very easy for RSD to destroy important relationships and make itself significantly worse. That extreme emotional sensitivity just doesn’t exist in most people, and a broken relationship is the exact kind of rejection RSD itself is in constant fear of.
Inattentiveness and other ADHD symptoms have certainly had an effect on my life, but I have never felt like I had my life under control unless I was in a degree program. Inattentiveness laid the traps, but RSD and emotion dysregulation set them off. ADHD may have started problems, but emotion was the last straw in nearly every situation. It led me to believe that my emotions were more important than they really are, because with RSD your emotions are out to hurt you at the slightest provocation. Suddenly every negative life event is a crisis, and every crisis becomes a downward spiral.
RSD not only covered up the significance of ADHD in my life, it acted as a red herring as I puzzled over why the anxiety and depression treatments weren’t working. A year ago I began to believe that anxiety and depression were symptoms of a larger problem, and the previous spring I found out my ADHD was still significant enough to need treatment. Even with two therapists and a psychiatrist- all of whom are skilled and dedicated- It took until March of 2021 to finally recognize the source of the problem. By then, ADHD and the lack of treatment for it led to the dissolution of a long-term meaningful relationship that I had banked my future on. Following that, RSD made the situation far worse. I lost more friends, and would lose even more as I struggled to get my life together. This all overlapped with the covid pandemic and was worsened by the loneliness that came with it. While this is a very specific scenario, it began and worsened due to what I once perceived as a minor affliction in adulthood. I had no idea it could cause symptoms so incredibly life-altering.
I am incredibly lucky despite it all, because there were many times where I may have cost myself the chance to figure out what was wrong. I also had privileges that cushioned the fall. While this may have prolonged the realization, it also meant the difference between life and death on many occasions. Many thousands don’t get that chance.
Presumably millions have tremendous emotional responses and may not know why, only that it drives people away. Some, like me, may not even realize their emotions hit harder than they do for most people. Those around them may think they’re mean, inconsiderate, or selfish. As with other ADHD symptoms, without knowing the source, the person internalizes these issues as personal failings. Potential wasted, happy relationships ruined, good jobs lost, and some of them have no idea it’s because of ADHD. Many may not know they have ADHD at all. When I began searching for the “umbrella cause” of my anxiety and depression, my first thought was Dependent Personality Disorder, then C-PTSD, and finally I learned about these important factors of ADHD a year after having been re-diagnosed.
RSD affects most with ADHD, as well as many on the Autism spectrum and even some who are neurotypical, depending on their childhoods. It isn’t a disorder and cannot be diagnosed the way ADHD can be, and since nobody can compare the internal power of their emotions with others, it can be difficult to figure out if you have it. As with any health-related issue, one should never attempt to self-diagnose. If you think you may have RSD I would ask a psychiatrist about it, especially if you’re neurodivergent.
Visibility and the DSM
What has been most alarming to me in all of this has been how easy it would have been to fix this had I known. In fact, since discovering RSD, my emotions have changed completely- or at least my handling of them has. Even without treatment, knowing the full extent of ADHD and its symptoms would have allowed me to avoid a prolonged living nightmare. While things did become difficult again as a result of the trial-and-error nature of pharmaceuticals and the side effects you have to overcome when starting a medication, I’m now on a regiment that I feel benefits me with minimal side effects and am even looking at potentially lowering dosages of my older medicines.
Medication is important, as is therapy and mindfulness, but in my experience, nothing helps ADHD symptoms better than education. There’s enlightenment when you learn several of your struggles are textbook ADHD symptoms, and that you’ve been diagnosed with it. Your whole perspective changes. Meanwhile, if you think it’s just your personality, you push back against criticism. You stay defensive. You feel you already have enough “wrong” with you, you don’t need more reasons to dislike yourself. You may end up rationalizing your way into a hole you can’t crawl out of.
All of this underscores just how powerful visibility and public knowledge is. Hearing “maybe your emotions are so painful because you have ADHD” could change someone’s life. I’m sure it would have changed mine. However, even the emotional aspects of ADHD, much less RSD, aren’t part of the public consciousness. RSD is so new that one of my sources was apparently written three days before I found it, after I began writing this article.
The emotional components of ADHD are supposedly well-known among mental health professionals. However, the DSM-5 (the diagnostic manual used in mental health) has no mention of emotion whatsoever in its diagnostic criteria on ADHD, and its terminology is very clearly tailored in reference to children. The DSM is not an encyclopedia, it’s a diagnostic manual, and the emotional components were apparently left out deliberately, out of fear of misdiagnosis. Specifically, mood disorders misdiagnosed as ADHD. I feel the need to point out here that for six years my ADHD was mistakenly treated as the mood disorders it caused. The result was very little progress and a growing sense of something missing. Between 2013, when I resumed professional help, and 2021, when I learned the answers, I saw five different psychiatrists (in four different clinics), five therapists, two or three counselors, and had Talkspace for a couple of months. The overwhelming majority of these professionals I wouldn’t speak negatively of, and I have the same therapist and psychiatrist now as I did in 2021. I am not in a position to speak as an expert on the matter, but from my layperson perspective, poor diagnostic criteria for ADHD means even good doctors cannot give adequate diagnoses.
There are many calling on the DSM committee to return emotion to the criteria. Sometimes it is better (or the only option) to treat the symptoms instead of the underlying problem, but wouldn’t the underlying problem at least need to be known? Stimulant medications also don’t directly aid emotion regulation, they just dumb down the limbic system, “blunting” emotions. In my case, stimulants haven’t helped in effective ways. Ritalin was effective for a short while in my first year in college, but for whatever reason I wasn’t given the same type of quick-release when I got a refill and the positive effects went away. Fourteen years later, Concerta helped, but felt like little more than an excess dose of caffeine. Adderall caused a catastrophic worsening of anxiety and emotion dysregulation.
Let’s not forget, psychiatry is incredibly difficult. It’s a comparatively young field of medicine and there are still countless mysteries contained within the human brain, as well as constant variation from person to person. Because of this, the public consciousness really needs to be aware of warning signs and when to reach out to a mental health professional. General practitioners have been known to downplay or misdiagnose ADHD because they aren’t specialists. There are untold numbers of people with this and other conditions who don’t know it, or on the flipside are trying to diagnose themselves erroneously.
Today, it’s easier than ever to increase visibility and public consciousness about an issue, and where mental health is concerned we’re seeing it happen at a greater rate every day. Current and future kids have a much better shot at avoiding the problems I faced, with a wider array of therapeutic and pharmaceutical options. But in order to receive that treatment they have to first know when to see a doctor, and have some idea of what the real problem inside them is, deep down inside where nobody else can see it. Sadly, the difficulty of diagnosing neurodivergence from the outside has impaired the entire psychiatric field. For adults, this means doing your own research and confirming it with a doctor is your best bet, because the diagnostic criteria and understanding of the scope of ADHD are over a decade out of date.
If you have any experiences you’d like to share about emotion regulation and ADHD, or some helpful information to add, please let us know in the comments.
Dodson, W., Dodson, W., & Saline, S. (2021, March 19). How adhd ignites rejection sensitive dysphoria. Retrieved April 30, 2021, from https://www.additudemag.com/rejection-sensitive-dysphoria-and-adhd/
Dodson, W., & Dodson, W. (2021, March 24). Why add makes you feel. so. much. Retrieved April 30, 2021, from https://www.additudemag.com/slideshows/adhd-emotions-how-they-affect-your-life/
Constance, L. (2020, July 07). New study: Adult adhd diagnosis criteria should include emotional symptoms. Retrieved April 30, 2021, from https://www.additudemag.com/adhd-and-emotions-diagnosis-criteria-study/
The importance of emotion in adhd – dr russell barkley [Video file]. (2015, August 01). Retrieved April 30, 2021, from https://www.youtube.com/watch?v=hzhL-FA2v10
Villines, Z. (2021, April 27). What to know about ADHD and rejection sensitive dysphoria (1347617621 987176764 N. Washington, Ed.). Retrieved April 30, 2021, from https://www.medicalnewstoday.com/articles/adhd-rejection-sensitive-dysphoria#symptoms-of-rsd