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= Rejection Sensitive dysphoria =

Rejection Sensitive Dysphoria (RSD) also referred to as Rejection Sensitivity (RS) is a mental state that is characterised by an extreme emotional sensitivity towards either perceived or real criticism and rejection. RSD is currently not a recognised mental disorder under the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and it can, as a result of this, be difficult to get a professional diagnosis. Whether or not someone suffers from RSD depends on their level of rejection sensitivity, which refers to how anxiously someone expects rejection/readily perceives it and intensely reacts to it. Rejection sensitivity involves a bias towards perception of rejection/critique, and a trigger of this often results in dysfunctional behavioural responses such as aggressive penalty and social withdrawal. Many have speculated that RSD originates during childhood, if rejection or humiliation is experienced, however, this is not known for certain. RSD can usually be distinguished from similar mental disorders by the intense yet short-lasted episodes.

Signs that one suffers from RSD include:


 * Feeling easily embarrassed
 * Responding to feeling hurt or rejected by getting angry and having emotional outbursts.
 * Having low self-esteem
 * Setting high (and often unreachable) standards for oneself
 * Experiencing social anxiety
 * Having relationship issues
 * Feelings of being a failure
 * Withdrawing from other people or social situations
 * Considering self-harming

RSD can have big impacts on relationships whether they be friendly or romantic. People who suffer with RSD will often withdraw from these relationships or put a lot of effort into being admired/loved by these valued people, which can lead to anxiety, low-self esteem, and feelings of loneliness. Furthermore, RSD sufferers may experience trust issues in their interpersonal relationships, since they are anxiously waiting for or expecting a rejection, and cannot trust that this won’t eventually happen.

People who deal with ADHD are one of the main groups that suffer from RSD. RSD is considered as a pretty common ADHD symptom which is particularly present in adults. Additionally it has been suggested that people who have autism are more vulnerable to it as well. Feldman and Downey created the Model or Rejection sensitivity (Figure 1.1) to explain the link between causes and consequences. Downey, Khouri and Feldman proposed that the maltreatment and rejection of basic needs f rom parents lead to an internalized assumption that rejection will reoccur. Once the anxious expectation of rejection is established and a trigger stimulus is introduced (e.g. two family members stop laughing when one approaches) the individual perceives rejection, even in ambiguous situations. This is followed by negative emotional reactions which lead to hostility, social withdrawal and aggression. Those over reactive responses can warrant actual rejection by others, leading to a cycle. Rejection sensitivity dysphoria can be diagnosed with the "Age-Based rejection Sensitivity Questionnaire" (RSQ-Age) which is based on the orginal RS questionaire developed by Downey and Feldman. There are multiple treatment options for RSD which depent on the severity of the syptoms and wether or not the individual suffers from other disorders. Psychotherapy, medications and other treatment options are currently available.

= Causes = People with ADHD and Autism are especially vulnerable to develop RSD.

Early childhood experiences like being overly neglected or criticized by a parent might lead to low self-esteem and rejection sensitive dysphoria. Also Factors like intense bullying as well as rejection by peers can be possible causes. Moreover rejection in romantic relationships can lead to rejection sensitive dysphoria.

Biological factors like Genes might play an important role. People with relatives who are diagnosed with rejection sensitive dysphoria are more prone to develop the condition too.

= Signs and symptoms = Symptoms of Rejection Sensitivity Dysphoria are


 * a low self-esteem
 * avoidance of social situations
 * having fear of failure
 * having high expectations towards oneself
 * when being hurt or rejected frequently bursting out emotionally
 * feeling of hopelessness
 * behaving approval seeking
 * angry and aggressive in uncomfortable situations
 * anxiety

These symptoms can also resemble certain other mental health conditions like depression, social phobia, bipolar disorder, borderline personality disorder and post- traumatic stress disorder. In contrast to those conditions, RSD symptoms tend to be brief and are triggered by emotional cycles, rather than actual events.

= Diagnosis = In a study done in 1996 scientists have developed a questionnaire called “Rejection Sensitivity Questionnaire (RSQ)”, which assesses anxious expectations for rejection by significant others. It is composed of 18 items that briefly describe scenarios of social interactions. In each one a rejection by a significant other person could possibly happen in response to a request. Candidates need to indicate their level of anxiety they feel according to the possible outcome of each situation and furthermore the perceived likelihood that the outcome will be a response of rejection.

Originally developed with undergraduate students the RSQ is now expanded and adapted for different peer groups and scenarios. A modified version developed in 2009 is called the "Age-Based rejection Sensitivity Questionnaire" (RSQ-Age) and measures within 15 items similar to the original RSQ individual tendencies for anxiously expecting and reacting to age-based rejection among older adults.

Rejection sensitivity dysphoria is not listed as an official disorder in the diagnostic and statistical manual of disorders (DSM-5) and therefore it has no own empirical-quantifiable assessment that is available in clinical use.

= Related disorders = Rejection sensitivity dysphoria can either be a symptom or a cause of different mental health disorders, which will be described in the following paragraphs.

Attention deficit hyperactivity disorder (ADHD)
Children with ADHD tend to be criticised at school more frequently than other children because of their noticeable behaviour which is often unwanted in the classroom. This leads to them feeling different from their peers. Furthermore, they also tend to receive more social rejection because other people do not want to interact with them or do not know how to react to their behaviour. This is why the patients are highly sensitive to the perceptions of such experiences of social rejection, which is considered as rejection sensitivity dysphoria. In addition, ADHD patients also report that they are very sensitive to criticism and in general feel an emotional dysregulation because of this they often overreact in specific situations, such as when they are rejected. The overreaction can happen in different ways, some patients tend to rather react aggressive, whereas others rather react with social withdrawal. These that react with aggression have an angry rejection sensitivity and usually externalize their problems and these that react with social withdrawal have an anxious rejection sensitivity and often internalize their problems. The higher rejection sensitivity in ADHD patients also leads to higher ratings of related problems and depression, as well as to a lower self-esteem. Those consequential problems strengthen dysfunctional thoughts, that further complicate social relationships. Furthermore, rejection sensitivity and attention are interrelated because people with a higher rejection sensitivity show in situations with social threats a disruption of goal-directed attention which hinders their performance. An avoidant attachment style in ADHD patients is associated with higher levels of rejection sensitivity, as well as higher levels of ADHD symptoms, since those are interrelated to a certain degree. Adolescents with ADHD that have an insecure attachment pattern have a high expectation of rejection and are therefore more rejection sensitive. In conclusion it can be said that more research into rejection sensitivity dysphoria would probably lead to a better understanding of ADHD, since those two issues appear to be closely related.

Depression
It is likely that there is a connection between rejection sensitivity dysphoria and depression or depressive symptoms. Research indicates that individuals which are high in rejection sensitivity and that have made experiences with rejection are likely to develop depressive symptoms in the future. There are no implications that one necessarily causes the other but rejection sensitivity can increase the risk of developing depressive symptoms. This especially counts for people who lack support from friends and family after having experienced rejection. Studies have also shown that RS patients were more likely to suffer from depression when they had previously been broken up with rather than when they themselves ended a previous relationship. This indicates that noticing they failed to prevent the experience of being rejected in a meaningful relationship leads to feelings of despair or hopelessness which could serve as a trigger for following depressive symptoms. Moreover, research implies that the constant state of anxiously anticipating rejection can lead to negatively interpreting ambiguous situations which increases the risk of depression.

Borderline Personality Disorder
Research done on the correlation between rejection sensitive dysphoria (RSD) and borderline personality disorder (BPD) suggests, that rejection sensitivity functions as a mediator between early childhood maltreatment and borderline personalty disorder, even in low levels of early childhood maltreatment. Acute, as well as remitted BPD patients scored higher on the Rejection Sensitivity Questionnaire than the healthy control group. Results suggest, that lower self-esteem was positively correlated with both increased BPD symptom intensity, as well as higher rejection sensitivity, and mediated the relation between the two.

RSD increases the risk of the development of a co-occuring BPD diagnosis (especially at low levels of childhood maltreatment). These findings point out the potential risk in RSD as a contributor to adult borderline personality disorder, that does not require childhood maltreatment, and rather emerges during the time of adulthood. Tough this effect needs to bet deepend through further research, because there cannot be made a definitive statement on the correlation yet, due to the lack of replication studies.

Another study focused on the relationship between rejection sensitivity, rage and borderline personality disorder suggests, that rejection is a predictor for rage. Both disorders intertwining, is causing the so- called ‘borderline rage’. When the criterion for anger is met in borderline personality disorder, the characteristic ‘rage’ can be observed in borderline patients. This type of rage is higher than average in intensity and inappropriateness, accompanied by an uncontrolled feeling to this particular type of anger, causing interpersonal problems for individuals with borderline personality disorder.

An increased risk for self-harm and suicidal behaviour associated with borderline rage can also be observed. It is important to note that though the research results show a strong association between rejection sensitivity and rage, rejection sensitivity may not be the only factor explaining this specific type of rage in borderline personality disorder.

= Treatments =

There are several different kinds of possible treatments for Rejective Sensitive Dysphoria. The availability of these treatments depend on the intensity of the symptoms, and if the person has any other current disorders, such as depression, anxiety or ADHD. If the symptoms are mild, the patient is usually offered behavioural therapy, and is encouraged to use  communication and lifestyle changes to improve relationships and everyday life. However, if the symptoms are more severe professional counseling and medication are the best options.

= Psychotherapy = In severe cases of Rejective Sensitive Dysphoria professional help may be needed. Psychotherapy works the best if the focus is on improving the understanding of emotional reactions and learning how to respond these emotions. Psychotherapy includes a variety of different kinds of therapies. Cognitive-Behavioural therapy is possibly the most common, however treatment is also possible with the help of Acceptance and Commitment Therapy and Dialect Behavioural Therapy. Cognitive-Behavioural Therapy consist of discussing and teaching different kinds of coping techniques a person with RSD can use to manage criticism.

Medication
There is no medicine yet for the sole purpose of treating Rejective Sensitive Dysphoria, but in some cases medication is still possible. There are medicines that work for RSD, even though it is not their initial purpose. For example, medicine used to treat high blood pressure can help with the symptoms of RSD and calm its physiological effects. Furthermore, in the case of overlapping disorders, using certain antidepressants to cure depression or anxiety can have a positive effect on treating RSD.

Other factors
Other factors that may help a person treat RSD are communication and lifestyle changes. Communication is important between the patient and their partner. It helps set boundaries and to figure out what the person needs to feel safe. On the other hand, lifestyle changes such as a balanced diet, exercise and regular sleep improve overall health and may help a person suffering from RSD to manage their emotions.