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= Rejection Sensitive Dysphoria = Rejection Sensitivity Dysphoria (RSD) describes the extreme emotional overreaction and pain caused by real or imaginary rejection. Individuals with RSD show signs of emotional dysregulation and are especially sensitive to rejection, criticism and teasing. RSD is a comorbidity of attention deficit hyperactivity disorder and belongs to the subcategory inattention of ADHD. The symptoms disappear quickly after being exhibited but when experienced often, the extreme negative emotions can be internalized, and it is likely that this leads to a Major Mood Disorder. A person diagnosed with ADHD can have several of these mood swing episodes a day because they generally disappear quickly.

What distinguishes RSD from general Mood Disorder is that the mood changes always have a clear trigger and the mood shifts instantly after it. Symptoms of RSD are evoked by emotional cycles rather than by actually occurring events.

What distinguishes RSD from social anxiety disorder is that being rejected is their main concern which in turn leads to feeling uncomfortable around other people. The closer they are to a person that could possibly reject them, the greater their distress.

RSD can be examined as a cluster of signs and symptoms associated with a set of severe consequences. But RSD is not yet an official disorder listed by the Diagnostic and Statistical Manual of Disorders (DSM-5).

Signs and symptoms
People suffering from RSD show especially strong emotional reactions when having the perception of being rejected, criticized or excluded in social settings. This feeling of being rejected is subjective and often exaggerated.

Further signs are sudden emotional outbursts, negative self-talk as well as low self-esteem. People with RSD often internalized overly high standards for themselves and their self-esteem depends a lot on what others could think. They are prone for intense rumination after being in a social situation. They tend to disengage from these in turn. An attention bias is typical for these individuals: they focus most on signs of possible rejection and disapproval by others and fade out on positive aspects of most social experiences.

Typical symptoms are the feeling of physical pain and anxiety when being around people and feeling like a failure when being not able to meet their own standards. Recurrent emotional outbursts can follow after a subjective feeling of being hurt and rejected and this can lead to a perception of hopelessness.

Individuals often engage in approval-seeking behavior. On the other side they might also express anger and even aggression in uncomfortable situations.

The symptoms can vanish quickly after being exhibited. But in the long term it is difficult for individuals to build friendships and romantic relationships and they often tend to show irrational jealousy.

Causes
The causes of RSD have not yet been fully explained and can vary greatly between those affected. In most cases, experience plays a major role in developing RSD but also genetic predispositions are thought to be involved.

Experience
Rejection Sensitive Dysphoria can be triggered by different situations. The development of the condition could be the result of early experiences of rejection, trauma, abuse, and neglect. Parental influence and social interactions play a crucial role in the development of a child. Based on these early interactions and relationships, the child forms a sense of themselves. Children who faced a lot of rejection in their childhood oftentimes have lower self-esteem and could develop this intense fear of rejection and abandonment.

Predisposition
Genetic predispositions are considered to facilitate the development of RSD. It has been proven that there is an increased risk of disease if a family history has RSD. Low levels of progesterone may cause experiencing RSD.

Other disorders such as ADHD, bipolar disorder, or PTSD may increase the risk of developing RSD.

Diagnosis
RSD is not a recognized mental health condition. The symptoms of RSD show parallels to the symptoms listed for ADHD, but RSD is not included in the official ADHD diagnostic criteria.

Questionnaire
The simplest option to test RSD is a self-test questionnaire which contains 15 questions. The closer the test score is to the highest possible score of 60, the more likely one suffers under RSD. This questionnaire has no real scientific value and is only meant to provide self-orientation. It recommends to visit a professional, if necessary.

When visiting a social psychologist is likely that he will use a Rejection Sensitivity Questionnaire (RSQ), which can be considered as a homogeneous measure with good psychometric properties. The first version of this is created by the psychologist G. Downey and S. Feldman in 1996. The test scores the patient suffering with symptoms of RSD on a 1 to 6 scale. In the modified RSQ the people are asked about expectations of rejection of imaginary events, where someone denies their request. Their reaction is then ranked in 2 categories: the amount of anxiety of the hypothetical outcome (‘How concerned or anxious would you be over whether or not your friend would want to help you out?’) and the expectations of acceptance of rejection (‘I would expect that he/she would willingly agree to help me out.’).

Calculation of the score works like this: the score for degree of anxiety or concern is multiplied with the reverse score for expectancy of acceptance, which consists of the expectancy of rejection minus the expectancy of acceptance. The total rejection sensitivity score is then the sum of the scores of the individual situations divided by the number of situations. RS patients have a score above the median, whereas low RS individuals have a score below the median of the respective sample.

The general RSQ was designed for college students, which is why there also exists another form of it, the Rejection sensitivity RS-Adult questionnaire (A-RSQ). In this version the goal to measure anxious behavior and overly intense reactions to rejection in any, but especially social, situations. Modifications were made in formulation like changing “girlfriend/ boyfriend” to “partner“.

Interview
Patients suffering from RSD are categorized into the psychiatric diagnose of ‘diagnostic and statistical manual of mental disorder, fifth edition’ (DSM-5). To test a patient with RSD, the semi-structured clinical interview for DSM-5 Axis I Disorder (SCID-I) is used in order to make a diagnostic examination.

This method is performed to establish mental disorders (SCID-I) as well as to examine personality disorders (SCID-II). The duration of an SCID-I interview usually takes one to two hours depending on the patient’s psychiatric history and its complexity to describe past and current symptoms. An SCID-II personality assessment durates half an hour up to an hour.

To proceed these interviews and diagnostic evaluations on patients, a professional training and experience is acquired. Health professionals such as psychologist or psychiatrists are recruited when it comes to administering the interview. The procedure of the interview contains a set of useful questions which is provided to the RSD patients. The interviewer tries to make judgements about the diagnostic criteria given by the answers of the patient which should improve by its accuracy via repeated conductions of interviewing. As of May 2021, RSD cannot be diagnosed properly since it has not according status in psychology.

Management
Since rejection sensitive dysphoria is neurological and genetic and therefore part of attention deficit hyperactivity disorder (ADHD), the treatment involves counseling or medication, either alone or in combination. Several experts suggest medication interventions, starting with the usual array of ADHD medication, as for example stimulants. Medication does not help to get rid of negative outcomes entirely, but medication can help to relieve the associated symptoms, such as depression or hyperactivity.

Cognitive behavioral therapy
A way that can make it easier to manage and cope with rejection is behavioral intervention. Doctors may also suggest psychotherapy which is believed to be a traditional method for helping people to cope with rejection sensitive dysphoria. One type of psychotherapy, which can be effective, is cognitive behavioral therapy (CBT). This type of therapy teaches coping techniques. Participants will learn how to deal with rejection-related problems in a relationship, how to handle stressful situations, how to improve communication, and how to overcome emotional trauma. The therapy also addresses another common problem among people with RSD which is Rumination (psychology). It helps with other ADHD symptoms by helping to improve time management and reducing negative impulses.

Medication
There is evidence, that medication can also help along with therapy.

One possible medication solution can be the alpha agonists Guanfacine or Clonidine. Guanfacine is normally prescribed to lower blood pressure but it also interacts with receptors in the brain, reducing hyperactivity and emotional response. An optimal dose varies from 0.5 milligrams up to 7 milligrams for guanfacine and from a tenth of milligram to five tenths of milligram for clonidine. With that dose range, some people feel relief from RSD. Both medications work equally well but should not be used at the same time. It has been shown that the symptoms of RSD can be significantly relieved with clonidine and guanfacine in about 60% of adolescents and adults.

Another treatment is prescribing Monoamine oxidase inhibitor (MOAI) off- label. It can be effective for the attention and impulsivity component of ADHD as well as for the emotional component.

Parnate (tranylcypromine) works efficiently with fewer side effects, such as low blood pressure, agitation and confusion.

MAOIs were found to be as effective for ADHD as Methylphenidate. They produce only a few side effects and are FDA-approved for both mood and anxiety disorders. However, the patient must avoid foods that are aged instead of cooked, as well as first line ADHD stimulate medications and Antidepressants.

Certain antidepressants could be helpful if the patient has co-occurring depression or additional kinds of Anxiety. They also help with some ADHD symptoms, especially rumination.

History
Rejection sensitivity is a symptom of the emotional dysregulation observed in various psychiatric conditions such as social anxiety, borderline personality disorder and ADHD.

Dr. William Dodson is the first to mention Rejection sensitivity as a dysphoria in his article Emotional Regulation and Rejection Sensitivity published in Attention magazine in October 2016. He describes it as a “triggered, wordless emotional pain that occurs after a real or perceived loss of approval, love, or respect” observed exclusively in ADHD patients.

RSD is not recognized in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) leading it to not being officially introduced in the clinical context.

Links to Attention Deficit Hyperactivity Disorder
RSD is a comorbidity of ADHD. In contrast to RSD, ADHD is a common diagnosed psychiatric disorder, diagnosed mainly in children. Its ubiquity is not determinate since the disease’s definition is constantly re-engineered or refined.

Individuals with ADHD have difficulties with cognitive-control processes. This includes the ability to plan and organize a task, as well as the quality of attention dedicated to it. Problems with upholding concentration and focus on a task can also occur. For example, distractions from the environment during a task is more demanding for an individual with ADHD.

One important aspect is self-control. Patients with ADHD have issues with paying attention to less capturing information. This leads to inefficacy in educational enhancements or at workplace and can increase the risk of academic underachievement.

Individuals with RSD are especially sensitive to rejection and criticism. They can have the perception to be excluded in social settings. Inefficacy in carrier matters might lead to criticism from others. Actual criticism can intensify the perception of individuals with RSD. The actual and perceived disapproval by others make it more difficult to deal with the disease and to carry out a successful treatment.

Research gained insights in brain signaling that explain the traits of impulsivity and emotional dysregulation in individuals with ADHD. The impulsivity is connected to anger and aggression that can occur in uncomfortable situations.

ADHD is heritable. This distinguishes ADHD as well as RDS from BPD. Research identified some genes that are linked to ADHD. These genes regulate the function of dopamine in the brain. Some of these genes might be associated with Schizophrenia. As ADHD is seen as an underlying disease of RSD, RSD might also be linked to Schizophrenia.

Links to Borderline personality disorder
Multiple studies have been conducted on links between RSD and multiple other psychological disorders. The same applies for the relationship between RSD and Borderline personality disorder (BPD). BPD is a mental disorder where individuals have unstable interpersonal relationships, self-image, emotions, and often behave impulsively. Having unstable and intense relationships which may be characterised by extremes between idealisation and devaluation as well as trying to avoid the feeling of being abandoned by their peers.

These characteristics match aspects of RSD well as it can be defined as a disorder which affects the emotions and behaviour in situations of social rejection acting intensely to the perception of being rejected. Bungert and Colleagues studied the effects of rejection sensitivity in BPD patients and if there is a correlation between the symptom severity of BPD and rejection sensitivity. They found out that BPD patients have higher rejection sensitivity as individuals without BPD. They perceive to have a higher expectancy of being rejected and are more anxious about it as well. The symptom severity in individuals with BPD also influences the severity of rejection sensitivity underlining the fact that RSD may be a stable feature in BPD patients.

Another link between BPD and RSD is that reduced self-esteem is linked to both higher symptom severity in BPD and RSD. An explanation for this finding can be deduced from the sociometer theory where self-esteem acts as a monitoring system which is accumulated over time and indicating whether an individual is accepted or rejected by others. The perception of the status of an individual´s self-esteem therefore influences social motivations. In order to guide social behaviour, people with low self-esteem use their knowledge of how accepted they perceive to be in their social environment. When this low self-esteem interacts with higher rejection sensitivity one might observe interpersonal relationships similar to those in BPD patients with less continual social interactions. This dysfunction in social relationships might be reduced if an individual has less anxiety of being rejected and feeling more security of being accepted which is being undermined by higher rejection sensitivity. The co-morbidity of RSD and BPD may lead to a vicious cycle of self-fulfilling prophecies if no perceived security of acceptance in interpersonal relations can be assured.

Although RSD might seem to play a role in other social anxiety disorders like social phobia and anxiety disorder, a study observed the highest RSQ score in patients with BPD. This finding is underlined by the fact that there is a high correlation between the RSQ and QTF which assesses borderline-specific cognitions and feelings.

Impairments in individuals with BPD include dichotomous thinking and having ambiguous strategies to cope with rejection either using drastic clinging behaviour or distancing oneself from interpersonal relationships. These behaviours may be decreased by reducing the influence RSD may have on BPD which could improve relationship difficulties in individuals with BPD and help to cope with extreme reactions when feeling rejected.