So I dipped my toe into Reddit for the first time in a while. (Relapses are always difficult things to deal with.)

On r/Psychiatry there’s a discussion running about Rejection Sensitive Dysphoria and there’s a really interesting spread of opinions. That sub is supposed to be exclusively for qualified psychiatrists, although it’s not very well moderated in that regard. Opinions ranged from being in favour, to fairly neutral, to extremely critical of the idea (and of ADHD itself [!!]).

This is what has prompted me to post this State of The Union Disorder Address today.

One thing that barely got any mention in the thread in question is the origins of the concept of, and I think even the term itself, Rejection Sensitive Dysphoria (don’t quote me on that part - I could be misremembering). My introduction to the concept of RSD was through scrambling to get myself up to speed on ADHD and absorbing information from Dr Russel Barkley in particular and also Dr William Dodson, two of the leading experts in ADHD (although both of them are kinda old, with Dr Barkley being in retirement by this point). In older talks from both of them, they each outline the emotional dimension of ADHD that get overlooked by the diagnostic criteria and, tbh, the term ADHD itself which doesn’t recognise the emotional aspect. I think one day, eventually, we are going to see the label itself shift to recognise that it’s a disorder characterised by executive dysfunction and emotional dysregulation rather than hyperactivity (which is sometimes present but often not and sometimes wholly absent, especially as a person matures) and attention deficit (same as above - sometimes absent, sometimes present). Both of these parts of ADHD are, imo, manifestations of poor executive function and I’d argue that it’s a dysregulation of executive function moreso than anything - it’s extremely common for ADHDers to report experiencing hyperfocus but the problem is in the difficulty in regulation of that focus. This is not necessarily an example of executive dysfunction in the way that it’s commonly understood, although the ability to regulate one’s attention “appropriately” (however you want to define that exactly) does fit into the true definition of the term but I digress.

From memory, Dr Dodson referred to RSD by a different term. It seemed pretty obvious that he was working towards the same conclusion independently that Dr Barkley had also been working towards, and the concept didn’t even have a conventionally-accepted label at this point.

As ADHD, and especially adult ADHD, has come into more mainstream acceptance and awareness, there has been a huge amount of peer knowledge and support filling what is honestly a pretty wide chasm of knowledge and understanding of the condition. (I realise I’m part of that phenomenon.) In an ideal world this wouldn’t exist, but alas. This has led to what I think is some fundamental misconceptions about ADHD on both sides of the professional/lay person divide, and these definitely emerged in the discussion on the thread.

With regards to professionals, in my opinion, some major misconceptions are:

• That ADHD is overdiagnosed

• That it doesn’t exist (ugh)

• That it is just the result of trauma (lookin’ at you Gabor Maté)

• That it’s some trendy diagnosis or that it’s something that is used as a diversion from people averse to the diagnosis of BPD especially (this definitely came up in the thread)

• That the emotional dysregulation dimension of ADHD doesn’t exist or that it’s is simply indicative of a co-occuring mental health condition

• That RSD is just some tiktok trend that popped into existence out of nowhere

• That RSD is just social anxiety or a trauma response, or something along these lines

On the other side, some of the misconceptions from lay people are:

• The glamorising/quirkification of ADHD (no, staring out of the window at work or in class when you’re bored is not the same thing as ADHD and nor is impulse buying shit online)

• That ADHD is just about dopamine/it’s just about a lack of dopamine (both are untrue)

• That ADHD can be “cured”

• That ADHD meds make you a zombie or that everyone responds to stimulants with better attention and so stimulants are just a crutch used by people who lack willpower or discipline

There’s probably a lot of other misconceptions on behalf of lay people but I’m not going to bore you with all of them - you’re probably aware of most of them already anyway.

One thing that stands out to me about all this is that ADHD, ironically, suffers from success - stimulant meds are the absolute envy of the rest of the psychopharmacological industry. (If an antidepressant had the rate of success that stimulant meds do for ADHD, it would be a defining moment in history akin to the advent of lithium in the treatment of bipolar.) What this means is that, for a long time, ADHD was diagnosed in mostly boys, and mostly the ones who exhibited a lot of hyperactivity, and the solution was to throw stimulants at the kid and move on because this would largely be seen to resolve the problem or the external and more disruptive aspects of it. Because of this, there’s a big gap in research into adult ADHD, the underdiagnosis of afabs, and examining what exists beneath the superficial, external observations of ADHD.

Hence where we find ourselves today and why I’m writing this post.

So where does this leave us?

Well, firstly I think there’s a lot of misunderstandings about RSD and incomplete understanding of RSD. (It’s gonna get a whole lot more anecdotal and extrapolation-y from here, so he warned.)

From what the good doctors above describe, it’s not really necessarily even rooted in rejection. The term RSD creates a fundamental misunderstanding that the experience is about feeling bad when people reject you or provide you with negative feedback whereas he experience itself is rooted in a very immediate, almost visceral emotional response to perceived mistakes and failures which is completely disproportionate to the situation. This can be something that occurs in a social setting, although not necessarily.

I think a good analogy of what it’s like to experience RSD is that it is a frequently occurring emotional response to things that are typically smaller and it feels like that one time in school when you suddenly got called to the principal’s office and you had no idea why. There’s this sudden, gut-wrenching emotional response where you feel like you’re in huge amounts of trouble for something and you don’t have any idea of what it is. (But then it turns out that, idk, they just wanted to congratulate you on winning some scholarship that you had forgotten about or they wanted to ask if you for some basic information.)

The difference between RSD and a trauma response or serious anxiety is that RSD is felt strongly in the body and it is completely disproportionate to the experience. An attack of anxiety typically has a solid basis in reality, and it is generally fairly quick to resolve when the perceived cause is addressed. Obviously for generalised anxiety disorder and more severe anxiety disorders, this is not necessarily the case but that’s its own discussion. Panic attacks often don’t have a particular triggering incident, RSD does.

Trauma responses are ones where your previous experience of a traumatic event is brought into your immediate experience due to some similarities or resemblance to it that occurs in the present - a car backfiring or a door slamming are two good examples. With regards to the difference between a trauma trigger and RSD, a trauma trigger is going to bring you right back to a past feeling when you were traumatised and your responses will be based in that past experience. RSD can fire off from something tiny and it isn’t something that dredges up an old traumatic experience for you while transporting you back to that moment in time and what you were thinking and how you were feeling back then.

RSD can kick off from really small things, like feeling as if you forgot to lock your front door this morning or maybe mispronouncing a word in conversation or arriving at an appointment at the right time but on the wrong day. A typical person might worry about their front door and go through the steps they took as they left the house this morning to arrive at the certainty that they did actually lock their door and then things feel okay again. A person with social anxiety might feel really nervous at that mispronunciation and it might really rattle them for quite a while or they might even freeze up or burst out into tears. Someone who finds out that they’ve arrived at their appointment on the wrong day might go beet red and feel extremely embarrassed. I’ve honestly done all of these things and experienced these responses before and RSD feels different.

RSD feels like a gut punch, and it often comes completely unexpectedly. I might often worry about forgetting to lock my door when I leave the house but today, inexplicably, today my response is different.

It’s that feeling when you realise you forgot to send the email and you lost the big contract but there’s nothing you can do because it’s already too late by this point, that feeling when you realise you left your purse on the bus and everything in it is gone forever, that feeling when you realise that your partner has been cheating on you and you’ve only just put all the pieces together.

Except it’s just some tiny little slip-up. Or maybe it’s not even a mistake at all but it feels like it might have been one.

As someone who has and is diagnosed with PTSD, RSD genuinely hits different. I have trauma triggers. I have trauma triggers for things that I’m not even aware of the historical source of because of extensive childhood trauma. But it’s taken me a really long time to realise that there’s this other, separate phenomenon that I experience which feels similar in a lot of ways and, for me, which had blurred into the “it’s just PTSD” narrative for the longest time, until I finally started developing my understanding that there was something else going on for me.

So anyway I hope that by rambling about the state of psychiatry, about being irritated by some shitty comments on Reddit (the horror!), and about my own experience of RSD along with the historical roots of the concept I’m helping to fill that gap in understanding and to push back against some of the misconceptions that exist surrounding RSD.