Understanding Rejection Sensitive Dysphoria (RSD) in Autism and ADHD

It’s perfectly normal for breakups to hurt, criticism to sting, and being excluded to feel lousy. But for people with rejection sensitive dysphoria, or RSD, rejection or failure is distressing on another level. Whether the rejection is real or perceived, RSD can cause severe emotional and sometimes physical pain. 

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While this is something I’ve dealt with as long as I can remember, I didn’t have a name for it until I was diagnosed with ADHD in my 30s. Once I found out that neurodivergent people often experience RSD, the extreme emotional responses I was having suddenly made sense. 

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Rejection sensitive dysphoria was initially acknowledged in relation to ADHD, but it's now increasingly recognized as a common autistic experience too, says Dr. Kelly Whaling, a clinical psychologist and research lead at Prosper Health. 

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While people are quick to point out that no one likes rejection, RSD is something else completely. The shame, humiliation, anger, and sadness I felt when I thought I was being rejected in some capacity would easily ruin my day. But that was only the beginning. From there, I’d start mentally catastrophizing everything, assuming the worst possible scenario was inevitable. 

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If my boss gave me feedback on a project, I thought it meant I’d be fired the next day. If a friend didn’t respond to my text, I thought it meant that I had done something unforgivable and that they were mad at me. It’s a feeling I have to manage to this day, but finding out that I wasn’t the only person whose brain worked this way did help. 

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It’s important to note that RSD itself is not a formal diagnosis, but rather a pattern of experience recognized by clinicians and neurodivergent people alike. So, whether you’re neurodivergent, love someone who is, or have questions about RSD, here’s a clear, compassionate guide to understanding and management.

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RSD is the experience of extreme emotional and physical pain as a result of real or perceived rejection, failure, or criticism. It can also occur because of real or perceived loss of approval or respect, teasing, or disappointing important people in our lives. 

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In fact, “dysphoria” is the Greek word for “unbearable.” According to William W. Dodson, MD, an adult psychiatrist specializing in ADHD, the use of the word “dysphoria” in the name of the symptom “emphasizes the severe physical and emotional pain suffered by people with RSD when they encounter real or perceived rejection, criticism, or teasing.” 

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However, according to Gina Romero, LCSW, a licensed clinical social worker and the owner of Wandering Pine Wellness, neurodiversity-affirming approaches call for us to shift away from using the term “dysphoria.” “The word ‘dysphoria’ can imply something is wrong or disordered, when in reality, rejection sensitivity is a really common experience for ADHD and autistic folks,” she explains. The term remains due to its ubiquity, but this is a good perspective to keep in mind as a neurodivergent person who experiences this phenomenon. 

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Kit, 45, found out she had RSD during her assessment and diagnosis for autism. “We spoke about my experiences with being accused of being too ‘touchy’ and taking any slight form of criticism as the end of the world,” she says. “My psychologist said in terms of my autism it relates to the fact I can often think in a very ‘black and white/right and wrong’ way, so if someone does slightly criticize me, in my mind it must be because I’m an inherently ‘bad’ person.”

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To reiterate, rejection sensitive dysphoria isn’t formally recognized in the International Classification of Diseases or the Diagnostic and Statistical Manual of Mental Disorders. “This does not mean RSD is not real,” Whaling says. “It very much is, and people experience tremendous challenges because of it. But professionally, we are still best trying to understand how to define and categorize it.”

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When it comes to signs of RSD, there are a number of common emotional and physical experiences associated with it.

Emotional signs of RSD

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Although RSD affects everyone differently, here are a few of the ways it can alter a person’s mood or emotional state: 

• Extreme and overwhelming feelings of sadness or anger after real or perceived rejection or failure
• Sudden mood swings, including the onset of severe anxiety or depression
• Deep shame, humiliation, or self-blame after a real or perceived rejection 
• Feelings of helplessness or hopelessness when facing real or perceived rejection
• Constant fear and worry about what others think
• Feelings of isolation, alienation, and exclusion

Physical signs of RSD

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Physically, RSD shares many of the same symptoms with anxiety, including:

• Queasy, “sour” stomach, or having a “knot” in your stomach
• Gastrointestinal distress
• Racing heartbeat
• Sweating or feeling clammy
• Shaking
• Feeling like you were stabbed or punched in the chest
• Tightness in the chest
• Hunched over posture
• Grimace

“It feels like a dark blanket envelops me and my mood,” says Marni, 54, who is autistic and has RSD. “All self-confidence vanishes, and I sink into depressive anxiety where my whole body feels heavy, with an emphasis on my chest caving in and my facial expression unable to smile. There's tension in my forehead as worry takes over.”

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For Ayla, 34, RSD feels like “panic and shame crash together” and take over her whole body. “My chest tightens, my stomach drops, and I just want everyone to get away from me,” she says. “It’s like my brain forgets logic and decides I am the mistake, not that I made one.”

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It’s important to note that RSD is not the same thing as “rejection sensitivity.” “Rejection sensitivity and rejection sensitive dysphoria have a similar relationship, in that rejection sensitivity appears to be a painful experience faced by all individuals, while rejection sensitive dysphoria is a clinically significant manifestation of rejection sensitivity,” Whaling says. 

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Though more research in this area is needed, evidence from existing studies and neurodivergent community discourse suggests that RSD “is likely a unique and significantly more intense manifestation of rejection sensitivity.”

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While RSD was first identified and popularized by Dodson as a symptom of ADHD, it’s not exclusive to those with the condition: it’s increasingly recognized as occurring within the autistic community. According to Whaling, more research into RSD and how it manifests in people with ADHD versus autism is needed, but she says that there are some key differences.

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In the context of ADHD

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For example, for those with ADHD but not autism, there may be an element of impulsivity in their response to RSD. “ADHD brains struggle with putting the brakes on actions and with creating space between impulse and behavior,” she explains.

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“As a result, the ADHDer might act on their feelings of rejection sensitivity quickly through things like quitting a job in the middle of a performance evaluation, or getting into an argument with a romantic partner, and then come to regret these impulsive actions.”

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Behaviorally, this manifests as avoidance of any situation where rejection might be possible, or frantic people-pleasing and overcompensation.

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In the context of autism

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RSD and autism can be a little different. Because autistic people often experience alexithymia—where you might have trouble identifying, labeling, and describing emotion—you might know you’re hurt, but have trouble identifying why or figuring out what to do about it.

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On top of that, autistic brains love patterns and predictability. “Once a rejection occurs, the RSD can trigger perseverating thoughts, causing autistic brains to loop through the scenario, scan memories for other social failures creating a pattern and narrative of inadequacy and social rejection,” Whaling notes. 

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Finally, because autistic brains are often rule-based, they try to solve the problem by creating self-imposed and strict laws based on past hurts. For example, they might think “I must always smile in social situations” or “I can never talk about my special interests because I get too excited.” Ultimately, someone may end up masking more to try to prevent the situation from happening again. 

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When someone is diagnosed with both ADHD and autism

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Additionally, co-occurring ADHD + autism (AuDHD) can amplify rejection sensitive dysphoria and create a compounding effect across multiple areas.

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“Many autistic folks spend a lifetime being misunderstood, excluded, or expected to mask in order to be accepted,” Romero says. “Over time, these experiences can lead to a heightened sensitivity to perceived rejection, activating trauma responses.

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This can show up as hypervigilance and fear, even in situations that seem low-stakes from the outside.”

For Ayla, pretty much anything that feels like disappointment—reading a message wrong, not getting something perfect on the first try, or feeling misunderstood—can trigger her RSD. “Just recently, during a shoot for an art show, the image wasn’t coming out like I’d imagined and I completely melted down,” she says. “In that moment, I wasn’t thinking about fixing the problem—I was convinced I was failing my whole team.”

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Some examples of RSD triggers specific to autistic adults, according to Romero, are:

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• Interpreting a small change in someone’s tone, facial expression, or body language as rejection or criticism
• Ruminating after a perceived social misstep or mistake
• Feeling overwhelmed or shutting down after receiving constructive feedback
• Reading delayed replies (texts, emails, etc.) as signs of disapproval, disinterest, or rejection
• Experiencing emotional distress when plans are changed or canceled, even with valid reasons
• Over-apologizing 
• Feeling unsafe or unworthy in relationships, even when no actual rejection has occurred

“The rejection that triggers RSD can be actual/real, simply perceived or interpreted by the individual as such when others might not perceive a rejection to have occurred, or sometimes can even be just the mere possibility/opportunity for rejection,” Whaling explains. 

In real life, this can look like anything from a breakup or getting passed up for a promotion, to someone not laughing at your joke, a canceled plan, or just feeling like you’ve let someone down, Romero says.

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“If I say something that I perceive as 'stupid' or if someone tells me something that I did was 'wrong' — if there's even a perception that someone is 'disappointed' in my actions or thinks less of me because of something I've done or said, [my RSD] can be triggered,” Marni says. “I hate silence—someone giving me the silent treatment is the worst for triggering my RSD.”

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Understanding the common triggers of rejection sensitive dysphoria is the first step toward managing its impact, but recognizing these triggers alone is not enough. Learning how to regulate the intense emotions that arise in response to these situations is crucial. Developing effective emotional regulation strategies can help reduce the severity of RSD episodes and improve overall mental well-being.

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Because RSD is itself a symptom—not an official diagnosis—there isn’t a list of criteria someone needs to meet.

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That said, here are some common emotional, psychological, and behavioral traits associated with RSD:

• Disproportionate responses or reactions to rejection
• People-pleasing in order to avoid possible conflict or rejection, and/or to seek approval of others
• Intense emotions
• Negative self-talk
• Low self-esteem
• Feeling rejected or feeling unwanted
• Avoiding social situations and/or communicating with others
• Replaying any perceived failure in your mind
• Abandoning projects, jobs, or relationships at the first sign of criticism or perceived rejection
• Avoiding tasks or responsibilities that come with the potential for failure or criticism
• Having trouble standing up for your own feelings and needs 
• Having a perfectionist mindset
• Easily feeling self-conscious or embarrassed

RSD can be a vicious cycle when it comes to emotional dysregulation, low self-esteem, and social anxiety. This often takes place within a feedback loop, where fear leads to withdrawal, which leads to isolation, and ultimately, increased sensitivity.

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“It’s exhausting,” Ayla says. “I’m tired before I even walk into social situations. I overthink everything, over-explain too much, and usually have to limit how much I go out.”

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Autism emotional sensitivity also plays a role. RSD, masking, and autistic burnout are closely connected. “Many autistic folks mask to avoid rejection,” Romero explains. “This constant self-monitoring—often fueled by fear of judgment or exclusion—can create chronic stress that can lead to autistic burnout. Rejection sensitivity isn’t the only driver, but it’s a common reason why autistic folks mask, and why it’s so hard to let go of.” Even when someone intellectually knows it's safe to unmask, their nervous system may disagree, especially if past experiences of rejection were traumatic or repeated over time.

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This is the case for Ayla. “RSD makes masking worse because you’re constantly trying to manage people’s reactions to avoid rejection,” she says. “It’s like emotional whiplash on repeat, and it drains you until there’s nothing left.”

In the context of relationships, rejection sensitive dysphoria can be a tricky thing to navigate. This is true of friendships, romantic relationships, and in the workplace, Romero says.

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Friendships

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RSD in friendships can take many forms including: 

• Overanalyzing texts, tone, or pauses in communication
• Withdrawing to avoid perceived rejection before it can happen
• Feeling devastated by canceled plans or minor changes in behavior
• Misunderstanding or misinterpreting someone’s words or actions as rejection
• Avoiding social situations

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Romantic relationships

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Similarly, RSD can manifest in romantic relationships in ways like:

• Seeking constant reassurance from a partner
• Reacting strongly to perceived emotional distance or disinterest
• Avoiding vulnerability 
• Over-apologizing or over-explaining to repair imagined ruptures
• Interpreting a partner’s need for space or independence as rejection
• Feeling intense shame or panic after conflict (even small disagreements)
• Constant fear that your partner will break up with you

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In the workplace

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RSD can also affect workplace relationships, including:

• Struggling with feedback 
• Avoiding leadership roles to avoid potential rejection
• Avoiding taking on projects to avoid potential failure
• People-pleasing or overcommitting to avoid disappointing others
• Constant fear of doing something to get fired

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How to navigate relationships with RSD

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As frustrating as rejection sensitive dysphoria can be, these reactions are completely understandable. Our relationships are important to us, and for someone with RSD, uncertainty about where they stand with friends, romantic partners, or in the workplace can be a source of stress and emotional pain. This is especially true for those with autism who have a sensitivity to criticism or rejection. 

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But there are effective ways to navigate relationships when you have RSD. Romero suggests the following strategies:

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Name it: Learning to identify experiences of RSD can help create space between the feeling and the reaction. Self-awareness is the first step in managing RSD in relationships. 

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Pause before reacting: RSD tends to trigger immediate responses. Giving yourself a moment to check the facts can prevent unnecessary spirals. 

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Communicate openly: If it feels safe, let trusted people know how RSD shows up for you. Clearly expressing feelings and needs can prevent misunderstandings and reduce anxiety around potential rejection. Sharing your experiences with RSD with trusted friends or partners can help them understand your perspective and support you more effectively. “Be honest and blunt—sugarcoating just confuses everyone,” Ayla says. “I tell my husband exactly what I’m thinking instead of assuming he’ll figure it out. Clarity helps both of us.”

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Boundary-setting: Try setting limits on how much social interaction you can handle or how often you extend your help to others if you’re a people-pleaser. This creates a sense of safety and predictability in relationships, which can reduce the fear of rejection.

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Work with a neurodiversity-affirming therapist: This could be helpful in individual, couples, or family therapy. It’s so important to work with a therapist who doesn’t shame the neurodivergent person for being neurodivergent. Instead of trying to “fix” the neurodivergent person, they focus on building understanding, reducing shame, and supporting nervous system regulation. That’s critical, because too many neurodivergent folks have had therapy experiences where they felt misunderstood or blamed for who they are. A therapist familiar with RSD and autism—such as those here at Prosper Health—can help find the right techniques for you.

Managing rejection sensitive dysphoria is possible with the right tools and strategies, including:

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Understanding and naming emotions

One of the first steps in managing RSD is developing a better understanding of emotional triggers. You may benefit from learning to recognize and label your emotions accurately, which can help de-escalate intense feelings of rejection. Tools like emotion-tracking apps or journaling can help you better identify these emotions.

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“Being honest with yourself and others can help you mitigate the damage RSD can do to your psyche,” Marni says. 

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Reducing stress levels

Reducing your overall nervous system load can make you less emotionally vulnerable so you’re better able to tolerate the RSD when it does happen. “When you’re chronically stressed, sleep deprived, hungry, or sensory overwhelmed, you’re way more vulnerable to RSD,” Whaling says. “Prioritize sleep, eat regularly, manage sensory input, and build in recovery time.” Setting boundaries may also help reduce stress and limit RSD traits. 

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Practicing self-soothing

Practicing self-soothing techniques, such as engaging with special interests or stimming, can help manage the intense emotions that RSD can trigger. 

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Engaging in activities

It’s also important to engage in activities that boost self-esteem and provide a sense of accomplishment. For example, someone might learn a new skill or work on creative projects. This can help reduce the emotional impact of perceived rejection, as well as stress and the chances of burnout.

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Building mastery and positive experiences

When your identity is entirely contingent on others’ approval, every rejection feels existential. The way around this is to develop areas of expertise and engage in activities that give you satisfaction independent of others’ judgments. 

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Create things, learn skills, engage with your interests. Build evidence that you have value beyond social acceptance. Values clarification helps too. “Get really clear on what matters to you outside of being liked or approved of,” Whaling says. “What do you care about? What kind of person do you want to be? When you’re oriented toward your values rather than others’ judgments, rejection still hurts but it’s less catastrophic.”

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Finding a community

Having a community that is safe, accepting, and affirming that you can go to when RSD does occur can help tremendously. “Reach out to them and share, whether it’s a neurodiversity affirming Discord server, or an autistic in person support group, or just a friend to play video games with,” Whaling says. “Having those connections makes such a difference.” Check out organizations such as the Autism Self Advocacy Network (ASAN) and the Autistic Women & Nonbinary Network (AWN). “Find your people—the ones who don’t make you feel like you’re too much,” Ayla says

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Practicing self-compassion

Practicing self-compassion is essential for everyone, but it’s especially helpful for those with RSD, which heavily impacts self-esteem. It’s important to remind yourself that rejection is a common experience that virtually everyone has. It does not reflect personal worth.

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“The best thing I can do is to tell myself ‘you are enough’ as often as possible,” Kit says. “I personally want to put more effort into having more alone time and down time to pursue the things I want to, rather than living for others and trying to gain validation through people-pleasing.”

You don’t have to manage RSD alone: various forms of therapy can help. Working with a neurodiversity-affirming therapist like the ones at Prosper Health can help with emotion regulation and perspective-building related to RSD. “It works in so many ways to help those with RSD to develop skills to manage the intensity, develop skills to cope with the cognitions that fuel it, and build skills to create some distance between impulse and response,” Whaling explains.

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Cognitive behavioral therapy (CBT) adapted for autistic adults is a great option. According to Whaling, third-wave CBT, like Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT) can be especially useful as well. “Studies are increasingly finding that ACT and DBT are both acceptable and effective interventions in neurodivergent populations, and they both directly target emotional regulation, which is the core mechanism underlying RSD,” she explains.

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Instead of trying to eliminate the painful feelings from RSD, which is a losing battle, ACT teaches you to fundamentally change your relationship with those feelings. ACT allows you to build the capacity to have the painful feelings and still move forward with your life.

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“DBT was literally designed for emotional dysregulation, so it’s incredibly well-suited for RSD even though it wasn’t explicitly developed for neurodivergent populations,” Whaling says. The four modules (mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness) each target different aspects of the RSD experience. “You’re learning to observe your emotions without being consumed by them”she explains. “It’s a comprehensive skill-building approach that addresses RSD from multiple angles simultaneously.”

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Medication and RSD

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At this point, there is no on-label, FDA-approved RSD medication. Because RSD isn’t a formal diagnosis, there’s no pathway for medications to be approved for it directly, Whaling explains. 

That said, prescribers may use medications off-label to target the underlying mechanisms that contribute to RSD. For example, medication providers might prescribe ADHD medications, like stimulants or non-stimulants, if they feel the RSD is associated with the broader emotional dysregulation and impulsivity that comes with ADHD. Anxiety medications can apply in this context as well. 

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“Many ADHDers find that medication—stimulants or non-stimulants—can indirectly help with emotional regulation, which may reduce the intensity or frequency of RSD-related reactions,” Romero explains. “For autistic folks, there isn’t an equivalent medication-based treatment path, since we don't Autism specifically, but rather co-occurring mental health challenges."

While RSD can be disruptive, it’s a completely normal and valid part of living with autism or ADHD. It’s also not a case of “well, nobody likes rejection or failure"—rejection sensitive dysphoria is real and can cause excruciating emotional and sometimes even physical pain beyond what neurotypical people experience. RSD can also affect friendships, romantic relationships, and your interactions in the workplace.

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Fortunately, neurodiversity-affirming therapists, like the ones at Prosper Health, can help people with RSD navigate these challenges. 

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Prosper Health’s virtual therapists provide mental health support for autistic and neurodivergent adults, covered by insurance. Throughout the treatment process Prosper's expert clinicians incorporate evidence-based therapies into our sessions, tailoring all care to the unique needs of autistic adults. Clients see a material improvement in their quality of life in as few as four sessions.
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With Prosper Health’s support, coping with RSD is possible. Fill out the form below or give us a call to start today!

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Frequently Asked Questions

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What causes rejection sensitive dysphoria?

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Although they vary from person to person, rejection sensitive dysphoria can be triggered by:

• Rejection or disapproval (real or perceived) 
• Teasing, bullying and harassment
• Feeling embarrassed (even for “positive” reasons)
• Exclusion
• Plans that change at the last minute
• Failure
• Abandonment
• Being misunderstood
• Confrontation or conflict
• Receiving feedback or criticism

How does RSD really actually feel?

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RSD can cause people to experience both emotional and physical pain. Emotionally, RSD can feel like:

• Extreme and overwhelming feelings of sadness or anger after real or perceived rejection or failure
• Sudden mood swings, including the onset of severe anxiety or depression
• Deep shame, humiliation, or self-blame after a real or perceived rejection 
• Feelings of helplessness or hopelessness when facing real or perceived rejection
• Constant fear and worry about what others think
• Feelings of isolation, alienation, and exclusion

Physically, RSD shares many of the same symptoms with anxiety, including: 

• Queasy, “sour” stomach, or having a “knot” in your stomach
• Gastrointestinal distress
• Racing heartbeat
• Sweating or feeling clammy
• Feeling like you were stabbed or punched in the chest
• Tightness in the chest

Can RSD improve over time?

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So far there haven’t been any longitudinal studies of RSD or randomized controlled trials of clinical interventions of pharmacologic interventions specifically targeting RSD, so the data aren’t available to answer this question. However, according to clinicians like Whaling, RSD can improve over time. Neurodiversity-affirming therapies like ACT and DBT can help.

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