Anxiety, Depression, & Rejection Sensitive Dysphoria

Medically reviewed by Julie Dodson, MA
Updated April 11, 2024by BetterHelp Editorial Team

While many of us experience emotional pain when we feel rejected, for some people this reaction is more serious, producing severe distress that can have a significant effect on their mental health. Such responses are indicative of what is known as rejection sensitive dysphoria (RSD), a set of symptoms that commonly arise out of developmental disorders and mental health conditions, such as anxiety, depression, ADHD, borderline personality disorder, and autism. Knowing how RSD connects with common mental health challenges can help individuals living with it understand and navigate its symptoms. This article will guide you through important information about RSD, its associations with anxiety and depression, and how to cope with the difficult emotions it can create.

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Do you experience complex emotions at the thought of rejection?

What is rejection-sensitive dysphoria?

Rejection sensitive dysphoria (RSD) is marked by a severe emotional reaction to a perceived or actual nonacceptance. RSD is not an official diagnosis but a group of symptoms that are often associated with certain mood and developmental disorders.

The symptoms associated with RSD can severely impact an individual’s mental health, often creating challenges related to anxiety, self-esteem, and anger. This can negatively affect the person’s career, create relationship conflict, and even cause physical health concerns. 

It’s hard to measure rejection, and it’s something that many people can have a challenging reaction to. For people with RSD, social nonacceptance can be accompanied by significant pain, both emotional and physical, that may manifest as negative self talk. This response may follow a real or perceived failure, such as a bad grade or a presentation the individual believes was poorly received. Rejection can also occur when someone is teased or criticized, which may result in a feeling of diminished self-worth. Individuals with RSD often have very high standards for themselves, making real or perceived deficiencies more difficult to process.

Is rejection-sensitive dysphoria linked to other conditions?

Rejection-sensitive dysphoria is thought to be closely linked to various developmental disorders and mental health challenges, such as ADHD, body dysmorphic disorder, autism, and borderline personality disorder, as well as anxiety and depressive disorders. These conditions often have a strong genetic component, so RSD can run in families. Rejection sensitivity can also be caused by frequent dismissal as a child or early traumatic experiences that affect later relationships. It is thought that certain variations in brain cells and brain structure can also lead to the development of RSD. For example, research published in the Journal of the American Academy of Child and Adolescent Psychiatry found that emotional lability in children with ADHD may be due to abnormal amygdala function.

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Symptoms of rejection-sensitive dysphoria

How is rejection-sensitive dysphoria diagnosed? Because it isn’t an officially recognized diagnosis, some practitioners may not be familiar with RAD, but there is a wide range of symptoms associated with this condition. Commonly, an individual will feel severe emotional distress, which can even manifest as physical pain. RSD can lead to extreme sadness, stress, low self-esteem, and anger. 

Sensitivity to criticism, whether or not it is actually meant to be criticism, is a common indicator of RSD. Someone with RSD may frequently perceive that others disapprove of them, causing them to seek frequent validation. Their concerns often result in defensive behavior, such as lashing out, over-explaining, and blaming others.  

Many symptoms associated with RSD are related to mental health conditions, such as depression and anxiety. People with RSD may experience loneliness, sadness and other depressive symptoms. They may also feel high levels of anxiety due to their desire to avoid embarrassment or shame. 

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Misdiagnoses and related disorders

A strong aversion to not being accepted is a feature of other mental health challenges that are often confused with rejection-sensitive dysphoria. Social phobia, more commonly known as social anxiety disorder, is similar to RSD in that both involve a response to nonacceptance. With social anxiety disorder, though, this is usually a broader fear, whereas in RSD it occurs more often as emotional dysregulation in a specific social interaction or situation.

RSD is also linked to borderline personality disorder (BPD). A person with borderline personality disorder can experience extreme sensitivity toward not being accepted and may lash out at others because of it. Individuals who have borderline personality disorder often struggle with self-esteem, and they might feel self-conscious and rely on the opinions of others for validation. This can create situations in which individuals with BPD react strongly to real or perceived slights. 

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The effects of RSD

Strong emotional reactions to dismissal can present several common challenges. And an individual who experiences RSD may utilize various maladaptive coping mechanisms in response. Many people with rejection sensitivity engage in people-pleasing to avoid being dismissed. This can result in someone with RSD struggling to stand up for themselves or fulfill their own needs for fear of upsetting someone else and being rejected. 

Additionally, RSD can make relationships difficult for some, as individuals with this sensitivity may frequently interpret that they have been insulted, hurt, or criticized, despite evidence to the contrary. They may then become angry and defensive or distant and withdrawn. 

This sensitivity can also cause an individual to avoid situations in which they could feel rejected, sometimes by going to great lengths. They might believe that if they attempt to do something, they will fail, so they would rather avoid the situation altogether. This can be harmful to their development and quality of life.

For the above reasons, nonacceptance sensitivity frequently leads to perfectionism. No one, though, can entirely avoid failures, meaning that this population may have an even harder time when they don’t live up to their own high standards. Perfectionism can keep them from seeing the value in their accomplishments as they are always striving for more. 

Links between anxiety, depression, and rejection sensitivity

Anxiety and depressive disorders are thought to be some of the primary conditions associated with rejection sensitivity dysmorphia. Even in cases where those disorders are not present, RSD can create symptoms of anxiety and depression that lead to emotional challenges. Researchers examined these connections in a meta-analysis of 75 studies, concluding that the “associations between rejection sensitivity and depression, anxiety, and loneliness were stable over time.” 

The experience of, or anticipation of, nonacceptance can produce elevated anxiety levels in someone with RSD. The individual may experience distress that manifests as anger, nervousness, physical discomfort, and worry. Their stress levels are frequently high due to concerns regarding performing well or garnering approval. 

In other situations, rejection sensitivity can cause sadness, shifts in mood, isolation, and other depressive symptoms. It has been suggested that uncertainty surrounding acceptance by others can cause these feelings to arise. This association is often situational. For example, the results of one study show that women with rejection sensitivity who had undergone a breakup initiated by their partner experienced increased depression symptoms

Rejection-sensitive dysphoria treatment

Because RSD is often connected to specific mental health conditions, treatment will often depend on the exact symptoms the individual is experiencing. There are two common medication options to treat RSD: alpha agonists (e.g., guanfacine) and monoamine oxidase inhibitors (MAOIs). These are not stimulant medications like what may be used to treat impulsivity hyperactivity in ADHD. Both medications are more often used to control blood pressure, but they can also help alleviate symptoms associated with RSD. Always consult a healthcare professional before starting or stopping any medication. 

Psychotherapy, particularly dialectical behavior therapy, is another primary treatment method for RSD, anxiety, and depression. Therapy can help the individual reframe negative thought processes that may lead to maladaptive reactions to rejection. A therapist can provide support, help the individual develop coping mechanisms, and role-play scenarios in which rejection commonly occurs. 

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Do you experience complex emotions at the thought of rejection?

Addressing emotional dysregulation with online therapy

Research suggests that online therapy can help individuals living with rejection sensitivity work through emotional challenges and improve their mental well-being. For example, in a study of 70 students, researchers examined the efficacy of online therapy for perfectionism, finding that it helped reduce rejection sensitivity, depression, and anxiety. The study also mentions that online therapy can help bridge the treatment gap that often exists in mental health care due to barriers such as cost and time limitations.   

If you’re experiencing RSD, anxiety, depression, or related mental health concerns, or adult ADHD, know that help is available. With an online therapy platform like BetterHelp, you can participate in therapy from home, which can be helpful if you’re not comfortable discussing rejection sensitivity in person. Online therapy is also an affordable option—BetterHelp registration starts at $65 to $100 per week (based on factors such as your location, referral source, preferences, therapist availability and any applicable discounts or promotions that might apply), and you can cancel anytime. A qualified mental health professional can guide you as you navigate complex negative emotions related to rejection, depression, or anxiety. Below are reviews of BetterHelp therapists from people experiencing similar challenges.

Therapist reviews

"I have really enjoyed working with Kim thus far. She has given me some excellent tools to manage and correct negative thought patterns in my daily life. I am so grateful for her patience, understanding, and just for her listening to me and helping me work through my thoughts."

"I worked with another counselor for over 6 months before working with Arielle Ballard. In one 30-minute session, I got more accomplished in terms of structuring goals, building coping mechanisms, and recognizing thought patterns, than I had in the 6 months working with the other counselor. I'm pleased with my progress and am very grateful to Arielle."

Takeaway

Rejection-sensitive dysphoria, while not a distinct mental health diagnosis, is closely connected to certain conditions, including mood disorders, anxiety, and depression. The symptoms of RSD can lead to complications in one’s social life, high levels of stress, low self-esteem, and other challenges—but these emotional responses can also be successfully managed. If you’re experiencing symptoms of anxiety, depression, or rejection sensitivity dysphoria or want to treat ADHD, know that help is available. With the guidance of a mental health professional, your journey toward feeling safe and confident around others can start today.

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