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ADHD Professionals

Dodson's Rejection Sensitive Dysphoria -- What do you think?
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In this summer’s issue of ADDitude, Dr. William Dodson is making a huge claim: that ADHD has two basic characteristics, the “Interest-based nervous system” and “Rejection sensitivity dysphoria.”
The articles I’m referring to are “Secrets of the ADHD Brain” and “Devastated by Disapproval.” Dr. Dodson will soon be coming out with a book that will expand upon these points.

I know that for myself, as an ADD therapist and coach and as a man with ADHD-PI, I was absolutely blown away by hearing the term “Rejection sensitivity dysphoria.” I have observed this time and again in my clients and I have deeply suffered from it myself, but it never had a name before, and suddenly here it was, not only named but given a central position in the syndrome of ADHD, the central component in the emotional dysregulation of adult ADHD, with the implication that it is a neurological condition that could be addressed by the proper medications.

I’m writing to ask what other ADHD professionals think about this. And more specifically, Dodson suggests that it can be successfully addressed with the alpha agonists, either Intuniv or Kapvay (Clonidine). But I have done a quick Google search of this idea and have not turned up any evidence, anecdotal or otherwise, for a transformative synergistic effect occurring from the combination of a stimulant and one of these drugs.

Anyone have any experience with this, who can weigh in on this matter?
Thanks,
Larry Letich, LCSW
Frederick, Md.

Replies

Larry,
Much as I respect, indeed admire, Bill Dodson as a thought leader, clinician and determined fellow partner on the path to grow ADHD understanding - I do disagree with this fresh label and the conclusions he reaches. I appreciate your bringing it to my attention.

Dysphoria is: “a state of feeling unwell or unhappy; a feeling of emotional and mental discomfort as a symptom of discontentment, restlessness, dissatisfaction, malaise, depression, anxiety or indifference” - from Wikipedia. Every synonym here is a word that describes serotonin related issues, that respond well to various serotonin related products [SSRIs, SNRIs] most of the time.

The problem we face as clinicians is simple: We are confusing the fact that depression has clear *cognitive dimensions* on several levels, but remains for the most part as several important, different presentations:  an Affect [down], a Cognitive condition [apathetic/negative] and a mixture of Both with anger and cognitive depression thrown in [Gran Torino].

See this article from almost 5 years ago:
http://www.corepsych.com/2008/11/grumpy-outed-add-and-depression-for-a-lifetime/

Hope this helps. Bottom line: dysphoria, and ADHD need to be treated together, simultaneously, as outlined carefully in New ADHD Medication Rules.

Best,
cp

Posted by Dr Charles Parker on Jun 25, 2013 at 1:03pm

Larry et al,
Don’t know Bill Dodson’s email, tried to bring him into this conversation…

Did think that ‘08 post needed upgrading so wrote another article this morning w a few more details:

http://www.corepsych.com/2013/06/dodson-dysphoria-and-adhd/

It’s a start,

Posted by Dr Charles Parker on Jun 25, 2013 at 5:09pm

There is no DSM definition of the term dysphoria, much less “rejection-sensitivity dysphoria.” Bill Dodson’s phenomenological description, which you can find in the short article, “Devastated by Disapproval,”

http://www.additudemag.com/adhd/article/10121.html

strikes me as absolutely spot-on. What’s more, I’ve started to talk to my ADHD clients about it and they are resonating to it, and I am seeing how it manifests in clients who don’t know how to identify and express their feelings well. I’ve seen it in myself and it’s given me a totally new understanding of my daughter.

It’s characterized by 1) a very strong propensity to detect disapproval or criticism, even when it isn’t there or it is only mildly there, and 2) an intensely dysphoric reaction to it—a criticism or rejection that someone else would shrug off can cause horrible emotional pain, resulting in intense emotions of shame and/or rage. The emotions are tied to an appropriate stimulus, and they are not totally bizarre, as they might be in a delusional patient, or chronic, as they might be in a borderline; but they are extreme, and debilitating, because it is simply debilitating to be so “sensitive,” and nobody wants to admit how easily hurt they are.

I think it’s worthy of a look. It adds an emotion regulation element to the whole ADHD picture.

Larry Letich, LCSW

Posted by Larry Letich, LCSW on Jun 25, 2013 at 7:40pm

By the way, Dr. Charles, I’ve been growing through your videos lately. They’re terrific!

Posted by Larry Letich, LCSW on Jun 25, 2013 at 7:42pm

Thanks Larry,
I really must to a video on this topic, as it’s so universally applicable and so confusing from the medical delivery side. If it is a serotonin problem and is treated with any kind of stimulant [not alpha 2 agonists] the strong possibility is there for a terrible reaction, even a dangerous reaction.

This particular problem is one of the main issues w the current stigma on ADHD, as it my have some relevance to cognition, but IMHO, just isn’t completely cognitively based in the final review.

Looking forward to reading the piece - thanks again, Larry for your input and your kind remarks.
Chuck

Posted by Dr Charles Parker on Jun 25, 2013 at 8:10pm

Dear Larry Letich &(others),

God Bless You!  Your daughter is lucky to have you to understand her and accept her as she is “wired,” or made!  Precisely a beginning…. Also, as with your medical background combined with personal connections, I hope to learn more from you and the others.

I am staying tuned in!

Thank you!

Posted by Unconventional on Jul 03, 2013 at 7:17pm

Hi Larry,
I’m a 52 year old male, recently diagnosed ADD. I saw this article on July 2nd and was blown away myself. Rejection sensitivity dysphoria, as described in the article, is everything I’ve been trying to explain to my mental health counselors. it completely crushes me.

Posted by BarneyS on Jul 08, 2013 at 4:01am

I was struck by that article when I read it - in a big way. I always considered that tendency to react emotionally to disapproval or rejection to be connected to early life experiences - a trigger - both for me and my clients. When I read the article, I wondered if I misunderstood what Dodson was referring to there. Is it possible that is a actually related to the ADHD instead?

I gave a copy of the article to one of my ADHD clients and she certainly resonated with it. I do as well - but as I said, just wrote it off to being triggered by old stuff.

I forwarded a copy of my psychiatrist, but have not had a chance to talk to her about it, other than to say that she is familiar with the regimen for aggressive kids.

I would be interested in hearing if anyone else is using this treatment, and what the success rate looks like.

LuAnn Pierce, LCSW

Posted by luannpierce on Jul 31, 2013 at 11:59pm

The theme that Dr Dodson is striking is one important for all clinicians - Cognitive Depression is serotonin not dopamine related and that’s why the glutamate product works better [Intuniv]. and Cognitive Anxiety [based on dopamine not serotonin] are routinely overlooked at nearly every turn.

Two videos that break this observation down a bit more:

Depression: http://youtu.be/Wsj219F9M2Q

Anxiety: In a diagnostic playlist - http://www.youtube.com/watch?v=fu0mN68rkEs&feature=share&list=PL95684D617668FE1B

Hope these help,
cp

Posted by Dr Charles Parker on Aug 01, 2013 at 2:11pm

I remember reading that article “Devastated by Disapproval” and just feeling relieved that I had finally found the missing piece! RSD has been the most crippling issue in my life. I now had a name for the problem. Learning about RSD has been just as impactful as my ADHD-inattentive diagnosis. I have been so puzzled by this recurrent theme - being criticized or rejected, and feeling so wounded and crippled by it. I have been able to master even harness my ADHD: I have an MD, an MPH, I write, I play music, I am often described as a vibrant charismatic person who will go far in life. But as an adult, this RSD has cost me my career, friendships and self esteem. I am currently a SAHM although I could potentially be anything I wanted to - but everytime I step out, this issue rears its ugly head and I find myself stuck. However, since I learned about RSD, I have been able to face my life differently - Using CBT via journalling and praying and meditating, I face criticism, negative feedback with the idea that I might be experiencing RSD. It keeps me calm and somewhat objective. I don’t react by lashing out, withdrawing or running away. I talk through issues, apologize if needed, make corrections if needed or just observe calmly and mine whatever lessons I can from that event. Dr. Dodson, thank you. You have saved my life in so many ways. RSD is the missing link! I hope more clinicians will address this issue. I know I will if I ever get accepted back into residency which I resigned from years ago in what I now see as an RSD event.

Posted by ADDmired on Sep 25, 2013 at 10:22pm

“But as an adult, this RSD has cost me my career, friendships and self esteem”.  Me too!  Intellectually I have always known I suffered from my name for it “self sabotage”.  Unfortunately knowing something on an intellectual level does not translate into being able to control it.  This article brings me to tears. Now it has a name, maybe I’ll be able to find a clinician to help.

Posted by KathleenK on Oct 27, 2013 at 4:04am

If Dr Charles Parker doesn’t like the term Dysphoria then to bad name it something else because being Devistated by Rejection is something I have suffered with my whole life. I have lost friends who just up and sya “I just can’t be your friend anymore” to job losses, to college professors ignoring or disliking me. either way it turns into depression and self loathing. There is no getting around it ADD & ADHD people either go it alone by choice and pamper their hearts or suffer bloody rejection in god aweful emotional hell& wondering why because you know you have always tried to be the best friend, employee, student you could.
Sue

Posted by missmix48 on Nov 08, 2013 at 12:55am

After being married to someone with ADD for over 10 years, and researching all I can on this topic, I 100% agree with the findings that there is such a thing as RSD. 

I have two step daughters with it and they never found any relief until they were on Intuniv and Welbutrin and it has been a miracle!  They no longer take things as personally as they did and can have emotionally healthy responses to people and circumstances in their lives. 

My husband has been frustrated by his emotional responses and he fits all the criteria of RSD which used to be called atypical depression.  We have tried diet, exercise, supplements, meditation, behavioral therapy, etc. with no positive results except for the few years he was on Welbutrin, which now makes sense why, and so now he will also try Welbutrin and Intuniv.

What is so sad is that the behavioral therapists out there are not really trained in ADD, ADHD or RSD and so they cannot and do not help their patients. So they listen but they don’t really have anything to offer the patient and so the patient suffers for years and the therapist just waits until their patient gets frustrated and leaves and then they get another patient, and they just listen until that patient gets frustrated and leaves.  It’s a crazy cycle, and very rarely asking the patient to see a psychiatrist. Sometimes only medication works.

I’m sorry that just like primary care physicians who over prescribed antibiotics gave the profession and the use of antibiotics a bad name, some doctors over prescribed Ritalin, but coming from a family with a genetic history of ADHD - and RSD - which is definitely different than Bipolar, and trying every other possible non medical solution, I have to say that sometimes, medication in the right dosage works.  I have a J.D. degree and a genius IQ, and went through medical school with my first husband, so I’m no dummy, and not coming up with these conclusions based on supposition, but on ALOT of research and facts. 

All I can do is tell people not to give up, trust your instincts, keep searching for the answers and pray alot to God that he will lead you to what you need.

Posted by ADDwifemotherstepmother on Mar 05, 2014 at 11:17am

Wait. Why is no one mentioning the fact that ADHDers do in fact experience significant and profound social rejection? We are ignoring the role of social dynamics in excluding those who are non-neurotypical.

If you stand a neurotypical in a room and have everyone turn their back to him/her, I imagine you could detect a mood change. Yes? How can we assume that a negative reaction to social rejection must be a form of mood or cognitive dysfunction? Especially in individuals for whom social rejection has been life-long and devastating? Wouldn’t they be expected to have it prioritized high on their radar? In a neurotypical we would call that normal and adaptive. But for ADHDers we blame the victim and call it a self-originated, self-fulfilling prophesy?

Posted by Nightingale on Apr 10, 2014 at 5:41pm

Awesome!

Posted by Unconventional on Apr 10, 2014 at 6:03pm

I’m a successful (non-medical) professional who was not diagnosed until in my 50s.  Long before I knew I had AD/HD I had repeatedly experienced both sides of this - actual stigmatisation, rejection and exclusion because I was “different”, as well as hypersensitivity to minor criticism.  Major criticism, interestingly, does not faze me - it is part of professional debate and I enjoy this.  You either win and teach or lose and learn.  But the sort of subtle criticism that my neuro-typical colleagues use either was a weapon or out of actual concern not to cause offence, has triggered feelings and reactions out of all proportion to their nature.

I will leave questions of labelling to the professionals, but based on my own reading and subjective experiences, this is a symptom of my ADHD and not a separate problem.  I see in Thomas Brown’s latest book a lot of discussion about emotional disregulation as yet another disrupted executive function and of “attentional biases” that tend to lead us to focus on and retain negative information, perceptions and emotional associations.  This is exactly consistent with what I have experienced, in the sense that I’m not just hypersensitive to criticism and rejection, but to other things as well.  I remember clearly childhood traumas like the (in my case frequent) humiliation of being the last kid picked for sports teams, and the ghosts of this trauma still haunt me every time I face some small exclusion or rejection at work.

On the question of labelling, whether we consider this as one disability or two, I do think having a descriptive label and the information that goes with it is important.  I still suffer from this frequently and fairly severely, but it does help a lot to understand that it is a real phenomenon and how it works to the extent that we do know how it works.  In having a label and an objective reality, one can step outside of the trauma, at least sometimes and doing this reduces the pain and a lot of the collateral damage to self-esteem.

Posted by Cedar on Apr 19, 2014 at 9:50am

Has anyone had success in treating rejection sensitivity?  I am suffering from this, and have all my life.  When I have discussed this with doctors I have seen they look at me as if I was from a different planet?  Like I have no idea of how I am feeling, and shouldn’t be so sensitive!  Typical or classic add meds are the only option in their minds.  Or go to a counselor they say, because it is in your mind!  BTW, I have tried that, and it is still in my mind…  I feel I need something else.  If anyone has something that worked if you could share this!  Also, how do I find a doctor who will listen to me, versus telling me all that is needed is a standard stimulant? It seems the clinics can’t seem to keep this line of doctors anyways, so I have seen at least 4 different ones in the past few years.

Posted by Unconventional on Nov 04, 2014 at 5:57pm

Hi @unconventional!

In the following article, Dr. Dodson (the expert on rejection sensitive dysphoria) advises the use of Intuniv or Kapvay (alpha antagonists). http://www.additudemag.com/adhd/article/10117.html

Talk with your doctor about this possibility.

Penny
ADDconnect Moderator, Author on ADHD, and Mom to Pre-Teen Boy w/ ADHD and LDs

Posted by adhdmomma on Nov 05, 2014 at 3:30pm

Thank you to everyone who is participating in this discussion!

Posted by HulaGirlinTexas on Nov 20, 2014 at 6:09am

In reply to Penny, thank you.  I did see, read, and printed the information on the suggested medications along with his the doctors name and referenced and gave links to his writings on this topic.  So, I did try talking to my providers, as I stated in my post, and more than once!  It seems they cannot keep a steady provider for mental health care, requiring those who use this provider to continually get use to a new doctor…thus starting over at ground zero! I have not had luck or success with the first 4, and the 5th has yet to be hired!... So, regardless I feel they don’t listen, or at least take me seriously, and not one was willing to recommend any change in treatment. It is adderall ...write the script and that’s it!  I am beginning to wonder if the doctors are compensated by the drug companies.

Posted by Unconventional on Nov 20, 2014 at 10:38pm

I have been looking for a solution for my problem with ‘sensitivity’ for most of my life, and I am 71 years old. Some comments have mentioned sensitivity even when rejection isn’t there, or is only minor, to which my reaction is “It is either there or it isn’t.”  My theory has always been that a rejection may only be suggested, but it IS present, and it Will grow.  I will be rejected eventually.  There is no ‘minor rejection’ for a person who has very little self left to be rejected.

I am using guanfacine; while it is not a cure, it surely seems to be helping a little—enough to diminish extreme reactions such as suicide.  I would like to try the combination, but I haven’t found anyone to prescribe it for me.  Dr. Dodson gave me the name of a doctor at Duke University, but when I called the number, it had been disconnected. 

My most recent provider just threw out the term PTSD for my condition, and that has always seemed correct for me. I respond to others based on what I learned about myself as a very small child.  In other words, I have a good reason for feeling the way I do.  People may not even be aware of their own behavior and moods.  If they reject me now, they most likely will very strongly reject me later.  I try to nip it in the bud.  But it does make me angry (frustrated).

Something I read in other posts made me think it might be similar to other illnesses that cause an intensified reaction.  Some people become obsessed about a certain idea or item, as in autism.  Maybe that’s what happens in the sensitivity…we just get a strong dose of emotions, more than other people do.

I am totally impressed that it has a name, after probably 65 years, it has a name.  But I don’t accept that it’s ‘imaginary.’  My ADD (diagnosed professionally) may make it hard for me to sort out the importance of each small rejection, but that doesn’t make it unreal.  Maybe, since I can’t figure out whether the rejection might have a life-changing importance, I just err on the side of caution, and assume it is something to be challenged or avoided.  This also seems to me to be possibly related to the compulsion to be honest.

I fear being among people because they will find out I’m not like them.  I tell people negative things about myself, 1) to be honest, and 2) to avoid the inevitable rejection when they find out I have a temper or anger.  I am really a nice person who cares about others, but the rejection brings out my temper.  Even when I see others rejected, I get angry. 

If anyone knows of a therapist for RSD treatment in Eastern North Carolina, I would like to hear of him or her.

Posted by minniespearl on Feb 28, 2015 at 9:00pm

I also have suffered from RSD all my life. I am 62 years old.  I was only diagnosed with ADHD 6 years ago. I only heard about RSD a few months ago. I also am trying to find out what medication I can use to quell these feelings. I am on adderall generic for my ADHD. Would be interested to find a doctor and an ADHD coach in western CT that deals with both of these. Thanks.            Pat Kemble

Posted by Petsitter13 on Mar 17, 2015 at 1:47am

In searching all the pharmaceutical info about RSD or atypical depression, I came across this on Amazon: “Lifting Depression: The Chromium Connection” by Malcolm Noell McLeod, M. D.

Really? Chromium?? I read the info on Amazon, read more on his website, and urge you to check it out. WHAT IF your decades-long symptoms would be relieved within days by taking chromium? Mine were.

If low chromium is not a factor you won’t respond, and no harm done. But if it is an underlying factor, pharmaceuticals won’t correct it. If chromium can help, wouldn’t it be good to know?

The background and research are there for you to review - and have been out there for 10 years. Why haven’t we heard more about this?

Posted by Vera Anderson on Apr 20, 2015 at 5:33pm

Hi.  I found a psychologist, and she gave me the name of a psychiatrist.  I hope I will be able to get the prescriptions that Dr. Dodson recommends.  The guanfacine is such a help that I fear ever stopping it. I still hear criticism, I still feel bad, but it stops after a couple of hours. I don’t go on to deeper thoughts and deeper depression.  Thanks Dr. Dodson…many thanks. 

Carol W

Posted by minniespearl on May 17, 2015 at 7:08pm

guanfacine or chromium?  I find the thought of relief from RSD to be so exciting!  I still do not have a permanent doctor, and once again had a substitute!  All the fill in doctors want to just refill the same old adderall and not consider RSD a condition that is treatable, just counseling or positive thinking!

How much chromium?  Is it safe?

Posted by Unconventional on May 21, 2015 at 4:43am

Hello, I made an account just for this discussion.

I suffer from ADHD and a particularly solid helping of Rejection Sensitivity Dysphoria, I was diagnosed at 35 with ADHD and discovered my RSD about 6 months later.
I also had a moderate level of emotional dissasociation. The first traumatic rejection even I can remember was about 6-7 years old and was compounded on many, many times over.

Anyway, I found 2 things that helped.
The first 2 weeks (roughly) of dexamphetamine treatment completely eliminated(or masked) the RSD, I remember I saying to people ‘it’s asif all the bad things from the past just don’t matter, I can remember them, but they don’t hurt’.

After that short initial relief it came back to normal levels. I thought it was just from the mild euphoria from the initial amphetamine treatment.

After researching my symptoms and potential medications I settled on guanfacine, however it is unavailable in my country (Australia), so I had to settle with clondine.
I was sure my body was essentially locked into a hyper-vigilent state, to my delight (I guess) I also found out about RSD at this time and low and behond clondine has seen succeful treatment.

At the lower dose of 1/2 a 100mg tablet, along with my stimulant medication, I have considerable relief from the RSD. I still have sensitivity, and I still have issues of perceived rejection, and the intense emotions that go with that, just less so. I can actually work on recovering and getting past this illness.

So yes, Clonidine, in my case, helps tremendously.

It actually makes a lot of sense when you look at the biochemsitry of it, across the WHOLE body, not just the brain. I have a biochem degree.

Posted by BrendanH on Feb 23, 2016 at 6:29am

Thank you Dr Dodson. You have given me the last piece of the puzzle. Neither Clonodine nor Guanfacine have helped but just understanding that I have RSD has helped me to recognize what is happening and I am able to name what’s happening. I’m less afraid to make friends because I now know they aren’t rejecting or criticizing me - it’s in my mind, not theirs. I used to think that because I was SO hurt, they must have MEANT to hurt me. Like ADHD, RSD will always be there but because I understand what’s happening, I don’t feel so crazy and now that I know it’s me, I can be less reactive.

Posted by I do try on May 12, 2016 at 4:51pm

I was diagnosed with adhd about a year and a half ago. I’m taking bifentin. Its been a long haul to find the right side and in between I just quit taking the meds. There were just too many side effects. Or so I thought. I listened to Dr Dodson’s webinar about adhd meds and found out that my dose was way too high. Therefore the side effects. And then I listened to his webinar about the emotions, and oh my… That was a word for word description of my life! But I am petrified of drugs. Help, anyone else out there like that? I’m just getting comfortable with actually taking my itty bitty dose of bifentin, and now I’m going to add more?
My doctor knows about adhd and treating it, but he’s not really aggressive about it. So any information I bring in, he’s totally willing to try out.
Thank you!!! Dr Dodson for all your excellent help!

Posted by Quilted Farmer on Jun 22, 2016 at 6:56pm

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