Nearly two-thirds of ADDitude readers ages 18 to 29 report feeling lonely “always” or “often,” according to a new survey of 4,170 adults with ADHD. Living or working with others made little difference; 89 percent of these young adults say they feel lonely even then. Only 19 percent say social media makes them feel more connected. In contrast, 46 percent of people ages 68 to 77—the demographic traditionally associated with social isolation — reported the same levels of loneliness.

“My ADHD makes it hard to remember to reach out or respond,” wrote one 28-year-old woman with inattentive ADHD, “but rejection sensitive dysphoria hits hard when I’m not reached out to or responded to, even though I acknowledge that hypocrisy. ADHD also makes it hard to leave the apartment (time management, overwhelm at what it takes to leave, energy to be social, executive function difficulties, etc.), so even if I’m invited, I find reasons to cancel.”

“For me, ADHD and loneliness impact one another,” wrote one survey respondent. “Now I neither want relationships nor do I have the energy to keep up the masking necessary to navigate relationships. It requires too much effort.”

When ADHD Symptoms Lead to Loneliness

The stories of social isolation shared by ADDitude readers were reflected in the findings of a recent meta-analysis of studies investigating whether young people with ADHD experienced greater loneliness than their neurotypical peers. The review of 20 studies, involving about 6,300 participants, concluded that people with ADHD who were younger than 25 had significantly elevated levels of loneliness due, in part, to mental health struggles, including anxiety and depression, and to “feeling different” because of their ADHD. Researchers called this an “important problem” of which clinicians should be aware for early identification and intervention, according to the study published in February in the Journal of Attention Disorders.¹

“I feel too quirky and awkward,” wrote one survey respondent. “I’m fun at first, but quickly become too much for others. I want there to be less of me.”

[Read: “Why Don’t I Have Any Friends?”]

For more than three-quarters of ADDitude survey respondents, feelings of loneliness are tied directly to ADHD symptoms, manifestations, and repercussions. According to the survey, the most common ADHD-related roots of loneliness include:

• low self-esteem: 67%
• rejection sensitive dysphoria (RSD): 65%
• social anxiety: 64%
• poor working memory: 63%
• “masking” who they really are: 59%
• executive dysfunction and disorganization: 57%

The Painful Toll of Loneliness

Loneliness correlates to mental health problems for 78 percent of adults with ADHD, who also report high levels of anxiety (65%) and depression (61%), among other comorbid conditions. For two-thirds of survey respondents, loneliness has led to toxic relationships, substance abuse, self-harm, binge eating, excessive spending, and porn addiction.

Among ADDitude readers who say they “always” or “often” feel lonely, only 26 percent live alone. Retirement, lonely marriages, physically limiting health conditions, and strenuous caregiving responsibilities were often cited by older survey respondents, who say that late ADHD diagnoses contributed to their loneliness as well.

“Grieving the loss of what I perceived as a ‘good’ life after my ADHD diagnosis made me feel like a failure,” wrote one older adult. “I cannot undo the damage or ill feelings caused by my past actions, and this recognition has caused me even more pain.”

[Read: The Science of Loneliness]

“When I feel lonely,” said one survey respondent, “I want to reach out, but I usually don’t because:

1.  ‘Out of sight out of mind’ has left too much time between interactions, and I feel shame over this.
2. When no one reaches out to me, or if I reach out and get no immediate response, RSD kicks in and I’m immediately overwhelmed with self-loathing.
3. I dwell on each previous interaction and why this person may be harboring ill feelings toward me.
4. Depression asks, ‘What’s the point of interaction? It’ll just exhaust you.’”

Causes of Loneliness For People with ADHD

More than half of the adults surveyed say they have trouble making and keeping friends for the following reasons:

• feeling overwhelmed
• fearing rejection
• experiencing social anxiety
• receiving few social invitations

“It’s a cruel loop,” one survey respondent said. “I feel safe when alone, so, much of the time, it’s a relief. But then, the loneliness is crushing.”

Coping with Loneliness

A spate of startups like the United Kingdom’s Timeleft and Friender are joining the veteran app Meetup in efforts to facilitate online connections that lead to real-life interactions. Some apps invite groups of strangers to meet for dinner at a specific time and place. Others work more like platonic dating apps where users scroll profiles before making plans. And some draw people together over common interests.

More than two-thirds of people say they feel less lonely when they reach out and connect with others in person, or via text or phone call. They also successfully alleviate loneliness through the following:

• physical touch: 62%
• engaging in a hobby: 58%
• spending time with their pet: 56%
• working with a therapist: 52%

“Letting the Mask Slip“ in Neurodivergent Friendships

More than half of adults surveyed say they relate better to, and feel less lonely around, other neurodivergent adults.

“Being with other neurodivergent folks validates my experience of living with ADHD,” wrote one survey respondent. “There’s less judgment.”

Said another adult with ADHD: “In a neurodivergent group, I don’t feel weird, and I can let my mask slip. It is less taxing and there is less of a chance of me freaking out later over social mistakes I might have made.”

Loneliness and ADHD: Next Steps

• Read: Birds of a Feather: The Joy of Neurodivergent Friendships
• Read: “How Do You Keep From Being Socially Isolated as an ADHD Adult?”
• Read: “Why Don’t I Have Any Friends?”

Sources

¹Jong A, Odoi CM, Lau J, J Hollocks M. Loneliness in Young People with ADHD: A Systematic Review and Meta-Analysis. J Atten Disord. 2024 May;28(7):1063-1081. doi: 10.1177/10870547241229096. Epub 2024 Feb 23. PMID: 38400533; PMCID: PMC11016212.

SUPPORT ADDITUDE

Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

“Social interactions rely on a complex orchestration of brain functions, from understanding another person’s point of view, recognizing their emotional state, feeling their emotional pain, and so on. Difficulties with any of these can affect our ability to connect to others,” says Ellen Lee, M.D., associate professor of psychiatry at the University of California San Diego. “The emotional pain and stress of loneliness can also take a toll on our brains.”

Lee was the corresponding author of a systemic review of 41 studies, involving 16,771 adult participants, examining the neurobiology of loneliness. Researchers in those studies used brain imaging and other scans to identify the differences in the brain structure and function of lonely people. The findings showed that some people were hard-wired for loneliness in the same way that some are hard-wired for anxiety.

Loneliness is defined as the emotional discomfort one feels when their need for intimacy and social connection goes unmet.

In the lonely participants, abnormal structure and/or activity was discovered in the prefrontal cortex, which mediates emotional regulation and inhibitory control; the insula, which plays a role in emotional pain and self-awareness; and in other parts of the brain. The review was published in the journal Neuropsychopharmacology in 2021.¹

[Test Yourself: How Severe Is Your Loneliness? Take This Quiz]

Lee says it’s possible that brain changes associated with ADHD, depression, and anxiety can lead to feelings of prolonged loneliness because people tend to withdraw from social interactions when they have low mood or other symptoms.

“Researchers are starting to study these links to understand if improving loneliness could be a way to improve these symptoms,” she says.

Lonely Brains Process the World Differently

In a study published in the journal Psychological Science in 2023, researchers discovered that lonely people viewed the world differently from each other and from nonlonely people. Using fMRI scans to examine neural responses to stimuli (videos) and other methods, the researchers also administered a loneliness scale and survey to evaluate the 66 study participants.²

They found that loneliness was associated with structural and functional differences in regions of the brain, and the researchers said their results remained significant even after controlling for individuals’ reported numbers of friends.

“Lonely people process the world idiosyncratically, which may contribute to the reduced sense of being understood that often accompanies loneliness,” the researchers said in the study. “In other words, we found that nonlonely individuals were very similar to each other in their neural responses, whereas lonely individuals were remarkably dissimilar to each other and to their nonlonely peers.”

The researchers said the findings “raise the possibility that being surrounded predominantly by people who view the world differently from oneself may be a risk factor for loneliness (even if one socializes regularly with them).”

Those findings echo the lived experience of many adults with ADHD who report feeling a sense of isolation due to their perceived difference. “I mostly feel like a dolphin in a sea of stingrays,” an ADDitude reader says. “I never meet people with whom I have anything significant in common, and with whom I can forge solid, lasting friendships.”

[Read: How to Make Friends As an Adult With ADHD]

The Evolutionary Function of Loneliness

Stephanie Cacioppo, Ph.D., a behavioral neuroscientist whose research seeks to understand how people experience different emotions, says evolution has sculpted the human brain to respond to biological mechanisms like hunger and thirst. Hunger, she says, is triggered by low blood sugar and motivates us to eat. Thirst helps us find water before we become dehydrated. Pain encourages us to take care of our body.

“Loneliness alerts us to potential threats, and damage to our social body, and in doing so, increases our motivation to bond with others,” says Cacioppo, author of Wired for Love. “It’s the brain’s way of telling you: You’re in social danger, you’re on the periphery of the group, you feel left out, misunderstood, you need protection, inclusion, support, and love. One of the most important things that love can do, it turns out, is shield us from the ravages of chronic loneliness.”

Cacioppo says it’s not uncommon for people to mask in the company of others when they don’t feel a sense of connection.

“Masking is totally understandable from a neuroscientific perspective,” she says. “The best solution is to stay authentic. Authenticity is the key to connectivity. Building connections with people while staying true to yourself can be a buffer against loneliness.”

How to Deal with Loneliness

Cacioppo offers several strategies to address chronic loneliness, encapsulated by the acronym G.R.A.C.E.:

Gratitude: Every day, write down five things you truly appreciate. Science shows that expressing gratitude improves emotional wellbeing.

Reciprocity: If you know someone who feels lonely, ask them for help or for advice. Showing respect can give a lonely person a sense of worth and belonging that decreases feelings of isolation.

Altruism: Helping others, and sharing your knowledge, will give you a feeling of self-expansion that is similar to what people experience when they are in a love relationship.

Choice: The tricky thing about loneliness is that, to some extent, it’s self-fulfilling. The more you think you are lonely, the more you are. To break the spiral, shift your mindset and choose to be curious about how you can make meaningful connections.

Enjoy: Smiling and sharing good times (or good news) with people helps reduce loneliness and increase happiness.

How to Deal with Loneliness: Next Steps

• Read: The Big Heart Approach to ADHD Acceptance & Self-Love
• Read: Are You Feeling Lonely?
• Read: Feeling Antisocial? Alone? Both? 3 Common ADHD Friendship Challenges
• Read: 13 Tips for Feeling Connected

Sources

¹ Lam JA, Murray ER, Yu KE, Ramsey M, Nguyen TT, Mishra J, Martis B, Thomas ML, Lee EE. Neurobiology of loneliness: a systematic review. Neuropsychopharmacology. 2021 Oct;46(11):1873-1887. doi: 10.1038/s41386-021-01058-7. Epub 2021 Jul 6. PMID: 34230607; PMCID: PMC8258736.
² Baek, E. C., Hyon, R., López, K., Du, M., Porter, M. A., & Parkinson, C. (2023). Lonely Individuals Process the World in Idiosyncratic Ways. Psychological Science, 34(6), 683-695. https://doi.org/10.1177/09567976221145316

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

The lives of girls and women with ADHD are jeopardized by exponentially higher rates of self-harm, suicidality, and intimate partner violence, as compared with their neurotypical counterparts or with neurodivergent boys and men.

“ADHD in girls portends continuing problems through early adulthood that are of substantial magnitude across multiple domains of symptomatology and functional impairment,” write the authors of the Berkeley Girls ADHD Longitudinal Study (BGALS) follow-up study.¹ “The sheer range of negative outcomes is noteworthy; the most striking include the high occurrences of suicide attempts and self-injury in the ADHD sample, confined to the childhood-diagnosed combined type.”

What We Know About Self-Harm

This is an arresting statistic, particularly considering how self-harm and suicidality have spiked in adolescent girls in general. The most recent CDC Youth Risk Behavior Survey (YRBS) report found that 1 in 10 girls has attempted suicide, and 1 in 3 of girls seriously considered suicide during the past year, which is an increase of nearly 60% from a decade ago.

Research suggests that neurodivergent girls face a significantly higher risk for self-harm than do neurodivergent boys, or neurotypical people of any gender. A 2020 study in European Child & Adolescent Psychiatry found that the rate of self-harm was four times greater in females than it was in males (8.7% vs 2.2%).²  A 2022 ADDitude survey found reports of self-harm among 18% of girls with ADHD versus 9% of boys with ADHD.

The correlation between teen girls with ADHD and self-harm is so strong that a 2021 study published in Child and Adolescent Mental Health proposed that all teen girls treated for self-harming behavior should be screened for ADHD:³ A full 83% of teen patients admitted to the hospital for self-harm were girls, the study found.

Indeed, early diagnosis and treatment of ADHD is critical to mitigating the risk of self-harm. “Girls and women with untreated ADHD are at double the risk for engaging in self-harm and significantly more likely to attempt suicide,” says Julia Schechter, Ph.D., of the Duke Center for Girls and Women with ADHD.

What We Know About Intimate Partner Violence

Low self-esteem, high rejection sensitive dysphoria (RSD), and social skill deficits put women and girls with ADHD at heightened risk for intimate partner violence (IPV). A study published in the Journal of Abnormal Child Psychology found that: ⁴

• Girls with ADHD were five times more likely to be victims of physical intimate partner violence than non-ADHD girls (30% vs. 6%)
• Greater ADHD symptom severity in childhood was associated with increased risk for physical victimization

“Findings indicate that in young women, childhood ADHD is a specific and important predictor of physically violent victimization in their intimate relationships,” write the authors of the study. “Given the devastating impact of intimate partner violence, additional research on how to empower females with ADHD in their social and romantic relationships is greatly needed.”

What We Know About Substance Use

The connection between SUD and ADHD has been well-established through research. We know that:

• People with ADHD are three times more likely to develop an SUD then those without⁵
• 25% of adults with SUD have ADHD⁶ 
• SUD is often more severe in individuals with ADHD⁷

Among the general population, we know that teen girls are more likely to use substances than are teen boys. According to the CDC’s YRBS:

• Alcohol: 27% of teen girls reported drinking in the last month vs 19% of boys
• Vaping: 21% of girls reported vaping in the last month vs 15% of boys
• Illicit drugs: 15% of girls reported ever using illicit drugs vs 12% of boys
• Misuse of prescription opioids: 15% of girls reported ever misusing opioids vs 10% of boys

That said, studies on the prevalence of SUD among girls and women with ADHD have resulted in mixed findings. An elevated risk of substance use was found in a large-scale study led by Joseph Biederman, M.D.,⁸  however no such association was found in the BGALS follow-up.

Most recently, researched at the University of Minnesota conducted a study investigating how ADHD symptoms may influence substance use in women and men, and it found a stronger association between alcohol use and ADHD for young adult women than for young adult men.⁹

“The current study confirms that ADHD-associated risk for adult substance problems is consistently greater in magnitude for women,” the authors of the study write. “The presence of adult ADHD increases risk for substance problems in women more than men.”

What We Don’t Know

No research exists on the relative efficacy of interventions that may reduce the risks for self-harm, suicidality, intimate partner violence, and substance use among girls and women with ADHD. Without fully understanding where these threats begin and how they escalate, we cannot devise and adjust solutions.

The BGALS follow-up study found elevated risks of self-harm and suicidality only among girls with combined-type ADHD, and not among those with inattentive symptoms alone, which leads researchers to speculate that impulsivity is associated with higher risk. Researchers also posit that psychosocial factors, such as the teen’s environment, contribute to the likelihood of self-harm. Longitudinal research is needed, however, to confirm this.

“What are the transition points — psychologically, family or school-related, community-wide — that predict impairment vs. resilience for girls with ADHD as they transition through adolescence to adulthood?” asks Hinshaw. “What are the strategies and supports that teen girls and women with ADHD find most helpful in self-advocacy and thriving?”

In the British Journal of Psychiatry,¹⁰ Hinshaw and doctoral student Sinclaire O’Grady call for longitudinal research on long-term correlated outcomes, such as the development of borderline personality disorder, as well as research into the intergenerational transmission of risk for negative outcomes in the children of women with ADHD.

Further research is needed to answer the following questions:

• What are the specific predictors and mediators of the high risk for self-harm in girls and women with ADHD?
• Does screening self-harming teens for ADHD reduce the occurrence of self-harm?
• What, exactly, makes early adulthood a time of heightened risk for substance use issues, specifically for women with ADHD?
• What are the impacts of ADHD treatment on intimate partner violence victimization?
• What psychosocial interventions, specific to girls and women with ADHD, may mitigate risk of intimate partner violence victimization?

Why It Matters

Researching suicidality, self-harm, intimate partner violence, and substance abuse among women with ADHD will, quite literally, save lives.

A study led by Russell Barkley, Ph.D., published in the Journal of Attention Disorders, found that life expectancy was 13 years lower for patients with combined-type ADHD diagnosed in childhood and with persistent symptoms, relative to control children.¹¹

However, because of the severely limited number of females in the study, the findings are largely not relevant. No major study has investigated the impact of ADHD on life expectancy specifically in women.

With dramatically higher rates of self-harm and suicidality, as well as intimate partner violence, this research is desperately needed to protect women from bodily harm, as well as devastating emotional consequences.

What ADDitude Readers Tell Us

Feelings of loneliness, RSD, emotional dysregulation, anxiety, and low self-worth exert a crushing emotional burden — and prompt some readers to harm themselves, to abuse substances, and to maintain toxic relationships.

“I made poor choices that led to abuse,” says Debs, an ADDitude reader in the United Kingdom. “I’ve taken substances to make the pain less, and I have self-harmed to try to take away the pain.”

“The inner turmoil just seems to get louder and louder and more difficult to turn down, which leads to unhealthy ways of coping like self-harm to help manage the stress,” shares Laura, an ADDitude reader in Texas.

“I abuse cannabis,” explains ADDitude reader Elizabeth, in the United Kingdom.

“Sometimes I feel worthless and want to self-harm because of RSD, assuming I’m not loved by my loved ones.”

“I get myself in relationships that aren’t good for me as I’m just happy that somebody finally loves me despite my flaws,” explains ADDitude reader Annika in Germany. “Self-harm comes into play when I feel like a failure because the relationship is rocky, and I get invalidated or criticized.”

“I constantly feel like I’m failing, which makes the thoughts about self-harm pop up often, although I haven’t given in to those for a while now,” says Lizzy in the Netherlands.

“I drink a lot right now,” says Nicole, an ADDitude reader in Washington. “I know it is unhealthy, but it is the only way for me to cope.”

“I have a history of self-harm, which was sometimes brought on my intense feelings of worthlessness and loneliness,” shares an anonymous ADDitude reader.

What ADHD Experts Say

The long-term ravages of underdiagnosed and undertreated ADHD in women are dire — a matter of life and death in some cases. To develop effective interventions, research is essential.

“There is a critical need for studies into how increasing degrees of isolation, shame, and despair lead to self-harm and earlier mortality, exploring the relationships to early chronic trauma, impulsivity, poor self-care,” says Ellen Littman, Ph.D. “Research must respond to outcomes signaling such a significant public health crisis.”

“Too little is known about later-adult outcomes of females with ADHD,” write Hinshaw and O’Grady. “Overall, we contend that the extraordinarily high risk for self-harm incurred by girls with ADHD as they mature requires a shift in clinical perspective.”

“Girls and women with untreated or undertreated ADHD — or those who have been misdiagnosed with other conditions — have been put at higher risk for an array of negative outcomes including higher rates of depression and anxiety, intimate partner victimization, and risky sexual behaviors resulting in teen and unplanned pregnancies,” says Schechter. “Research specifically devoted to girls and women with ADHD is not only an issue of equity but a life-or-death issue for some girls and women.”

Self Harm & Intimate Partner Violence: Related Resources

• Suicide &Crisis Lifeline: Call or Text 988
  988lifeline.org
• National Sexual Assault Helpline: 1-800-656-HOPE
• National Substance Abuse Helpline: 1-800-662-HELP
• Stop Bullying

Related Reading

• Teen Girls Are Not Alright. ADHD Magnifies the Crisis.
• ADHD in Women and Girls: Why Female Symptoms Slip Through Diagnostic Cracks
• Why Do Toxic Relationships Swallow People with ADHD?
• Girls and Women with ADHD: Unique Risks, Crippling Stigma
• Substance Use Disorders and ADHD: 5 Key Facts and Additional Resources
• “If the Story of My Unplanned Pregnancy Helps Just One Person, It Was Worth Sharing.”

We Demand Attention: A Call for Greater Research on ADHD in Women

Intro: Top 10 Research Priorities

1. Sex Difference in ADHD
2. The Health Consequences of Delayed ADHD Diagnoses on Women
3. How Hormonal Changes Impact ADHD Symptoms in Women
4. How Perimenopause and Menopause Impact ADHD Symptoms, and Vice Versa
5. The Elevated Risk for PMDD and PPD Among Women with ADHD
6. The Safety and Efficacy of ADHD Medication Use During Pregnancy and While Nursing
7. How ADHD Medication Adjustments During the Monthly Menstrual Cycle Could Improve Outcomes for Women
8. The Long-Term and Short-Term Implications of Hormonal Birth Control and Hormone-Replacement Therapy Use Among Women with ADHD
9. How and Why Comorbid Conditions Like Anxiety, Depression, and Eating Disorders Uniquely Impact Women with ADHD
10. Early Indicators of Self-Harm, Partner Violence, and Substance Abuse Among Girls and Women with ADHD

Sources

¹ SP, Owens EB, Zalecki C, Huggins SP, Montenegro-Nevado AJ, Schrodek E, Swanson EN. Prospective follow-up of girls with attention-deficit/hyperactivity disorder into early adulthood: continuing impairment includes elevated risk for suicide attempts and self-injury. J Consult Clin Psychol. 2012 Dec;80(6):1041-1051. doi: 10.1037/a0029451. Epub 2012 Aug 13. PMID: 22889337; PMCID: PMC3543865.

² Ohlis, A., Bjureberg, J., Lichtenstein, P. et al. Comparison of suicide risk and other outcomes among boys and girls who self-harm. Eur Child Adolesc Psychiatry 29, 1741–1746 (2020). https://doi.org/10.1007/s00787-020-01490-y

³ Ward JH, Curran S. Self-harm as the first presentation of attention deficit hyperactivity disorder in adolescents. Child Adolesc Ment Health. 2021 Nov;26(4):303-309. doi: 10.1111/camh.12471. Epub 2021 May 3. PMID: 33939246.

⁴ Guendelman MD, Ahmad S, Meza JI, Owens EB, Hinshaw SP. Childhood Attention-Deficit/Hyperactivity Disorder Predicts Intimate Partner Victimization in Young Women. J Abnorm Child Psychol. 2016 Jan;44(1):155-66. doi: 10.1007/s10802-015-9984-z. PMID: 25663589; PMCID: PMC4531111.

⁵ Wilens T. E. (2004). Attention-deficit/hyperactivity disorder and the substance use disorders: the nature of the relationship, subtypes at risk, and treatment issues. The Psychiatric clinics of North America, 27(2), 283–301. https://doi.org/10.1016/S0193-953X(03)00113-8

⁶ Charach, A., Yeung, E., Climans, T., & Lillie, E. (2011). Childhood attention-deficit/hyperactivity disorder and future substance use disorders: comparative meta-analyses. Journal of the American Academy of Child and Adolescent Psychiatry, 50(1), 9–21. https://doi.org/10.1016/j.jaac.2010.09.019

⁷ Wilens, T. E., & Morrison, N. R. (2011). The intersection of attention-deficit/hyperactivity disorder and substance abuse. Current opinion in psychiatry, 24(4), 280–285. https://doi.org/10.1097/YCO.0b013e328345c956

⁸ Biederman J, Monuteaux MC, Mick E, Spencer T, Wilens TE, Klein KL, Price JE, Faraone SV. Psychopathology in females with attention-deficit/hyperactivity disorder: a controlled, five-year prospective study. Biol Psychiatry. 2006 Nov 15;60(10):1098-105. doi: 10.1016/j.biopsych.2006.02.031. Epub 2006 May 19. PMID: 16712802.

⁹ Elkins IJ, Saunders GRB, Malone SM, Wilson S, McGue M, Iacono WG. Differential implications of persistent, remitted, and late-onset ADHD symptoms for substance abuse in women and men: A twin study from ages 11 to 24. Drug Alcohol Depend. 2020 Jul 1;212:107947. doi: 10.1016/j.drugalcdep.2020.107947. Epub 2020 Feb 27. PMID: 32444170; PMCID: PMC7293951.

¹⁰ O’Grady SM, Hinshaw SP. Long-term outcomes of females with attention-deficit hyperactivity disorder: increased risk for self-harm. Br J Psychiatry. 2021 Jan;218(1):4-6. doi: 10.1192/bjp.2020.153. PMID: 33019955; PMCID: PMC7867565.

¹¹ Barkley, R. A., & Fischer, M. (2019). Hyperactive Child Syndrome and Estimated Life Expectancy at Young Adult Follow-Up: The Role of ADHD Persistence and Other Potential Predictors. Journal of Attention Disorders, 23(9), 907-923. https://doi.org/10.1177/1087054718816164

But if you’ve tried some of these ADHD interventions with limited success and ended up feeling like you “failed” at treatment, rest assured that you did not -— and you’re not alone in feeling this way.

In ADDitude’s recent treatment survey, we asked 11,000 readers about their experiences with 10 different kinds of treatments for ADHD, from medication to meditation. Readers shared what worked and what didn’t, plus stories of how painful the process of finding effective treatment can be, especially for those with rejection sensitive dysphoria (RSD), perfectionism, or feelings of shame.

“I felt as though I flunked mindfulness because I couldn’t pay attention for that long!” said one ADDitude reader. Another shared: “I felt like I was failing in talk therapy when I couldn’t talk in straight lines or remember what I had just said.”

Robyn, an ADDitude reader in Canada, simply said, “I always feel like I’m failing.”

[Read: ADHD and the Epidemic of Shame]

Feelings of Failure, Easily Triggered and Intense

Many people are quick to blame themselves when supplemental therapies don’t work as rapidly or as well as they’d hoped. This instinct has everything to do with the wiring of the ADHD brain, explains Tamar Rosier, Ph.D., in the ADDitude article, “Silence Your Harshest Critic — Yourself.”

“Neurotypical people have prefrontal cortexes that act like a butler. ‘Sir,’ the butler calmly says, ‘your keys are on the table.’ Or ‘Madam, you must leave now if you want to be on time,’” Rosier explains. “Instead of a tranquil butler, individuals with ADHD have an angry neighbor threatening them with his shoe. ‘If you lose your keys again,’ he yells, ‘I’ll throw this at you!’”

Zak, an ADDitude reader in Florida has experienced this first-hand: “My doctor is still working with me to get the meds correct and I feel at times it’s my fault; that I am the one whose body is not adjusting.”

[Download: 2024 Scorecard of ADHD Treatments]

For many, these feelings of falling short or failing to meet expectations are amplified by RSD, which triggers intense emotional sensitivity and pain, explains William Dodson, M.D., LF-APA in “How ADHD Ignites Rejection Sensitive Dysphoria.” “For people with RSD, these universal life experiences are much more severe than for neurotypical individuals. They are unbearable, restricting, and highly impairing.”

This description resonates with ADDitude reader Calvin in Florida. “When I have tried things like mindfulness, exercise, or therapy, I have not had success and I just felt awful,” Calvin says. “I thought mindfulness might help to end the snow-piercer-like train that lives in my head, but instead I felt like a child unable to do a simple concept.”

In addition to the neuroscientific factors that play a role in triggering feelings of failure, a long history of negative experiences exerts a powerful force, says J. Russell Ramsay, Ph.D., ABPP, clinical psychologist.

“Adults with ADHD are often more susceptible to feelings of failure and defeatism when undertaking new endeavors,” Ramsay explains. “This is likely due to past experiences with setbacks, which often result in criticisms. This, in turn, makes adults with ADHD sensitive to the first signs that something seems to not be going well.”

Clinical psychologist Sharon Saline, Psy.D., agrees, adding: “These past struggles resemble a thousand paper cuts per day and accumulate over time into larger wounds which leave sensitive scars. Feelings of shame and not measuring up haunt folks and make it tougher to try new things.”

How to Reframe Feelings of Failure

Experts agree that to optimize treatment for ADHD, trial-and-error is essential. The “error” part of that process can be demoralizing, but it is critical. To discover interventions that work, you’ll have to try ones that don’t — and knowing that from the get-go can be helpful.

“It is important to normalize setbacks as a part of the process of establishing new habits. It is rarely, if ever, a straight line,” Ramsay says. “Reframing a new habit as a challenge or as an experiment is important, as is setting up realistic expectations.”

“I have a hard time planning and sticking to a good regular habit, like exercise and mindfulness meditation. I used to get so aggravated with myself, and feel helpless,” says an ADDitude reader. “My therapist has taught me to not make a big deal of it and simply get back on track.”

Fine-tuning the therapies, lifestyle changes, and medications that best address your particular constellation of symptoms — and dealing with the emotional fallout of that process — is hard work, make no mistake. You can make that hard work a little easier by being kind to yourself, says Saline.

“Treat yourself with compassion, understanding that change usually involves forward motion along with some backsliding,” Saline urges. “Stumbling, regrouping and trying again is part of living for everybody—ADHD or not.”

 Fear of Failure & Treatment: Next Steps

• Read: You Are Worthy of Self-Compassion – How to Break the Habit of Internalized Criticism
• Read: “My Fear of Failure Becomes Paralyzing Perfectionism”
• Free Resource: Understanding Rejection Sensitive Dysphoria

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Teenage girls who often ruminate exhibit patterns of brain activity different from their non-ruminative peers after encountering social rejection, according to new research published in Developmental Cognitive Neuroscience.¹ Increased activity was seen in the parts of the brain involved in developing self-concept, which researchers say suggests that ruminative teens internalize social rejection and integrate it into their view of themselves.

“Everyone experiences rejection, but not everyone experiences it in the same way,” explained Amanda Guyer, Ph.D., one of the study’s authors and associate director of the Center for Mind and Brain at the University of California at Davis. “Our results suggest that girls who tend to ruminate are experiencing more than just momentary sadness after rejection. They are deeply internalizing this negative feedback into their self-concept.”

The study, conducted by researchers at the UC Davis Center for Mind and Brain, involved 116 female participants, aged 16 to 19, who were asked to self-report their tendency to ruminate, defined by the study’s authors as engaging in repetitive, negative thought patterns. The participants were also asked to perform two tasks related to social selection. In their initial visit, participants viewed photos of 60 teens, and were prompted to select 30 they’d like to talk to online. At the follow-up visit, the teens were informed of which of those selected teens had chosen them, and which teens had not. While receiving this information, the teens received functional MRIs to measure blood flow and electrical activity in different areas of the brain.

Social Rejection Plus Rumination Impacts Self-Concept

The study showed that, among girls who ruminate, there was increased activity in the parts of the brain associated with developing one’s sense of identity and interpreting the intentions of others. This led researchers to conclude that ruminative teen girls tend to deeply reflect on the negative feedback of social rejection, incorporating it into their self-concept.

This type of emotional distress is frequently experienced by people with ADHD, among whom rejection sensitivity is common, and painful. “The emotional intensity of rejection sensitive dysphoria (RSD) is described by my patients as a wound.” explains William Dodson, M.D., in his ADDitude article “New Insights Into Rejection Sensitive Dysphoria.” “One-third of my adult patients report that RSD was the most impairing aspect of their personal experience of ADHD.”

The pattern of brain activity revealed in the study also helps explain why teen girls who ruminate are compelled to analyze peers’ behavior, particularly social rejection, which researchers say “aligns with high ruminators’ need to understand a situation and their propensity to ask ‘why’-type questions.”

Rumination Taxes Working Memory

The study also found that rumination caused increased activity in the parts of the brain associated with working memory. Researchers believe that because ruminative teen girls are using much of their working memory to revisit negative social feedback, it may be harder for them to perform cognitive tasks that demand working memory.

For individuals with ADHD, who frequently struggle with deficits in working memory, this may cause additional strain on already limited resources.

Impact of Rumination on Mental Health

By demonstrating the neurobiological basis of rumination and its relationship to rejection sensitivity, the study reveals the importance of equipping teen girls with strategies to decrease rumination.

Left unaddressed, rumination, which is more common among girls than boys, is associated with a higher incidence of many mental and behavioral health challenges. Previous research has demonstrated that rumination is a risk factor for:

• Depression and anxiety²
• Substance abuse ³
• Self-injury ⁴
• Disordered eating ⁵
• Sleep problems ⁶
• Aggressive behavior ⁷

Rumination Intervention Strategies

To avoid these negative outcomes, the study’s researchers stress the benefit of interventions that break the rumination cycle.

“Our study suggests that it can make a difference to reframe their [teens’] negative experiences in a way that makes them feel better afterward instead of worse,” said Guyer.

These strategies may be particularly important for individuals with ADHD, among whom patterns of negative thinking are common.

“Obsessing and ruminating are often part of living with ADHD,” explains ADHD coach Beth Main in her ADDitude article, “ADHD and Obsessive Thoughts: How to Stop the Endless Analysis.” “No matter how hard you try to ignore them, those negative thoughts just keep coming back, replaying themselves in an infinite loop.”

Rather than attempting to ignore ruminative thoughts, Main suggests the following strategies:

• Re-frame the experience: Cognitive reframing involves identifying familiar negative thought patterns, and then shifting the way situations, emotions or experiences are viewed.
• Repeat a mantra: Positive self-talk in the form of a short, repeated phrase with a positive message, like “I am worthy of love,” can counterbalance the negative self-talk to which ruminators are prone.
• Redirect focus elsewhere: Attention modification through a healthy dose of distraction can help break a negative loop, particularly if it’s something that demands your full attention. Activities involving exercise or being in nature can be especially therapeutic.

Sources

¹ Yoon L, Keenan KE, Hipwell AE, Forbes EE, Guyer AE. Hooked on a thought: Associations between rumination and neural responses to social rejection in adolescent girls. Dev Cogn Neurosci. 2023 Dec;64:101320. doi: 10.1016/j.dcn.2023.101320. Epub 2023 Oct 30. PMID: 37922608; PMCID: PMC10641579.
²K.A. McLaughlin, S. Nolen-Hoeksema, Rumination as a transdiagnostic factor in depression and anxiety, Behav. Res. Ther., 49 (3) (2011), pp. 186-193.
³A. Grierson, I. Hickie, S. Naismith, J. Scott. The role of rumination in illness trajectories in youth: linking trans-diagnostic processes with clinical staging models.
⁴J. Ying, J. You, S. Liu, R. Wu. The relations between childhood experience of negative parenting practices and nonsuicidal self-injury in Chinese adolescents: The mediating roles of maladaptive perfectionism and rumination
Child Abus. Negl., 115 (2021), Article 104992.
⁵L.M. Hilt, C.A. Roberto, S. Nolen-Hoeksema. Rumination mediates the relationship between peer alienation and eating pathology in young adolescent girls. Eat. Weight Disord. -Stud. Anorex., Bulim. Obes., 18 (3) (2013), pp. 263-267.
⁶Y. Li, S. Gu, Z. Wang, H. Li, X. Xu, H. Zhu, et al. Relationship between stressful life events and sleep quality: rumination as a mediator and resilience as a moderator. Front. Psychiatry, 10 (2019), Article 348.
⁷K.A. McLaughlin, S. Nolen-Hoeksema, Interpersonal stress generation as a mechanism linking rumination to internalizing symptoms in early adolescents, J. Clin. Child Adolesc. Psychol., 41 (5) (2012), pp. 584-597.

As someone who also feels emotions intensely (growing up, my parents called me Super Sensitive Sharon), I understand completely where you’re coming from when you question the validity of your feelings. When I have big feelings, I truly think that something is the matter with me. The typical thoughts in my head are, “What is wrong with me that I’m getting this upset? No one else seems to be reacting this way.” But as I’ve learned, and as I hope you’ll come to learn, there is nothing wrong with being sensitive. (It’s really helped me in my career as a psychologist.)

Your feelings are valid — RSD or not, neurotypical or not. You are entitled to have your emotions however you would like to have them. Is it true that your ADHD brain is wired to feel emotions more intensely? Yes. And we can’t talk about ADHD without bringing up emotional dysregulation, which also affects how you process emotions. It’s also the case that RSD makes it difficult to perceive responses neutrally; you may perceive injury or threat where there is none.

[Get This Free Download: Understanding Rejection Sensitive Dysphoria]

But penalizing yourself for feeling how you’re feeling is counterproductive. It’s much more helpful to normalize your feelings. More importantly, you can acknowledge your emotional reactions and still investigate them.

Checking in with a friend, partner, coach, therapist, or anyone who understands the type of brain that you have is a good, safe way to gauge your interpretation of a situation. Say, “This thing happened, and I’m not sure if I’m overreacting. What do you think in this situation? How would you feel if someone said this to you?” These conversations can help you reframe the situation. You may find that the remark someone directed at you was simply a thoughtless comment that bears no reflection on who you are. Or maybe the situation was that unfortunate; if that’s the case, focus on the fact that you survived it, and think about what you’ve learned from it.

Regardless of whether RSD is in the picture, I’d like to leave you with a parting thought by Maya Angelou: “You may not control all the events that happen to you, but you can decide not to be reduced by them.”

Your Feelings Are Valid: Next Steps

• Take This Self-Test: Rejection Sensitive Dysphoria Symptom Test for ADHD Brains
• Read: “I Can’t Handle Rejection. Will I Ever Change?”
• Read: How to Counteract Imposter Syndrome, Perfectionism, and RSD

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “RSD Toolkit: Strategies for Managing Your Sensitivities in Real Time” [Video Replay & Podcast #476] with Sharon Saline, Psy.D. which was broadcast on October 19, 2023.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Apparently not. “Only 27 likes?” my brain scoffed. My mother-in-law’s voice rang in my ears: “Your expectations are your worst enemy.” I hate it when she’s right.

The truth is that she’s going to be right as long as I have ADHD, which, unfortunately (but, also fortunately), will be always. Rejection sensitive dysphoria (RSD) exists, and learning about it for the first time as a clinical psychologist allowed me to better understand my patients and finally name one of the most perplexing aspects of my own ADHD. I understood why I couldn’t handle rejection in all forms, including the rejection that is baked into social media use.

I’ll admit that the time I spent off social media was incredible. The world looked and felt brighter and clearer when I finally put down the phone and took a look around. But after seven years, social media has called me back – a desire that has caused equal parts confusion and intrigue.

I’m not back for the likes or validation. I returned because, as a psychologist who specializes in working with children, teens, and young adults, I have something to say to youth struggling with mental health challenges today. I want to be there for them, and I cannot be heard or reach youth, I fear, without using social media.

[Read: Compare & Despair – Social Media & Mental Health Concerns in Teens with ADHD]

Since re-entering the social media sphere and navigating the sensory overload that is YouTube and TikTok (I’m @drgillykahn on both platforms) I’m taking note of the healthy social media habits that are keeping me balanced – habits that may help you use social media in a healthy way, too.

1. Ask yourself why you’re using social media. You’re more likely to have positive experiences with social media if you tie its uses to a concrete purpose or value – like staying in touch with people you care about. Notice how you feel as you visit platforms and consider if the benefits outweigh the costs. It may be time to limit your use or get off certain platforms completely if social media is encouraging compare and despair, keeping you up at night, and anxiously attaching you to your phone.

2. Stick it to The Man. Think of social media breaks as a way to stick it tor the corporate giants who use you as pawns for consumerism and data collection. That’s another reason to use social media with intention, not passively. In other words, use social media in the same way that it uses you. Joke’s on you, social media!

3. Don’t be afraid to create physical distance from your phone. I remember the good old days when we had a landline and had to sprint across the house to answer the phone. Nowadays, it’s like our phones are fused to our hands. Unless you have a valid reason for keeping your phone near you, keep it in your bag, in another room, or out of sight somehow. If you must, build up to keeping your device away in 30-minute increments. Take it a step further by disabling notifications.

[Read: “My Phone Was My Drug”]

4. Remind yourself that social media is not real life. If you catch yourself in an RSD or comparison spiral after spending time on social media, ride out the wave of your emotions and then remind yourself that a lot of what you see on these platforms is simply not representative of reality. There aren’t beauty filters to activate on the fly in real life, for one, and most people only post the good part of their days, not the boring or negative stuff. Also remember that the relative anonymity of the Internet often emboldens users to post mean comments; don’t let this skew your perception of how interactions actually work in the real world. Your emotional responses to negative experiences online are valid, but keep in mind that platforms are designed to raise the volume on entertainment and drama while often muting sensitivity to, well, rejection sensitivity.

5. Let RSD inspire your posts. Shake things up by showing the world that being vulnerable is acceptable and admirable. Our heightened sensitivities should be nothing to be ashamed of. Allow yourself to be yourself on social media and consider sharing your emotional experiences in the moment. Who knows, maybe you will help someone recognize RSD in themselves and encourage others to spread support and acceptance of big emotions as a pertinent and underrecognized aspect of ADHD.

Healthy Social Media Habits: Next Steps

• Read: Wasting Time on Social Media? 6 Ways to Stop ADHD Brains from Doom Scrolling
• Read: I Need a Digital Detox. How Do I Break a Social-Media Habit?
• Read: Can’t Stop Clicking? Here’s How to Beat “Infomania”

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Healthy friendships help people feel supported, provide a sense of belonging, and stave off loneliness. But for many neurodivergent adults, making and keeping friends is a lifelong challenge. They might overshare, struggle to fully listen, and experience social anxiety, all of which can lead to feelings of rejection. To try and avoid these feelings, many adults adopt people-pleasing behaviors or wall themselves off from others.

In this webinar, Caroline Maguire, M.Ed., will explain strategies to help adults with ADHD and co-existing conditions feel empowered, raise their levels of confidence, and understand the friendship strengths they have to offer. Learning how to stand up for yourself, set healthy boundaries, and speak from the heart are important skills in developing and maintaining friendships that are valued and healthy.

In this webinar, you will learn:

• Why neurodivergent adults often have a history of relationship struggles
• Why adults adopt people-pleasing behaviors and the consequences of these in friendships
• What healthy friendships look like and how to develop them
• How to identify when friendships aren’t healthy or equal
• How to be more authentic in your friendships

Watch the Video Replay

Enter your email address in the box above labeled “Video Replay + Slide Access” to watch the video replay (closed captions available) and download the slide presentation.

Download or Stream the Podcast Audio

Click the play button below to listen to this episode directly in your browser, click the  symbol to download to listen later, or open in your podcasts app: Apple Podcasts; Google Podcasts; Audacy; Spotify; Amazon Music; iHeartRADIO.

More on Adult Friendship and ADHD

• Download: Become a Small-Talk Superstar
• Read: “I’m Sorry — What Were You Saying?”
• Read: Where Does ‘Introvert’ End and Social Anxiety Begin?

Obtain a Certificate of Attendance

If you attended the live webinar on November 2, 2023, watched the video replay, or listened to the podcast, you may purchase a certificate of attendance option (cost: $10). Note: ADDitude does not offer CEU credits. Click here to purchase the certificate of attendance option »

Meet the Expert Speaker

Caroline Maguire, M.Ed, ACCG, PCC, earned a master’s degree at Lesley University with a specialization in social emotional learning (SEL). She is the author of the award-winning book, Why Will No One Play with Me? written to coach emotional regulation, social and self-awareness, and responsible decision-making skills. She founded The Fundamentals of ADHD Coaching for Families training program at the ADD Coach Academy which is accredited by ICF. Visit her website, CarolineMaguireAuthor.com, follow her @AuthorCarolineM and download her free video, How to Tell a Tighter Story.

Listener Testimonials

“This webinar was incredibly helpful, and I love how both relatable and insightful Caroline Maguire was.”

“Thank you for putting normalcy around this!”

“Wow, I learned so much about myself. This webinar brought to light some of the barriers I face that I didn’t even know were connected to ADHD! Thank you!”

“Loved this! I really needed to hear about the topic of friendship. I just turned 60 and have never been diagnosed but know without a doubt. I appreciate the speaker’s honesty and knowledge.”

Webinar Sponsor

The sponsor of this ADDitude webinar is…

Brain Balance is an integrative cognitive development program designed to help kids, teens and adults with ADHD, Learning Differences, Anxiety & beyond. An exploratory study with Harvard’s McLean Hospital found the Brain Balance Program to be as effective as low-dose stimulant medication in alleviating ADHD symptoms in children. Visit brainbalance.com to learn more about Brain Balance today.

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Do you ever feel so devastated by criticism or ‘constructive’ feedback that you shut down and recovery seems impossible? Is it overwhelmingly tough to rebound after feeling left out or saying something you regret? Rejection sensitivity dysphoria (RSD) is almost ubiquitous with ADHD, though it’s not included in the condition’s formal diagnostic criteria.

RSD refers to unbearable feelings of pain following an actual or perceived rejection. These intense feelings, directly related to emotional dysregulation, lead to an expectation that others will pull back their support, love, or respect. In this webinar, award-winning author, international speaker, and consultant Dr. Sharon Saline will show you how to manage the heightened emotional sensitivity that often accompanies ADHD. She will explore various treatment options and practical techniques for managing RSD in real time based on cognitive behavior therapy, positive psychology, and mindfulness.

In this webinar, you will learn:

• How rejection sensitive dysphoria manifests in adults and older teens with ADHD
• How to develop effective strategies for managing intense feelings of hurt and pain by improving emotional regulation skills
• How to identify triggers and bounce back from criticism and rejection by improving communication skills, relying on self-compassion, and shifting your mindset
• About practical tools for coping with heightened emotional sensitivity at work, with peers, and in intimate relationships
• About methods for overcoming limiting beliefs and behaviors based on cognitive behavioral therapy, positive psychology, and mindfulness
• How to build resilience and be prepared to face challenging situations with more confidence and competence

Watch the Video Replay

Enter your email address in the box above labeled “Video Replay + Slide Access” to watch the video replay (closed captions available) and download the slide presentation.

Download or Stream the Podcast Audio

Click the play button below to listen to this episode directly in your browser, click the  symbol to download to listen later, or open in your podcasts app: Apple Podcasts; Google Podcasts; Audacy; Spotify; Amazon Music; iHeartRADIO.

More on RSD and ADHD

• Download: Understanding Rejection Sensitive Dysphoria
• Read: Challenging the Fallacy of “Not Good Enough”
• Read: Rejection Sensitivity Is Worse for Girls and Women with ADHD

Obtain a Certificate of Attendance

If you attended the live webinar on October 19, 2023, watched the video replay, or listened to the podcast, you may purchase a certificate of attendance option (cost: $10). Note: ADDitude does not offer CEU credits. Click here to purchase the certificate of attendance option »

Meet the Expert Speaker

Sharon Saline, Psy.D., clinical psychologist and author of the award-winning book, What Your ADHD Child Wishes You Knew: Working Together to Empower Kids for Success in School and Life and The ADHD Solution Deck. (#CommissionsEarned) She specializes in working with children, teens, emerging adults and families living with ADHD, anxiety, learning disabilities, autism, twice exceptionality and mental health issues. Her unique perspective, as a sibling in an ADHD home, combined with decades of experience as a clinical psychologist and educator/clinician consultant, assists her in guiding families and adults towards effective communication and closer connections. She lectures and facilitates workshops internationally on topics such as understanding ADHD, executive functioning, anxiety, motivation, different kinds of learners and the teen brain.

#CommissionsEarned As an Amazon Associate, ADDitude earns a commission from qualifying purchases made by ADDitude readers on the affiliate links we share. However, all products linked in the ADDitude Store have been independently selected by our editors and/or recommended by our readers. Prices are accurate and items in stock as of time of publication.

Listener Testimonials

“Fantastic seminar. Will be watching it again with my whole family.”

“This felt like someone scooped out my brain and put it in a slide deck. So insightful.”

“Thank you all for talking about RSD. It’s so validating to hear that I’m not alone and to get more information and knowledge surrounding this debilitating symptom.”

“I don’t miss any presentation Dr. Sharon provides; she is a huge asset to the ADDitude community. ”

Webinar Sponsor

The sponsor of this ADDitude webinar is….

Inflow is the #1 app to help you manage your ADHD. Developed by leading clinicians, Inflow is a science-based self-help program based on the principles of cognitive behavioral therapy. Join Inflow today to better understand & manage your ADHD.

ADDitude thanks our sponsors for supporting our webinars. Sponsorship has no influence on speaker selection or webinar content.

Follow ADDitude’s full ADHD Experts Podcast in your podcasts app:
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If someone doesn’t value spending time with me as much as I value spending time with them, I feel rejected. Last month, I said to one of my closest friends that I would like to hang out with him more like we used to. He said that he was cool with the way things are. This hurts a lot. What can I do to make this less painful?”

When teens with ADHD struggle with rejection sensitive dysphoria, it affects their relationships — and their self-esteem. Often, they don’t know how to cope with their intense emotions and, feeling overwhelmed, they may lash out at friends and/or family members.

[Read: Why ADD Makes You Feel. So. Much.]

One of my teen clients told me: “When I come home from school, sometimes I just can’t hold it all together. I yell at my mom and then I feel bad afterward, but I know that I can’t get kicked out of my family.” Other kids will withdraw quietly into their rooms and swallow their pain. As parents, there’s a fine line between supporting your adolescent in managing their big feelings and intervening to diminish their distress.

While some ADHD non-stimulant medications or antidepressants, such as SSRIs, can reduce sensitivity and overwhelm, the following behavioral tools can be very effective to quiet the inner critic, shift perspectives, and develop self-confidence.

Sharon Saline, Psy.D., a licensed clinical psychologist, is an expert in how ADHD, learning disabilities, and mental health issues affect children, teens, and families. She is the author of What Your ADHD Child Wishes You Knew.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Social anxiety is a debilitating fear of judgment, humiliation, or rejection by others in social situations. Socially anxious adults carry distorted, negative self-perceptions driven by a core belief of deficiency. This restricts their participation in activities, relationships, and other areas of life.

We know that anxiety and ADHD frequently co-occur. Experiences common to ADHD, like rejection sensitive dysphoria, shame, and emotional dysregulation, may exacerbate social anxiety. ADHD symptoms, like hyperactivity and inattention, may also undermine social skills and cause difficulties. Social anxiety treatment often involves behavioral interventions and working to improve social skills.

Signs of Social Anxiety

Intense fear of negative judgment from others is a common marker of social anxiety disorder. Other signs include:

• Discomfort interacting with people outside the immediate family
• Difficulty making or keeping friends
• Excessive worry in the days or weeks leading up to an event
• Fear of being observed (e.g., when eating and drinking)
• Fear of performing in front of others
• Avoiding places or events that involve socializing
• Nausea, shaking, or excessive perspiration in social environments

Fear, anxiety, or avoidance of social situations must cause clinically significant impairment and persist for at least six months to merit a diagnosis.

[Self-Test: Does My Child Have Generalized Anxiety Disorder?]

Social Anxiety Treatment: Behavioral Interventions

Cognitive behavioral interventions effectively target the distorted thoughts that fuel social anxiety. Medication for anxiety may help, but as with ADHD, pills don’t teach skills. To cope with social anxiety, find ways to reduce your worries.

1. Shift your thinking. Identify limiting core beliefs and notice negative self-talk. What social situations trigger those thoughts and worries?
2. Recall positive social experiences. Anxiety erases memories of courage and success. Think back to times when you rose to a challenge despite your fears. What steps did you take?
3. Stay in the moment. Show curiosity about others and practice reflective listening, such as nodding. Notice your surroundings. Take deep breaths to quell physical symptoms.
4. Build up tolerance. Gradually expose yourself to low-risk, uncomfortable social situations. Join a hiking group, for example, and smile at a few new faces. On the second hike, talk to a few people. You might feel awkward and nervous, but you’ll see that you’ve survived.
5. Foster connection. Pay attention to body language that signals interest (like a relaxed posture) versus discomfort (looking away). Ask open-ended questions to encourage conversation and let others know that you’re listening.

[Download: Social Anxiety Facts and Falsehoods]

Improve Social Skills with an APPLE

To navigate social situations:

• Ask to join in a conversation.
• Physical proximity and volume. Are you too close? Too loud?
• Participate with curiosity. Use reflective statements and ask open-ended questions.
• Listen and lay off the self-criticism.
• Enjoy connection. Share what’s special and fun about you.

Social Anxiety in Children: Next Steps

• Download: Get a Grip on Tough Emotions
• Watch: Anxiety in Children: Overlooked Signs and Effective Supports
• Read: How Can I Help My Son Overcome Social Anxiety?

Sharon Saline, Psy.D., a licensed clinical psychologist, is an expert in how ADHD, learning disabilities, and mental health issues affect children, teens, and families. She is the author of What Your ADHD Child Wishes You Knew.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

• The ability to inhibit inappropriate responses triggered by strong emotions
• The ability to self-soothe to reduce the severity of an intense emotion
• The ability to refocus attention from emotionally provocative events
• The ability to substitute healthier responses in the interest of long-term welfare

Though it’s not included in the condition’s DSM-5 criteria, DESR and emotional impulsivity are fundamental components of ADHD that shape an individual’s experiences and challenges throughout their lifetime.

Because DESR is a novel concept to many, questions abound. Below, I answer several posed during my recent ADDitude webinar titled “Deficient Emotional Self-Regulation: The Overlooked ADHD Symptom That Impacts Everything.”

Q: Does emotional dysregulation change over time? Does it ever improve?

Emotional dysregulation does change and it can improve, but it depends on the individual and the factors involved. For instance, emotional self-regulation is rarely elevated as an issue in toddlers. We don’t expect 4-year-olds to manage their emotions very well. Parents are typically more concerned with the impulsive aspect of emotion at this stage.

But by the time we get into late adolescence, and especially adulthood, we do expect individuals to have developed that second stage of emotional control: top-down executive management (or moderating emotional reactions to evocative events). However, DESR impairs just that —processes related to emotional self-regulation. And that leads to more disparaging moral judgment about adults with ADHD than it would in much younger individuals.

It’s almost like the two components of this emotion problem in ADHD — emotional impulsivity (EI) and DESR — trade places as individuals age. The former is more problematic in children, while the latter becomes a more compelling deficit for the adult individual.

[Get This Free Download: 5 Emotional Control Strategies for Kids with ADHD]

We also know that ADHD symptoms fluctuate over time for many individuals, which may mean that issues like emotional dysregulation also change in severity or degree of impairment. And keep in mind that ADHD mostly persists to some degree from childhood to adulthood for 90% of people.

But can emotional regulation be “trained?” In children, the chances of that are quite slim because they haven’t yet developed the appropriate self-regulation skills that such training would require. Interventions like medication, parent training, and controlling for environmental triggers may be most helpful for this stage. Adults, however, may benefit from cognitive behavioral therapy (CBT) and mindfulness-based programs especially reformulated for adult ADHD in recent books, both of which help the individual deal with many aspects of emotional dysregulation.

Q: Do men and women with ADHD experience emotional dysregulation differently?

Generally, we know that males are more prone to exhibit aggression and hostility, which are associated with externalizing disorders, while females are more prone to anxiety and mood disorders. Both, however, do struggle with impatience and frustration, and the emotional dysregulation component in ADHD will only exacerbate that.

Q: When might DESR symptoms start to appear in children?

DESR usually appears between ages 3 and 5, though it may be quite obvious in a younger child who is significantly hyperactive and impulsive. Still, many families write off this behavior, believing it to be developmentally normal (i.e. the terrible twos), only realizing later on that the child is quite hot-headed and emotional compared to peers. Some of these children will go on to develop oppositional defiant disorder (ODD). If we accept DESR as a core feature of ADHD, we can see why the disorder poses such a significant risk for ODD and related disorders.

[Read: Why Is My Child So Angry and Defiant? An Overview of Oppositional Defiant Disorder]

Q: Can parents manage DESR in children with ADHD without medication?

It will be very, very difficult to do so. With ADHD in children, we’re looking at a dysregulated brain with a highly variable, immature executive circuitry — part of which includes this problem with emotional expression and regulation. To expect to try to find some other social or psychological intervention that can change that underlying neural network problem is asking for too much of psychotherapy. It may be best to work with the aforementioned interventions as parents await the greater maturity of these neurological systems that comes with further development.

Q: Is there residual emotional difficulty in children and adults even after taking ADHD medication?

Yes — sometimes medications can create their own problems. Stimulants, for example, may create emotional blunting, which is the absence of natural emotion in some children or adults. As stimulants wear off, it’s not uncommon for the emotional brain to go through a rebound. In some cases, that may look like irritability, a proneness to weepiness or crying, and sadness.

These experiences with stimulants are not universal, but remember that you’ve been suppressing an emotional brain and, as medication wears off, that could come to the fore. We don’t see this issue with non-stimulants so much because they’re not suppressing the emotional circuitry of the brain. Ultimately, each drug works on the brain a little differently, and therefore works on emotion a little differently. It’s why some clinicians sometimes opt to combine these medications to get much broader coverage over patient symptoms than any single drug could do alone.

Q: You noted that a parent’s own ADHD symptoms could exacerbate their child’s symptoms and thus make emotional dysregulation worse. Can you give some examples?

Let’s say a child is engaging in some defiant, oppositional behavior. A parent with ADHD may experience a much stronger reaction to that compared to a typical parent. They might exhibit a more impulsive reaction of anger or hostility toward the child, or they may arrive at that level of emotional upset faster than would a parent without ADHD.

When a parent exhibits these behaviors, they are, in effect, modeling these reactions to their child. They are also provoking the child, who has their own emotional regulation problems. What you have, I think, is an emotional tornado in the family — each person is triggering the other to higher levels of conflict.

Q: Does trauma exacerbate DESR? What about PTSD?

It’s bi-directional. Research suggests that ADHD, because of the emotional dysregulation factor, especially, puts children at a higher risk for exposure to trauma. And once trauma has occurred in a child with ADHD, it’s more likely to progress to a PTSD reaction. This is why ADHD is one of the strongest predictors of who will develop PTSD if exposed to trauma. Once PTSD develops, it will only worsen existing emotional regulation problems.

Q: Is it ever too late to get help for emotional dysregulation?

Absolutely not. It is never too late to get help for ADHD and its symptoms, even if emotional dysregulation has been an impairing factor for a long time. Multiple studies show that a diagnosis in late life and subsequent treatment only benefits the individual.

DESR and Emotional Dysregulation: Next Steps

• Free Download: 9 Truths About ADHD and Intense Emotions
• Read: How’s Your Emotional Resilience? Learning to Cope with Intense ADHD Feelings
• Read: The ADHD-Anger Connection: New Insights into Emotional Dysregulation and Treatment Considerations

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What is DESR?

Deficient emotional self-regulation (DESR) is a relatively new term used to describe the problem of impulsive emotion coupled with emotional self-regulation difficulties — issues long associated with attention deficit hyperactivity disorder (ADHD or ADD). DESR may be new to the ADHD lexicon, however I argue that it is a core and commonly overlooked component of the disorder — and one that can help predict a patient’s impairments, and even improve diagnostic and treatment practices.¹

Emotional dysregulation is noticeably missing from diagnostic criteria for ADHD. However, most patients and experts recognize that it is central to the disorder². DESR, a manifestation of emotional dysregulation, specifically refers to deficiencies with these four components of emotional self-regulation³:

• Ability to inhibit inappropriate behavior triggered by strong emotions. I argue that this emotional impulsiveness (EI) is an aspect of poor inhibition associated with ADHD that is illustrated by low frustration tolerance, impatience, being quick to anger, aggression, greater emotional excitability, and other negative reactions, all of which are related to the impulsivity dimension of the disorder
• Ability to self-soothe and down-regulate a strong emotion to reduce its severity
• Ability to refocus attention from emotionally provocative events
• Ability to organize or substitute more moderate, healthier emotional responses in the service of goals and long-term welfare

To understand the role of EI and DESR in ADHD is to acknowledge the prominent role of emotional control difficulties in the disorder’s appearance and outlook, including understanding the following:

• Why these issues are prevalent in individuals with ADHD
• Why major comorbid disorders often develop as a result of these challenges
• The major life impairments not adequately explained by traditional symptoms of ADHD

A wealth of compelling evidence — from ADHD’s clinical conceptualization over time to neuroanatomical and psychological research — clearly shows that EI and DESR are key components of ADHD and should be incorporated into the disorder’s diagnostic criteria and treatment practices.

[Free Download: 15 Ways to Disarm (and Understand) Explosive ADHD Emotions]

EI and DESR: Evidence of Its ADHD Ties

1. EI and DESR in Historical Concepts of ADHD

Conceptualizations of ADHD have included emotional control problems for centuries. One of the earliest references to attention disorder in western medical literature⁴, a textbook written by German physician Melchior Adam Weikard in 1770, characterizes those who have a “lack of attention” as “unwary,” “flighty,” “careless,” mercurial,” and “bacchanal.”

EI and DESR through history⁴:

• 1798: Alexander Crichton, a Scottish-born physician, includes emotional frustration in his description of disorders of attention, especially problems with persistent attention
• 1902: George Still, a British physician widely considered to be the “founder” of ADHD, includes emotional impulsiveness and poor regulation of emotions in his conceptualization of “defective moral control of behavior” (the precursor to ADHD)
• 1960s-1970s: Major clinical researchers at the time — including Mark Stewart, Dennis Cantwell, and Paul Wender — include emotion as a core feature in their concepts of “hyperactive child syndrome (now ADHD).”

So why isn’t emotion considered in the diagnostic criteria for ADHD today?

• 1968: DSM-II references ADHD for the first time (as hyperkinetic impulse disorder) but fails to list EI or DESR as a feature of the disorder. It is excluded from all future DSMs, for unknown reasons, despite continuing research linking emotion to ADHD.

2. EI and DESR and the Neuroanatomy of ADHD

The brain structures and networks implicated in ADHD are also involved in emotion and would thus logically be expected to give rise to EI and DESR and be part of the disorder.
The frontal lobe, the anterior cingulate, the ventral striatum, and the amygdala all comprise the executive circuitry that has been repeatedly shown to be involved in causing ADHD². Some of these structures also form the brain’s emotional circuitry — the amygdala and larger limbic system to which it is connected is where emotion is generated, and the prefrontal cortex and related structures attend to these generated emotions. Thus, how we feel also influences how we think, and the dorsolateral PFC is where some thinking occurs, as well as working memory (or what we are holding in mind).

[The ADHD-Anger Connection: New Insights into Emotional Dysregulation]

3. EI and DESR in Neuropsychological Theories of ADHD

The frontal-limbic circuit — one of the four executive networks of the brain — is associated with ADHD and with symptoms of emotional dyscontrol, motivation deficits, hyperactivity-impulsivity, and aggressive tendencies. This emotional regulation network is also known as the “hot” circuit. I also refer to it as the “why” circuit, because it’s absolutely crucial in decision making.

This network is also connected to the other executive networks that we know are implicated in ADHD. ADHD, of course, would be expected to disrupt this emotional regulation network substantially.

4. EI and DESR in ADHD Psychological Research

Emotional self-regulation is a major dimension of executive functioning required for daily life activities. It is also one of the most impaired dimensions in children and adults with ADHD^{5 6}. Ample evidence from an abundance of psychological research shows that children and adults with ADHD are highly likely to manifest EI-DESR² including low frustration tolerance⁷, anger, poor inhibition of emotion, and emotional excitability^{8 9}.

Additional research on EI-DESR and ADHD:

• Meta-analysis: Emotional dysregulation is a core feature of ADHD’s psychopathology in adults¹⁰
• Developmental studies on preschool children find that negative temperament, irritability, and poor emotional regulation are strong predictors for ADHD later in life^{11 12}
• Studies on family genetics and ADHD show that the genes implicated in ADHD are also responsible for associated emotional problems¹³

5. EI and DESR Underpinning ADHD Comorbidities

Putting impulsive emotion and emotional self-regulation problems back into the realm of ADHD also helps us understand the basis for several of the comorbid conditions commonly associated with ADHD, especially that of oppositional defiant disorder (ODD)¹⁴.

ODD is two-dimensional, comprising aspects of social conflict and emotion dysregulation. These two dimensions significantly contribute to the risk for later disorders. The emotional dimension, for example, in children contributes to the later risk for anxiety and mood disorders in teens.

Given ADHD’s prevalence in ODD, we can assume that the emotional component of ODD arises biologically from ADHD. That is, ADHD likely creates one of the two dimensions involved in ODD. Indeed, the longer ADHD goes untreated and emotions remain dysregulated, the greater the odds that comorbid conditions, particularly anxiety disorders, will develop¹⁵. This framework helps us understand why emotion and ODD are managed so well by ADHD medication, but only if ADHD is also present¹⁶.

Meanwhile, the social component of ODD predicts later conduct disorder and antisocial behavior. This component of ODD, contrary to the biological aspect of emotionality, is likely learned, most often within family interactions.

6. EI and DESR and Impairment in Major Life Activities

Centering the role of emotion in ADHD predicts a variety of impairments that are not similarly associated with the traditional symptoms of ADHD: hyperactivity, inattention, and/or impulsivity.

Emotional dysregulation has been shown to uniquely predict the following⁶

• social rejection in children with ADHD
• interpersonal hostility and marital dissatisfaction in adults with ADHD
• greater parenting stress and family conflict in parents of children with ADHD; greater stress in parents with ADHD
• road rage, DUIs, and crash risks during driving
• job dismissals and workplace interpersonal problems
• dating/cohabiting relationship conflict
• impulse buying; poor finances

EI and DESR: Diagnostic Implications

Elevating EI-DESR’s place in ADHD would greatly assist with differential diagnosis of the disorder from mood disorders and other conditions involving emotional dysregulation. In other words, it would reduce the odds of misdiagnosis for patients who are simply experiencing what is central to ADHD itself. (Individuals with ADHD are commonly misdiagnosed with mood disorders.¹⁷)

Mood disorders, however, are common in individuals with ADHD, so comorbidity must be considered¹⁸. Duration could be a guiding diagnostic principle used to distinguish a legitimate mood disorder from the emotional dysregulation associated with ADHD. Emotions, unlike moods, are of short duration, setting-specific, provoked, and easily traced to the source. EI-DESR is a “top-down” deficit in regulating rational emotional responses to events; its impact is typically shorter in duration than that of a mood disorder.

Mood disorders are generally “bottom-up” excessive expressions of emotions likely attributed to underlying amygdala-limbic system activities. Moods are of long duration — lasting hours, days, or weeks. Moods are cross situational, and irrational in the case of mood disorders (it is often not clearly understood, for example, what triggers a patient with bi polar disorder to become manic, or the opposite).

EI and DESR: Treatment Considerations

Re-centering ADHD on emotions also helps us understand treatment outcomes. It’s why we often observe that ADHD medications impact core EI and DESR problems in patients with ADHD, albeit in different ways¹⁹. Stimulants appear to quell and even dampen the limbic system, sometimes leading to complaints from patients about having robot-like, bland emotions. Non-stimulants like atomoxetine, on the other hand, act on a different part of the brain. They help to up-regulate the executive brain, giving patients more self-control of emotion. Prescribers sometimes utilize different drug combinations to allow patients more control over ADHD, including emotional problems.

Other treatment implications:

• Secondary impairments from EI-DESR on major life activities may also be improved by ADHD medication.
• Cognitive behavioral therapy (CBT) programs that target EF deficits, along with mindfulness-based approaches, might help with emotional regulation in adults with ADHD, especially if they are taking ADHD medication.
• In children, emotional dysregulation is better handled through medication and then, to some extent, through behavioral parent training programs that focus on restructuring situations and interactions so as not to trigger strong impulsive emotions.
• Parental ADHD could contribute to emotional dysregulation in children with ADHD, not just genetically through inheritance, but through modeling of poor emotional control and by engaging in emotionally provocative encounters with the child. Clinicians should screen parents for ADHD and treat their symptoms as well.

EI and DESR: Conclusions

Impulsive emotion and emotional dysregulation are core facets of ADHD. Impulsive emotion is linked to the impulsivity dimension of ADHD, and difficulties with emotional control is part of the large inattentive/executive dimension of ADHD. Historical concepts of ADHD include EI-DESR, and research in the fields of neuroanatomy, neuropsychology, and psychology also link ADHD to EI and DESR. This core relationship may help to explain, at least in part, why the disorder poses high risk for ODD and mood disorders, as well as the unique impairments some patients experience.

By recognizing that EI and DESR are involved in ADHD, we can significantly improve diagnostic and treatment practices.

DESR and EI with ADHD: Next Steps

• Essential Reading: New Insights Into Rejection Sensitive Dysphoria
• Free Download: 9 Truths About ADHD and Intense Emotions
• Read: Why We Feel So Much — and Ways to Overcome It
• Read: Learning to Cope with Intense ADHD Feelings

The content for this article was derived from the ADDitude Expert Webinar Deficient Emotional Self-Regulation: The Overlooked ADHD Symptom That Impacts Everything [Video Replay & Podcast #369] with Russell Barkley, Ph.D., which was broadcast live on August 26, 2021.

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Sources

¹Barkley, R. A. (2015). Emotional dysregulation is a core component of ADHD. In R. A. Barkley (Ed.), Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (pp. 81–115). The Guilford Press.

²Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014). Emotion dysregulation in attention deficit hyperactivity disorder. The American journal of psychiatry, 171(3), 276–293. https://doi.org/10.1176/appi.ajp.2013.13070966

³Koole, S. et.al. (2011). The self-regulation of emotion. In Vohs, K., Baumeister, R. (Eds).Handbook of self-regulation, second edition: research, theory, and applications.(pp 22-40). Guilford Press.

⁴Barkley, R. A., & Peters, H. (2012). The earliest reference to ADHD in the medical literature? Melchior Adam Weikard’s description in 1775 of “attention deficit” (Mangel der Aufmerksamkeit, Attentio Volubilis). Journal of attention disorders, 16(8), 623–630. https://doi.org/10.1177/1087054711432309

⁵Barkley, R. A. (2012). The Barkley Deficits in Executive Functioning Scale: Children and Adolescents.New York: Guilford Press.

⁶Barkley RA, Fischer M. The unique contribution of emotional impulsiveness to impairment in major life activities in hyperactive children as adults. Journal of the American Academy of Child & Adolescent Psychiatry. 2010;49(5):503–513.

⁷Seymour, K. E., Macatee, R., & Chronis-Tuscano, A. (2019). Frustration Tolerance in Youth With ADHD. Journal of attention disorders, 23(11), 1229–1239. https://doi.org/10.1177/1087054716653216

⁸Jensen, S. A., & Rosén, L. A. (2004). Emotional reactivity in children with attention-deficit/hyperactivity disorder. Journal of attention disorders, 8(2), 53–61. https://doi.org/10.1177/10870547040080020.

⁹Barkley, R. A. & Murphy, K. R. (2011). Deficient emotional self‐regulation in adults with ADHD: The relative contributions of emotional impulsiveness and ADHD symptoms to adaptive impairments in major life activities. Journal of ADHD and Related Disorders, 1(4), 5‐28.

¹⁰Beheshti, A., Chavanon, M. L., & Christiansen, H. (2020). Emotion dysregulation in adults with attention deficit hyperactivity disorder: a meta-analysis. BMC psychiatry, 20(1), 120. https://doi.org/10.1186/s12888-020-2442-7

¹¹Dougherty, L. R., Smith, V. C., Bufferd, S. J., Kessel, E., Carlson, G. A., & Klein, D. N. (2015). Preschool irritability predicts child psychopathology, functional impairment, and service use at age nine. Journal of child psychology and psychiatry, and allied disciplines, 56(9), 999–1007. https://doi.org/10.1111/jcpp.12403

¹²Vogel, A. C., Jackson, J. J., Barch, D. M., Tillman, R., & Luby, J. L. (2019). Excitability and irritability in preschoolers predicts later psychopathology: The importance of positive and negative emotion dysregulation. Development and psychopathology, 31(3), 1067–1083. https://doi.org/10.1017/S0954579419000609

¹³Merwood, A., Chen, W., Rijsdijk, F., Skirrow, C., Larsson, H., Thapar, A., Kuntsi, J., & Asherson, P. (2013). Genetic association between the symptoms of attention‐deficit/hyperactivity disorder and emotional lability in child and adolescent twins. Journal of the American Academy of Child and Adolescent Psychiatry, 53(2), 209‐220.

¹⁴Connor, D. Steeber, J. et.al.(2010) A review of attention-deficit/hyperactivity disorder complicated by symptoms of oppositional defiant disorder or conduct disorder. Journal of Developmental & Behavioral Pediatrics, 31(5), 427-440. doi: 10.1097/DBP.0b013e3181e121bd

¹⁵Geffen, J., & Forster, K. (2018). Treatment of adult ADHD: a clinical perspective. Therapeutic advances in psychopharmacology, 8(1), 25–32. https://doi.org/10.1177/2045125317734977

¹⁶Newcorn, J. H., Spencer, T. J., Biederman, J., Milton, D. R., & Michelson, D. (2005). Atomoxetine treatment in children and adolescents with attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 44(3), 240–248. https://doi.org/10.1097/00004583-200503000-00008

¹⁷Ginsberg, Y., Quintero, J., Anand, E., Casillas, M., & Upadhyaya, H. P. (2014). Underdiagnosis of attention-deficit/hyperactivity disorder in adult patients: a review of the literature. The primary care companion for CNS disorders, 16(3), PCC.13r01600. https://doi.org/10.4088/PCC.13r01600

¹⁸Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC psychiatry, 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3

¹⁹Schulz, K. P., Fan, J., Bédard, A. C., Clerkin, S. M., Ivanov, I., Tang, C. Y., Halperin, J. M., & Newcorn, J. H. (2012). Common and unique therapeutic mechanisms of stimulant and nonstimulant treatments for attention-deficit/hyperactivity disorder. Archives of general psychiatry, 69(9), 952–961. https://doi.org/10.1001/archgenpsychiatry.2011.2053

Maybe it sounds strange to label my diagnosis as a good thing. But it is – because knowing that I have an ADHD brain explains so much about my life and my experiences that previously didn’t make sense. My diagnosis was like a blurry lens suddenly coming into focus.

It was a long, four-year journey from thinking I could have ADHD to finally getting an official diagnosis. Learning about RSD was actually one of the first dominos to fall.

You see, I had spent nearly 40 years unknowingly masking and compensating for what I now know are ADHD symptoms. As I had done all my life, I felt I could continue to learn new strategies to work with time blindness, executive dysfunction, and other issues. But something was amiss – the emotional component seemed to be getting worse, not better, with age.

As I researched ADHD and intense emotions during those pre-diagnosis years, I learned that guanfacine and clonidine, both blood-pressure medications, are sometimes used to treat RSD symptoms in ADHD patients. And as I learned about people’s experiences on these medications and how their emotional symptoms dissipated, I thought, That’s what I want.

[Read This: New Insights Into Rejection Sensitive Dysphoria]

The Rejection Sensitive Dysphoria Experience

For anyone who doesn’t experience RSD, let me try to describe it.

Let’s say I read something directed toward me that isn’t really a rejection or criticism, but feels like it could be. Before I can even think, my guts immediately feel like they are in a giant blender. My veins feel like they are on fire. Then, my brain clicks into full panic mode, spinning scenarios about how the person on the other end of the message doesn’t like me. My brain then decides that no one, in fact, likes me.

Even if I know these thoughts to be objectively false, I worry that they could be true. The episode comes on quickly, and it consumes my entire day. Efforts to “calm down” barely seem to make a dent.

It’s not that people with RSD want to feel this way. It very much feels out of our control, which is why it’s frustrating to hear advice like, “Everyone is in control of their feelings.” That’s just not true for those of us with RSD, and for many other people with the emotional dysregulation associated with ADHD.

[Click to Read: Shame – The Devil on My Shoulder]

Besides, my reactions feel valid to me. They are an appropriate response to the situation, according to my brain in that moment.

I think of RSD and emotions like tsunamis versus regular waves. If you are neurotypical, the waves in your emotional sea could be calm, or choppy, or even harrowing. But, for the most part, you can ride out the waves, maybe even swim or play or surf on them.

With RSD, you have a fairly calm sea interrupted by frequent tsunamis. They come on suddenly, without warning, triggered by things you cannot control. And once you realize what’s about to happen, you have two choices – get out of Dodge, or stay and risk drowning. Either way, you are displaced, and left to deal with the destruction left behind. 

Plus, no one ever talks about controlling a tsunami.

Coming to Terms with Rejection Sensitive Dysphoria

Despite all the problems inherent to RSD, it is not the worst thing in the world, even when I believe it to be in the moment. Just as a force of nature can be powerful and destructive, RSD can also bring me to my knees in awe and wonder. It feels amazing and special to be able to contain such enormous, intense feelings – and come out on the other side.

I’ve also realized that it’s not me who feels most uncomfortable with RSD – it’s those around me. For them, it would be easier if I could just make my feelings “smaller.” But I don’t always have that option. Over the years, RSD has wreaked havoc on my relationships — friendships, family, and even professional connections. The memories and the losses are painful to think about.

Thankfully, guanfacine has been an absolute game-changer for my RSD.

Nothing changed overnight, but slowly I noticed that situations and remarks that normally would have sent me over the edge were not doing so. I was perceiving them as neutral.

Don’t get me wrong – I still feel the pain sometimes. It’s just not as excruciating.

Is this how “normal” people feel all the time? Who knew! No wonder they were so confused by me before.

But also, how sad. How much of my life have I spent feeling physically ill and mentally anguished over situations that perhaps were not as threatening as they seemed to be? How many of us have endured “helpful” critiques about controlling feelings — ones that suggested our reactions were a personal failing — when we weren’t failing at all? We were doing the best we could.

Now that I am starting to see RSD in the rearview mirror, I feel grateful that I have a little bit of extra mental space, the “spoons” to deal with the challenges in my life. But at the same time, I can look back and feel grateful for my RSD.

I was blessed with an immense capacity for feeling, and I love that. It has made me a stronger person, a more empathic person. Though the painful moments were plentiful, I can’t deny that those powerful feelings probably steered me away from situations that were not beneficial to me in the long run.

Ultimately, I know that what might have appeared like “weakness” to some was actually, all along, my greatest source of strength.

ADHD Rejection Sensitive Dysphoria: Next Steps

• Self-Test: Could You Have Rejection Sensitive Dysphoria?
• Download: Understanding Rejection Sensitive Dysphoria
• Read: Why ADD Makes You Feel. So. Much.

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Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Academia is founded on criticism. A crucial and unavoidable part of this process is receiving feedback from my committee. So, I recently sent out an email requesting necessary revisions so I can be done with this. This is time-sensitive stuff. To defend my dissertation this semester, and avoid additional financial expense, I have to implement the feedback to get the project ready for defense. So, when responses to my email started coming in, I hurried to open them so I could see what my mentors said.

Not really. I was terrified of the content of those emails. Despite my intense desire to complete my degree and the ticking clock on defending this semester, I spent hours, if not days, working up the nerve to read what my advisors think of my work. This was followed by hours, if not days, of recovering from the criticism they provided, no matter how constructive, no matter how kindly it may have been offered.

The Surprise of RSD

When I started the Ph.D. program, I assumed that the forgetful, inattentive aspect of my ADHD would be the most difficult part to overcome. And it has been difficult — sitting through classes, reading boring books, and consistently attaining and maintaining a level of focus and concentration necessary for this work. But I’ve spent the last 15 to 20 years developing strategies to overcome these challenges of ADHD. So instead, my greatest challenge is something I didn’t know existed until a couple years ago: Rejection Sensitive Dysphoria (RSD), the intense emotional discomfort and pain I feel due to criticism or rejection (perceived or real) from others.

RSD is a disabling feature of ADHD. Like all other aspects of ADHD, it’s a feeling that everyone feels at various times. Yet the frequency, and intensity of these feelings, separate these feelings from typical responses to perceived rejection. It is difficult to find words to describe the intense emotional discomfort that rejection or criticism produce. As with much of my experience with ADHD, it is when I research and see how intensely this can affect people that I realize how fortunate I am to experience a version of it that is manageable.

[Do I Have Rejection Sensitive Dysphoria? Take This Test]

The Pain of RSD

Almost all teens and adults with ADHD are more sensitive than others to perceived criticism, and nearly a third report that this is the most difficult aspect of ADHD to live with. While RSD is not ubiquitous — like inattentiveness, forgetfulness, impulsivity, and the features most commonly associated with ADHD — it is, for me, the most painful symptom.

RSD can dominate people’s lives, driving them to please and impress those around them. Or it can produce the opposite effectt, leading individuals to withdraw from social interactions. When it is internalized, its effects range from low self-esteem to suicidal ideation. When it is externalized, it often results in intense and inexplicable anger directed at the source of the rejection.

Those of us with RSD are more sensitive to criticism, often perceiving it where none exists. Yet, it is not always imagined, since most of us grew up labeled the “problem child,” receiving more than our fair share of criticism from those we looked to for approval. It can degenerate into a self-fulfilling prophesy, with our sensitivity to criticism causing us to act in ways that draw the very criticism we fear.

For me, RSD often manifests as general anxiety, caused by a subconscious fear of embarrassment. It also results in my feeling that those in my life me don’t like me as much as they seem to (pretend to). The feelings can be acute. The knowledge that I am overreacting does nothing to alleviate the crippling agony that criticism can produce, especially when it comes from a source that is important to me and touches on important subjects.

[Use This Free Resource: Understanding Rejection Sensitive Dysphoria]

The Way Forward with RSD

Which brings me back to those emails, written by people I respect and admire, written about a project into which I have invested so much of myself that it feels like an actual part of me. That reluctance to confront the criticism contained in these messages suddenly makes a bit more sense. Soon, I will tear off the bandage — a metaphor that seems so inadequate in describing the intense, personal, emotional discomfort I feel.

If I’m lucky, it will turn out to be a good day, and I’ll be able to set aside that pain and feel inspired to improve my dissertation. If it’s not a good day, I’ll take my embarrassment and my certainty that, no matter what they say, these folks are deeply disappointed in me. I’ll climb into a hole somewhere while I go through the routine of pain, embarrassment, anger, and eventual acceptance.

Assuming I can overcome the sense that I am simply not good enough to do this — the feeling that this perfectly ordinary struggle to bring a dissertation to defense is a sign that my reach has exceeded my grasp — I’ll sit down and write. If I go through this process enough times, I will soon defend and earn a Ph.D. in history. It will be worth it.

Overly Sensitive with RSD: Next Steps

• Understand: Exaggerated Emotions: How and Why ADHD Triggers Intense Feelings
• Read: New Insights into Rejection Sensitive Dysphoria
• Learn: Why You Feel Rejection So Intensely

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.