How philosophy can help us to understand adhd: Rejection Sensitive Dysphoria

Rejection Sensitive Dysphoria (RSD) is still not widely known and is even more poorly understood but, in my clinical experience, globally experienced by those of us who have adhd. I was recently in a conversation with a client, who has had an adhd diagnosis for the past fourteen years. When I told them that their extreme sensitivity to mild criticism by their partner had a name—RSD—and that it was a recognized part of the phenomenon we call adhd, they were shocked. They believed that their powerfully strong feelings were theirs alone and that to experience these feelings was a rightful source of shame. I can say without hesitation that they are not.

What exactly is RSD? First, let me say what it is not: it is not an accepted diagnosis, and it does not appear in the bible of psychological disorders, the DSM-V. The fact that it is not an accepted diagnosis and that it has only been very recently even been recognized and named does not work against its importance as a concept. I think RSD is fundamentally important to understanding adhd and other neurological and psychological phenomena.

Rejection

In what follows, I am going to offer my analysis of the phenomenon by examining the three components of its name. But first, some of the basics about RSD: it was coined by the American Physician, William Dodson, and popularized over the past couple of decades. When I introduce the topic to clients, I tell them that the name—the rejection part—is too narrow. Rejection is certainly an aspect of it, but it can be provoked by all sorts of experiences, e.g. feeling criticized, feeling slighted, and feeling ignored as three prominent examples.

It is important to note that RSD is very often domain specific, e.g. prominent in certain environments such as work or home, or in this relationship but not that one. We’ll explore the specificity later in the post. As well, RSD is episodic. It is not something that people with adhd experience all the time but is something that is provoked by one’s environment. It can cause very large swings in a person’s emotional life, and it does so very quickly.

RSD produces psychological and physical distress and pain, sometimes severely so. And RSD is not treatable by conventional therapeutic means. That is, cognitive and behavioural therapies are not effective, because RSD is not a behaviour or a cognitive mindset.

With those basics stated, let’s dig into the details of the phenomenon one word of its name at a time:

Sensitivity

Let’s just pause on the name for a moment and examine its composite parts more precisely, because each of the three words is its own lens to understanding the phenomenon. I’ll start with the second word first, sensitivity: sensitivity points to the amplitude of a stimulus needed to provoke a response. I’ve written about this in previous posts—Feelings vs Emotions, Parts I and II—that fundamental to understanding adhd one must understand that the world of a person with adhd is extremely loud. When I write “loud” I don’t simply mean the auditory experience of loudness—I mean the experience of perception more generally.

Announcement - OrangeIt is important to point out that loudness is not experienced by all people with adhd the same way: for some, the auditory world is extremely loud. Some with adhd are extremely sensitive to touch. For some, particular tastes and textures of food produce big responses. For many with adhd, loudness comes from signals inside one’s body, which we call interoception. Interoception includes all the signals we receive from our bodies. Examples are the felt experience of hunger, pain, and the need to urinate. And for many, the loudness they experience is temporal: that is, memories of things past and/or projections of things to come.

What accounts for this experience of loudness in people with adhd? There are multiple ways of conceptualizing it, but my own way I call The Inhibitory Hypothesis. The Inhibitory Hypothesis points to a metabolic deficit as the root of the sort of sensitivity I am describing in the context of RSD. I have much more to say about The Inhibitory Hypothesis, but for the time being let me say the following: my hypothesis is that people with adhd lack the metabolic resources to keep bodily processes in check. This means that the perceptual hardware of those of us with adhd are the same as anyone. That is, the physiology of our ears and skin and pain receptors and bladders are the same as anyone else. The transmission of those signals via our nervous system is the same as anyone else. But the interpretative mechanisms in our brains differ, because people with adhd have a reduced capacity for, what I call, inhibitory tone.

It seems as if everyone has a pretty good sense of the important neurotransmitters: serotonin, norepinephrine, and dopamine. These three are the main targets of nearly all medications produced for psychological disorders—antidepressants, mood stabilizers, antipsychotics, and adhd medication. But there is a more fundamental neurotransmitter system that is composed of two molecules: glutamate and gaba. These two molecules represent the global processes of excitation (glutamate) and inhibition (gaba). All processes in the body can be described in terms of these two. All processes in the body need to be able to start and increase in amplitude. And all processes in the body need to be able to be diminished and stopped. All of this activity requires energy. It is important to underline the energy requirement part here: slowing down and stopping bodily processes—which we call inhibition—requires energy. Think of it this way: when you are sleeping, there are a variety of powerful inhibitory processes that need to be in place to keep your conscious mind offline and your body still. What this means is that the inability to get to sleep or stay asleep is not the result of being too energetic but the result of being metabolically fatigued or having a lack of inhibitory tone. In other words, you might be exhausted and dearly need rest, but your lack of metabolic resources means that your body doesn’t have the fuel it needs to enter into and maintain sleep.

This is the meaning of sensitivity: the relative inability to inhibit the amplitude of bodily processes. To return to our topic at hand—RSD—this means that the feeling of being rejected, which is universally experienced by all people, is experienced by those with adhd with greater amplitude, that is, much more loudly. And loud stimuli produce loud responses.

Dysphoria

The use of the word dysphoria has increased greatly over the past couple of decades not as a result of the popularization of the term RSD but because of the movement for and recognition of Trans rights and Trans people more generally. One of the phrases that has been important in that fight for recognition and compassionate treatment of Trans people is Gender Dysphoria. It has been a critically important concept in the fight for Trans rights, because to experience dysphoria is to experience a deep and bodily sense of unease and unwellness. Dysphoria is the definitional opposite of a word we are more familiar with, euphoria. Imagine the highest of highs, the peak of joyousness: that is the feeling of euphoria. Now… turn that peak upside down. That is the feeling of dysphoria.

Dysphoria is from the Greek dúsphoros, meaning “grievous to bear”. To feel dysphoric thus means to carry something, and that something is grief, pain, and anguish. It needs to be noted here that this discussion of pain in particular is not metaphorical. The pain people experience in the context of dysphoria, whether gender dysphoria or RSD, is physical pain.

Burden

In my experience, all people with adhd experience RSD, but two descriptions from clients stand out in regard to the degree to which they experienced physical pain. One client told me that when they experienced RSD it felt as if “their skin was on fire”. Another client told me the experience of RSD felt like getting “stuck in the back with a knife”—the metaphorical meaning here is not lost. Those descriptions were told to me years ago, when I was still at the stage of formulating the ideas that have produced my ideas around adhd and my therapeutic methods for working with this population. I remember my own skepticism as I heard these stories. They seemed like such an exaggerated response… but that is precisely the point. They are exaggerated responses, but they are not exaggerated because the people who reported those stories are “drama queens”. They are exaggerated because the loudness of the signal requires an equally loud response.

Rejection

I’m mindful that I’ve approached the composite parts of RSD out of order. But I’ve done so, because doing things in order is obvious and a little boring. But more importantly, I wanted to save the best for last. By that, I don’t mean that rejection is the best, but only that rejection—and, importantly, its variants—are the most important from a philosophical perspective, and I have titled this post, “How philosophy can help us to understand RSD”, so… it’s a little over-determined.
How is rejection important to the history of philosophical thought, and why is that important to a discussion about the cognitive/emotional/bodily dysregulation of folks with adhd in 2023?

Let’s turn our attention to the early 19th century and the work of G.W.F Hegel. Hegel’s best-known work, entitled The Phenomenology of Spirit, contains one of the most important passages in the whole of the history of human thought. It is generally referred to as Lordship and Bondage or The Master-Slave Dialectic. It is the story of how human consciousness comes to be, and it is in this story that we, amazingly, find the answer to the questions posed by adhd and RSD: that is, why we feel so deeply badly—the deep unease we’re calling dysphoria—in the presence of rejection and its variants.

A little backstory to the brilliance of Hegel and his importance here. Prior to Hegel, consciousness in the West—mine is a parochial story that does not include the history of thought outside of the West—was understood in terms of the individual self. We’ve all come across Descartes’ famous dictum: “I think, therefore I am.” Descartes wrote this in 1637. It is one of the foundational premises on which Western thought developed… and it is completely wrongheaded. In Descartes’ story, there is only a single character. The story of a being that becomes a self is done in isolation. Descartes famously worked in isolation, and his apprehension of himself as a self is done in isolation. Descartes is only interested in the lone “I”.

Hegel’s great insight was to recognize that there cannot be an I without first there being a we. Hegel was the first to tell the story of the development of an individual’s self-consciousness as an outgrowth of their connection with another. The following is the opening sentence of the section on Lordship and Bondage. He writes,

Self-consciousness exists in and for itself when, and by the fact that, it so exists for another; that is, it exists only in being acknowledged. (my emphasis)

What is he saying here that is so radical? Descartes tells the story of the development of self-consciousness with only one character, himself or a single I. Hegel tells the same story but his requires the presence of another. There can be no I in Hegel’s story without another who sees and acknowledges and ultimately recognizes the I-ness of another.

Let me put it into more contemporary language: if you’ve ever heard—or experienced yourself—someone say that they feel seen or heard, then you have a first hand experience of Hegel’s story. Think about the that feeling of being seen and heard and understood. Think about a time that a boss or a friend or a romantic partner has offered something—words or a gift or even a look—that communicated to you that they had a deep understanding of the person you are. That feeling is extraordinary. It is extraordinary, if we take Hegel seriously here, because in that seeing and hearing and understanding, in the acknowledgement and recognition of you by another, you become a self. Let me repeat that, because this is such an important point, and it will help below to tell the story of the power of rejection: in being acknowledged by another self and seeing that recognition of oneself in the other, you yourself become a self.

If we accept Descartes’ story, it doesn’t much matter what others do, because the foundation of the self is in the individual I. But if we accept Hegel’s telling, we require another to be a self. And, if being seen and heard and acknowledged and recognized by another brings our selfhood into the world and that feeling is beautiful and sublime and euphoric… then the corollary is also true. The corollary is that if another mis-sees or mis-hears or refuses acknowledgement or recognition, then the other holds the keys to our sense of being a self. This is the immense power of rejection and abandonment and being ignored.

If what I am saying is correct, it means that rejection and its variants are not just experiences that feel bad or sting; rather, they are ways of robbing us of our sense of self or personhood. I know that might sound a bit over the top, but this is the feeling of dysphoria. Remember, dysphoria means “grievous to bear”. What grief does one bear in the presence of rejection? In the face of rejection, one loses the acknowledgement and recognition of the other, and in so doing that one loses their sense of self. But that doesn’t quite do it justice, one loses their self. We might even say that at that moment, the grief that we bear is the death of our self.

An example

The story I’ve told about Rejection Sensitive Dysphoria contains for many readers, I imagine, new concepts and unfamiliar language. Let me end this post by offering the story that a client shared in session. I have received their consent to include this story. It is an excellent example of an everyday, low stakes interaction between two people that nevertheless caused deep dysphoric feelings of misrecognition that we call RSD.

Broken glassThe story begins with a broken glass. It is the morning. The night prior, the dishwasher was loaded in such a way that the glasses were more likely to bang together as they were being washed, and, as a result, a glass broke. There’s nothing more low stakes than a broken glass, but the everydayness of this example underlines the ways in which the extreme sensitivity of those of us with adhd can result not just in simple hurt feelings but in the deep unease of the dysphoria that is the result of experiencing a kind of death of one’s self by feeling unrecognized and unacknowledged by another.

A glass has been broken, and one partner says to the other that they would appreciate it if they would be more mindful of the way they load the dishwasher. The one doing the asking is a person with adhd, and is particular about the objects they (the couple) own. This is not the first glass that has been broken in the dishwasher, and though it is not a life or death scenario, the broken glass represents a number of important things: first, it simply represents something broken that can no longer be used. People with adhd tend to be extremely averse to waste. That is a story for another day, but it is a very common characteristic. The broken glass also represents a kind of disorder, because the glass was a part of a set that was purchased together. Again… it is a very common characteristic of people with all varieties of neurological differences to be sensitive to order/disorder in their environments (another aspect to leave for another day). And finally, the broken glass represents a prior discussion, when it was communicated to the other that loading the dishwasher in a particular way to diminish the chances of the glass breaking was important.

Now… the partner who loaded the dishwasher that led to the broken glass was not immediately aware of the meanings that were present for the other. In that moment, the partner who loaded the dishwasher wasn’t available for any of it and responded defensively. They experienced the entrée to the discussion as aggressive and acted to defend themselves by claiming that this was the first time that such a thing happened. Escalation can now proceed.

I should say before continuing, that there are no good and bad characters in this story. Both are good faith actors in a long and loving relationship. But it is precisely in this kind of environment—a loving relationship—where the capacity for deep hurt exists. I often quote Neil Young on this count and the title of his song from 1970, Only Love Can Break Your Heart. Recognition and misrecognition only function in relationships that matter.

In this particular instance, the defensiveness of one was experienced as a lack of acknowledgement and recognition of the other. Recall what our German friend Hegel says about the way one’s self comes to exist: “it exists only in being acknowledged.” Without that acknowledgement to a person who is particularly sensitized to their relational environment—another way of describing the thing we call adhd—their sense of self is now in question. And remember the meanings that were important to the partner concerned about the broken glass: thoughts and emotions and even physical sensations around waste, order, and perhaps most importantly, that they had expressed concern about this topic in the past. In the moment of defensiveness, a space opened up between these two, and I think it would be fair to say that both felt unseen and unheard and unacknowledged and unrecognized by the other. And what is the response by both? They both begin to raise their voices and speak more forcefully to the other. Why? Because they both experience the distance, and with distance recognition becomes more difficult.

Distance

It is impossible to see and hear across increasing distances. It’s hard to make out the other. And we can’t acknowledge what we can’t see or hear. So, we raise our voices to make ourselves heard. When we yell at another, we are communicating the following: you don’t get what I am saying. There’s something in the way that is making it difficult for you to acknowledge what I am saying but, even more importantly, that I am human person, a self. And because your acknowledgement of me is fundamental to my own sense of self, I need to yell across that divide. I desperately need you to see me. And we likely all have a good and personal sense of the kinds of behaviours that desperation provokes in us.

This is the meaning of an escalation such as this one about a broken glass that concludes in two people who care deeply about each other yelling at each other. They are a metre apart in physical space, but they are kilometres apart in relational space. And though there is some particular content that they are yelling at each other, they are actually yelling (with increasing volume) something of the following flavour: why do you refuse to acknowledge me! How can I go on in this world if the person who knows me best can’t see that the meanings I attach to something as everyday as this glass. If this person who knows me as fully as anyone in the whole of this universe can’t understand the way I live in the world, what is the point of any of this? To repeat Neil Young, “only love can break your heart.” This is heartbreak and dysphoria that produces feelings of desperation and existential lostness… and it came out of a discussion of about a broken glass that neither party had any particularly strong feelings about.

What to do about it?

RSD is one of the most challenging aspects of adhd. It is experienced lightning fast, much faster than we can process thought or language. And, if you buy my philosophical story, it is something that hits at the very core of our being. Though the experience of RSD is something that we might call in the therapeutic world emotional dysregulation, the dysregulation is not pathological but rather a reasonable response to a catastrophic possibility, namely the death of one’s self. Like all things with adhd, the dramatic responses those of with the condition regularly have is not the thing on which to focus. The dramatic responses are the downstream effects—the behaviours—that result from experiencing the world in the way we do.

So, in the story of the broken glass, what could have been done to produce a different outcome? In the story I told, each step of the escalation was an instance of creating relational distance. Each step was one partner telling the other, I refuse to see you, and I refuse to acknowledge you. But if there is an opportunity to mis-see and mis-hear and misunderstand, and misrecognize the other… then there is the opportunity to see and hear and understand and recognize.

The key is to find a way to bridge distance. That can be done with words and that can be done by physical contact. Let’s revisit each step of the conflict: in the very first instance, the partner who was upset about the broken glass could have prefaced their remarks by saying something that would have acknowledged the personhood of other and put them at a much lower risk of provoking defensiveness. The partner who was upset about the broken glass knows very well that their partner is likely to be defensive in certain situations, and they might have used that knowledge towards a better outcome by touching the partner on the shoulder or by approaching them with some softness. Similarly, the partner who loaded the dishwasher might have recalled that a broken glass is not just a broken glass, that there are important meanings associated with such everyday things. And in recognizing those meanings, there might be the opportunity for some softness and connection.

At each and every step of an escalating conflict, there is the opportunity to see and hear and acknowledge and recognize the other, because doing so is not to give in or roll over or to even admit anything about the particular content of the conflict. Doing so offers the other secure access to their own self. If that is available to both, any conflict can be resolved. In the absence of acknowledgement and recognition, something as low stakes as a broken glass can cause great loves to wonder if the other even cares or if they have ever really cared.