Rejection Sensitivity, ADHD, and Quackery

To hear people talk about it, rejection sensitive dysphoria, also known as rejection sensitivity, is unique to ADHD. I even saw toxic people on Tumblr accusing non-ADHD people who described their experiences with rejection sensitive dysphoria as "culturally appropriating" (even though ADHD isn't a culture, it's a neurotype, and neurotypes are inherently arbitrary categorizations). And on a Google search for rejection sensitive dysphoria, the first six results discuss it in association with ADHD, with only the sixth result mentioning any other diagnosis that could be associated with RSD. Google also reveals the person who seems to be responsible for the belief that RSD is unique to ADHD - William Dodson.

But what does the research literature say? Is rejection sensitivity unique to ADHD?

This is actually two questions in one. First, are people with ADHD more likely to experience intense negative emotions from rejection, and secondly, are intense reactions to rejection common in any other clinical group?

ADHD and Rejection Sensitivity

Canu & Carlson (2007) studied NT, ADHD-C and ADHD-IA men in undergraduate university, and did not find significant differences in rejection sensitivity, assessed via self-report questionnaire, between the three groups.

Motamedi et al (2016) studied kindergarteners who either met criteria for ADHD, showed subthreshold ADHD tendencies, or were neurotypical, and assessed “rejection reactivity” by having the children customize an abstract shape as an avatar and then watch their avatar play with another shape, and then get abandoned for a third shape. Afterwards, they were asked how the video made them feel and how intense their feeling was, and those who said they felt “a lot” of a negative emotion were classified as rejection reactive. Hyperactivity, but not inattentiveness, was correlated with rejection reactivity.

Apart from these two studies, I wasn’t able to find any other publicly-accessible studies of rejection sensitivity in ADHD. Overall, it seems like there’s mixed evidence regarding whether or not rejection sensitivity is associated with ADHD.

Rejection Sensitivity in Other Clinical Groups

Unsurprisingly to anyone who knows anything about borderline personality disorder, rejection sensitivity is clearly correlated with this condition. I found many studies of BPD and rejection sensitivity, three of which are described below.

Ayduk et al (2008) studied the correlation between borderline personality features, rejection sensitivity, and executive control in several general population samples, and found that the combination of low executive control and high rejection sensitivity predicted higher borderline personality features.

Meyer et al (2005) studied borderline personality features and their association with rejection sensitivity measured both by a questionnaire and reactions to a vignette of an ambiguous social situation that could be interpreted as involving rejection, in a heterogenous general community sample. Borderline features were associated with rejection sensitivity as measured by both the questionnaire and the vignette.

Barros (2016) assessed borderline personality features and rejection sensitivity in staff and students at a university, and found a significant correlation between the two, indicating that individuals with more borderline personality features were more sensitive to rejection.

Depression is also, unsurprisingly, associated with rejection sensitivity. Here’s several studies:

Waller (2015) studied 11-17 year olds with major depressive disorder compared to mentally healthy controls, and found that self-report rejection sensitivity was significantly higher in depressed teens.

Bondü et al (2017) studied 9-21 year olds in a 1-2 year longitudinal study of several dimensions, including depression and two types of rejection sensitivity - anxious and angry (divided by what negative emotion rejection elicited). Participants with higher depression symptomatology were higher in both types of rejection sensitivity at both times. However, the association between time 1 rejection sensitivity and time 2 depression (controlling for time 1 depression) differed by type - anxious rejection sensitivity was associated with increases in depression over time, whereas angry rejection sensitivity was associated with decreases in depression. Meanwhile, time 1 depression was associated with increases in both types of rejection sensitivity by time 2.

Ng & Johnson (2013) compared adults with bipolar I who were currently in remission to mentally healthy individuals, and found that the bipolar participants had higher rejection sensitivity. However, when current depression symptoms were controlled for, this difference disappeared. On 6 month follow-up, rejection sensitivity predicted increases in depression symptoms but not mania symptoms.

There’s also some other diagnoses that came up in a few studies.

In addition to borderline features as mentioned above, Meyer et al (2005) also studied avoidant personality features and their association with rejection sensitivity measured both by a questionnaire and reactions to a vignette of an ambiguous social situation. Avoidant personality features were very strongly correlated with rejection sensitivity in the vignette, and less strongly but still significantly correlated with rejection sensitivity using the questionnaire measure.

Keenan et al (2018) studied autistic traits and rejection sensitivity in university undergraduates, and found that the two were positively correlated, indicating that individuals with more autistic traits were more sensitive to rejection.

In conclusion, rejection sensitivity is definitely not exclusive to ADHD, and it’s unclear if it’s even associated with ADHD at all. Rejection sensitivity appears to be primarily associated with depressed mood states and with borderline personality disorder, and possibly seen in other conditions such as autism and avoidant personality disorder.

So why do people think it is?

In my impression, there’s a lot of quackery in the ADHD world, and it seems to have a unique flavor. ADHD symptoms can be associated with a variety of underlying causes, and sometimes it’s more accurate to describe a person’s ADHD symptoms as simply manifestations of another condition, rather than as true ADHD. However, it seems like ADHD “specialists” rarely consider any differential diagnosis for ADHD, and instead treat variation in symptomatology in ADHD as different types of ADHD.

A good example is the book Healing ADD: The Breakthrough Program that Allows You to See and Heal the 7 Types of ADD by Daniel Amen. If you look through Amen’s seven “types of ADD”, defined by fMRI and symptoms, a lot of them sound suspiciously like other conditions that should be considered in differential diagnosis. “Ring of Fire” ADD is defined by an fMRI pattern that is highly distinctive and unique to an acute manic episode, not ADHD/ADD, and the symptoms described seem more fitting with mania, as well. Meanwhile, overfocused ADD sounds like obsessive-compulsive disorder or an anxiety disorder, temporal lobe and limbic ADD sound more like different flavors of depressive disorders, and anxious ADD sounds like - you guessed it - anxiety disorders. Whether or not these cases actually do have ADHD in addition to these other conditions is unclear, but in any case, symptoms of other conditions in a person with an ADHD diagnosis should be addressed and assessed directly, not treated as just “subtypes of ADD”.

I think William Dodson is cut from similar cloth as Daniel Amen - another ADHD “specialist” who forgets that ADHD isn’t the only possible explanation for his patients’ symptoms, and neglects to look for any other psychiatric conditions that might explain the symptoms he’s observing.

Of course, ADHD isn’t the only neurodivergence that’s riddled with quacks. Autism has plenty of quacks, too, although their tactics are generally different. The biggest difference I’ve noticed is that autism quacks tend to be liked by NT parents of autistic kids and absolutely detested by actual autistic people, whereas ADHD quacks seem to be able to get the respect of their actual patients and not just their patients’ parents. This means that the social justice heuristic of “nothing about us without us” is far less effective at weeding out quackery in ADHD than in autism.

However, autistics should take this as a caution. I’ve seen more and more autism “experts” who are paying lip service to listening to autistic voices, meanwhile still peddling misinformation that could be harmful to autistic people. As we gain more power and influence, the quacks could start to pay more and more attention to marketing directly to us instead of just to our families.