How to Manage ADHD-Related Rejection Sensitivity

Attention-deficit hyperactivity disorder (ADHD) is a mental health disorder that triggers a variety of impulsive and hyperactive behaviors. It’s usually diagnosed early in childhood, but both children and adults may be diagnosed with it. Generally, it’s a life-long issue, though some children do outgrow it.

At Memphis Neurology, our expert team of neurologists treats all manner of behavioral disorders, including ADHD. One aspect of the disorder that’s not widely known is rejection sensitivity. Here’s what our experts have to say about the problem and how best to manage it.

The fundamentals of ADHD

According to the CDC, 1 in 10 children aged 5-17 years receives an ADHD diagnosis, making it one of the most common childhood neurodevelopmental disorders in the United States. Boys receive a diagnosis more than twice as frequently as girls, which may be because they more often exhibit hyperactivity.

ADHD is often associated with problems in classroom settings, where behaviors can be highly disruptive, though it affects all aspects of a child’s life. Symptoms include:

• Daydreaming often
• Forgetting things or losing them
• Squirming and fidgeting
• Chattering excessively
• Making careless mistakes or taking unnecessary risks
• Having difficulty resisting temptation
• Having difficulty getting along with others

A lesser-known but just as important symptom is rejection sensitive dysphoria (RSD). RSD leads to extreme emotional sensitivity and pain triggered by the perception that the person has been criticized or rejected by important people in their life. It can also be triggered by a sense of failure to meet either their own high standards or others’ expectations.

Dysphoria comes from the Greek for “difficult to bear.” It’s not that people with ADHD are weak; it’s that the emotional response pains them more intensely than it does people without the condition. For people with RSD, the experiences of what feels like criticism and failure become restricting and highly impairing.

Managing RSD

Rejection sensitivity is both genetic and neurologic, and it comes part and parcel with ADHD. Psychotherapy isn’t generally useful for treating RSD because the emotions hit suddenly, and they completely overwhelm the mind and senses. When the person externalizes these feelings, it presents as an instantaneous rage at whatever person or situation is responsible for causing the pain.

People with RSD generally cope with these feelings in one of two ways:

1. They become people pleasers

They scrutinize every person they meet to determine what that person admires and praises, then they present those traits to others, even though they’re not an integral part of themselves. Sometimes, pleasing others becomes such a dominating goal that they forget what they wanted from their own lives.

2. They stop trying

If the person feels there’s the slightest possibility that when they try something new they’ll fail or fall short of others’ expectations, they decide it’s too painful or too risky to make the effort. That leads many bright, capable people to avoid any activities that could be anxiety-provoking, and they end up giving up things like dating, applying for jobs, or speaking up in public.

Medications are often the best choice of treatment, and there are two possible solutions for RSD.

The first is to prescribe an alpha agonist such as guanfacine or clonidine, which were originally designed as blood pressure medications. When the person receives an optimal dose of either one, about one in three gets relief, and the change can be life-altering. At times, this treatment can make an even greater impact than the usual prescription stimulant does to treat the underlying problem.

The second is to prescribe monoamine oxidase inhibitors (MAOIs) “off-label,” which has traditionally been the treatment of choice. It can have a dramatic effect on both the attention/impulsivity component of ADHD and the emotional component.

MAOIs produce very few side effects (e.g. low blood pressure, agitation, sedation, and confusion) with true once-a-day dosing, they’re not a controlled substance, they’re available in inexpensive generic versions, and they’re FDA-approved for both mood and anxiety disorders. However, they do come with one major disadvantage: patients must avoid foods that are aged instead of cooked; first-line ADHD stimulant medications; all antidepressants; OTC cold, sinus, and hay fever medications; and OTC cough remedies.

If you or your child has ADHD and is experiencing rejection sensitivity, it’s time to come into Memphis Neurology for a complete evaluation and effective treatment. To get started, give us a call at either our Germantown, Tennessee, or Southaven, Mississippi, location, or book a consultation online. We can help.