ADHD sufferers often suffer from a particularly intense fear of rejection and criticism (rejection sensitivity).
We know about this special sickliness in the sense of a sensitivity of ADHD patients to actual or feared rejection from many reports of ADHD patients. Almost all of the ADHD patients we interviewed confirmed the presence of RS.
1. Rejection Sensitivity (RS)
Rejection Sensitivity (RS) is the predisposition to
- Anxious expectation of rejection,
- Willing acceptance of rejection and
- Intensive reaction to (real or perceived) rejection.
Rejection Sensitivity is known as an independent disorder and occurs as an original symptom in various disorders (depending on severity):
- Borderline: Offendability (Leitsymptiom)
- Narcissism: narcissistic sickliness (Leitymptom)
- Bipolar disorder
- Social phobia
- Anxiety disorders
In ADHD, Rejection Sensitivity has not yet been addressed as a specific ADHD symptom in the standard (German-language) literature on ADHD.
1.1. Rejection Sensitivity in ADHD
Offendability is mentioned again and again as a specific and typical characteristic of many ADHD-HI patients , e.g. as quick offendability, as sensitivity to criticism as a subcategory of a negative hyperfocus, in a questionnaire (Were you very sensitive and offendable as a child?) or in other descriptions as a consequence of self-esteem problems . Dietrich calls this a low tolerance for criticism from the social environment or a difficulty in accepting criticism and admitting guilt.
Only rarely, however, is Rejection Sensitivity described as a specific ADHD-I symptom. In our opinion, the special significance of the symptom of Rejection Sensitivity as an ADHD symptom is considerably underestimated.
Several larger studies found a clear association between severity of ADHD symptomatology and the presence of Rejection Sensitivity An older small study found no association.
One of the studies established a link between ADHD sufferers’ heightened sense of justice and Rejection Sensitivity.
Affected persons perceive themselves much more as outsiders and “not integrated into the group” than, conversely, the group perceives the affected persons.
The degree of rejection by group members (peer rejection) and the degree to which sympathy for others exceeds reciprocally demonstrated sympathy are the most reliable parameters for distinguishing children with ADHD from nonaffected individuals based on group surveys, according to one study.
ADHD symptoms and the resulting social rejection (peer rejection) between the ages of 4 and 6 are a mutually reinforcing vicious circle. Social rejection causes stress and stress causes current ADHD symptoms. Especially in early childhood stress manifests the genetic disposition, so that ADHD intensity is furthermore influenced throughout life.
However, actual rejection by others is not a measure of Rejection Sensitivity.
Rejection sensitivity is not characterized by objective rejection by others, but by vulnerability to subjectively perceived rejection. It is about sensitivity to actual rejection on the one hand and the perception of perceived rejection and rejection on the other.
1.2. Conceptual differentiation from “Rejection Sensitive Dysphoria” (RSD)
Occasionally, the term “Rejection Sensitive Dysphoria” (RSD) is used instead of Rejection Sensitivity in reference to ADHD.
However, the term “dysphoria” does not refer to a real dysphoria, but Rejection Sensitivity as such is meant and it is regarded as a special atypical depression. Winkler, who was probably one of the first to present Rejection Sensiotivoty in ADHD in the German-speaking world, establishes with reference to Dodson a direct connection between Rejection Sensitivity and mood slumps / dysphoria in ADHD, whereby he probably considers Rejection Sensitive Dysphoria as a form of atypical depression.
We consider Rejection Sensitivity on the one hand and Dysphoria (with inactivity) on the other hand as two original symptoms, i.e. directly caused by ADHD - even though they often occur together in ADHD. To avoid confusion with the specific ADHD symptom dysphoria (with inactivity), we use the term Rejection Sensitivity.
2. Rejection Sensitivity as an Original Symptom of ADHD
The phrase Rejection Sensitivity as an original symptom of ADHD used here means that Rejection Sensitivity in ADHD is, according to this assessment, a symptom directly caused by ADHD itself (just like attention problems or hyperactivity) and is not a mere consequence of bad experiences made over a long time.
Nevertheless, RS is not unique to ADHD. RS is therefore not an exclusive symptom of ADHD. RS alone is by no means evidence of ADHD.
2.1. Rejection sensitivity more than purely psychological reaction
First of all, it is obvious to attribute the hypersensitivity to rejection in ADHD sufferers to
- That due to the lifelong negative social experiences with the environment and the resulting massively impaired self-esteem,
- The feeling of being different, of not belonging, as well as
- The high sensitivity induced by genetics (DRD4-7R, 5-HTTPRs, COMT Met-158-Met, see the aspect Opportunity/Risk genes ⇒ How ADHD develops : genes + environment) induced vulnerability (sensitivity and vulnerability due to the stimulus filter being too wide open) or
- A generally low self-esteem
Certainly, a lifetime of rather negative experiences with other people contributes to the development of a fear of rejection.
Videos showing footage of ADHD sufferers compared to depressives are perceived by third parties as equally unpleasant. However, while videos of depressives tend to evoke an equally depressed, tired mood, videos of ADHD sufferers tend to evoke a more hostile mood.
This difference, while relevant, cannot alone explain the Rejection Sensitivity of ADHD sufferers.
In our opinion, the massiveness in which ADHD sufferers suffer from Rejection Sensitivity and the high frequency of its occurrence in ADHD cannot be explained solely by the stressful experiences that ADHD sufferers additionally have in the course of their lives as a consequence of their problems with other people. Since Rejection Sensitivity also occurs in other psychological disorders, where it is not perceived as a “mere” consequence of a self-esteem problem (narcissism: narcissistic sickliness; borderline: core symptom), we believe that the probability of a learned reaction is further reduced.
A study in healthy individuals showed that the character trait of wanting to belong, but not the trait of rejection sensitivity, caused an elevated cortisol response (typical of stress) to exclusion from participation in a group game.
2.2. Stimulants reduce Rejection Sensitivity immediately
Most of the ADHD sufferers interviewed on this side confirmed an immediate improvement in rejection sensitivity with methylphenidate. (More on this below under 3.5.)
For non-affected persons, the respective triggers would also be unpleasant, but not cause the intense sensation of being hurt due to perceived rejection described by the affected persons. The direct effect of medication on the intensity of rejection sensitivity does not allow any other conclusion than that it is a direct (neurophysiologically mediated) symptomatology of ADHD.
That dopaminergic stimulants positively influence symptoms may be conclusive in light of the modulation of the affiliation motive by dopamine described in 2.6 below.
On this side, therefore, a direct neurophysiological manifestation of RS in terms of a specific neurophysiological mechanism of action is suspected.
2.3. Early childhood stress experience as a cause of Rejection Sensitivity
The psychological models of Rejection Sensitivity attribute this to traumatizing experiences in early childhood, which activate the DMS (“Defensive Motivational System” as one of the two behavior-controlling motivational systems according to Gray, which animates the affected person to active avoidance and fight-or-flight reactions) as well as form a defense mechanism (overcautiousness as protection against unexpected injury), which can no longer be adequately controlled due to deficient (emotional) self-regulation.
2.4. Rejection Sensitivity and Attachment Styles
Different attachment styles clearly predict rejection sensitivity in ADHD.
A secure attachment style is least affected by Rejection Sensitivity, whereas an insecure-entangled (preoccupied) attachment style showed the most ADHD symptoms, even more so than in an insecure-avoiding (dismissing) attachment style. Against this background, rejection sensitivity could be understood as a direct expression of insecure attachment.
This fits into the this-side picture that even an insecure attachment style can cause enough early childhood stress to activate the genetic disposition to psychological problems (here and especially in ADHD due to the high sensitivity present there).
More on attachment styles and what parents can do preventively: ⇒ Attachment styles in the chapter ⇒ Prevention.
2.5. Similar symptoms in similar disorders
The symptom of Rejection Sensitivity does not exclusively occur in ADHD, but is frequently found as a comorbid disorder in affective disorders such as depression, narcissism (there as narcissistic offendability), Bipolar Disorders (1 & 2) as well as Borderline (there again significantly more massive and determining the disorder pattern).
It is well known that the symptoms of borderline and ADHD partially overlap (⇒ Differential Diagnosis in ADHD). However, the neurological causes differ considerably. The dopaminergic system is involved in both disorders. Whereas dopamine levels in the PFC and striatum are decreased in ADHD, they seem to be rather increased in borderline.
2.6. Affiliation motive is dopaminergically controlled
Motivation is mediated by different neurotransmitters depending on the type of motive. Motivation can basically be divided into the groups of power motive, affiliation motive, and achievement motive. In the case of fear of rejection, the affiliation motive is specifically addressed, not the achievement motive and not the power motive. Only the affiliation motive is dopaminergically controlled. Since ADHD is characterized by a dopamine deficiency in the PFC as well as in the striatum, the reward and reinforcement center of the brain, it seems plausible from this point of view that ADHD sufferers are particularly susceptible to a fear of rejection and criticism.
2.7. Affiliation motive can fix procrastination
The special importance of the affiliation motive in ADHD is also reflected in the fact that ADHD-HI sufferers find it much easier to perform for someone else the activity that they cannot perform for themselves (due to pronounced procrastination). This goes so far that Passig, Lobo recommend as a coping strategy for procrastination that those affected do the activities they procrastinate on in exchange for someone else.
2.8. Overestimation of own social skills as RS
ADHD sufferers often overestimate their own social skills. This symptom is not so serious that it could be described as bearing ADHD.
In a test group of n = 82 girls aged 9-12 years, the n = 42 ADHD sufferers overestimated their social skills significantly more than non-affected compared to third-party assessments (teachers, parents, and third-party observers). If oppositional defiant behavior was added, this increased further, as did decreased depression symptomatology. Overestimation of self correlated only in ADHD sufferers with the tendency of sufferers to bias responses toward social desirability (socially desirable reporting bias). In ADHD sufferers, self-overestimation of social competence was linked to measures of imbalance. With increasing balance, self-overestimation decreased, whereas it increased with balance in non-affected individuals.
This could be interpreted as an effect of ADHD-typical rejection sensitivity, especially due to the bias towards social desirability.
3. Social phobia as a possible consequence of rejection sensitivity
Social phobia is characterized by:
- Fear of scrutinizing observation in manageable groups (not in crowds)
- Appearance of fear
- Is usually limited to or predominant in certain social situations, e.g.
- Public speaking
- Meeting with people of the desired sex
- But can also be indeterminate and occur in almost all social situations outside the family
- Low self-esteem
- Fear of criticism
- Possible accompanying phenomena:
- Avoiding eye contact
- Urinary urgency
- Symptoms may intensify to the point of panic attacks.
- The phobic situations are avoided.
- Onset often in adolescence
- Pronounced avoidance behavior can lead to complete social isolation
A very pronounced Rejection Sensitivity is said to be able to trigger a Social Phobia.
In this sense, a social phobia, which can be observed more frequently in ADHD, could occur as a consequence of a rejection sensitivity already described above as an original ADHD symptom. Since rejection sensitivity as an ADHD symptom can be remitted by treatment with ADHD medication, a social phobia that is a consequence of a pronounced rejection sensitivity should theoretically decrease at the same time. Evidence for this is not yet known to us.
4. Medication for Rejection Sensitivity in ADHD
Many ADHD sufferers reported that stimulants had a significant and immediate influence on their rejection sensitivity. Thereby, 90% reported a positive and RS decreasing influence, 10% a rather increasing influence by MPH.
One ADHD sufferer reported that his long-standing intense Rejection Sensitivity had decreased significantly since treatment with MPH. He further reported that he had several relapses of Rejection Sensitivity when suitable triggers were present and at the same time he had forgotten the MPH medication even for a few hours. The intensity of RS triggered by an evening argument with a girlfriend (outside the daytime MPH medication) was dramatically reduced within 10 minutes of taking MPH.
Methylphenidate significantly reduces feelings of mistrust in ADHD sufferers.
4.2. Guanfacine and clonidine
In the case of rejection sensitivity, a combination of the alpha-2-adrenoreceptor agonists guanfacine and clonidine is particularly effective, according to a single field report by an American physician (Dodson). He reports that at doses of between 0.5 and 7 mg guanfacine and between 0.1 mg and 0.5 mg clonidine, one in three sufferers loses their rejection sensitivity symptoms. He further reports that the impact on quality of life from this treatment is greater in outcome than stimulant treatment.
Dodson further reports from a Harvard University study that increasing the dosage for guanfacine up to 4 mg and for clonidine up to 7-8 mg resulted in a 40% greater response, although this dosage was above the recommended limits. This also results in increased side effects.
Guanfacine is more effective as an ADHD medication compared to atomoxetine.
Alpha-2 adrenoreceptors (adrenoceptors) are activated by the neurotransmitters adrenaline and noradrenaline. They are thus responsible for the effects mediated by adrenaline and noradrenaline.
Agonists enhance the action of the receptors. Guanfacine and clonidine thus have a noradrenergic effect and reduce the adrenergic effect.
4.3. MAO-A reuptake inhibitors
Dodson further describes success with MAO-A reuptake inhibitors, particularly Parnate (tranylcypromine), which has been the common treatment for rejection sensitivity. MAO-A reuptake inhibitors have also been used successfully for ADHD symptoms.
4.4. Imipramine, Phenelzine
Imipramine and phenelzine are each reported to be better suited (than valproate) to address Rejection Sensitivity, depending on the nature of the broader symptomology..
Imipramine is a conceivable supplementary medication to stimulants in ADHD. However, the mutual effect of imipramine and methylphenidate should be taken into account.
4.5. Valproate in BPD
Valproate (250 mg to 500 mg) moderately improved symptoms of irritability, anger, anxiety, rejection sensitivity, and impulsivity in 50% of BPD sufferers. Results varied widely from affected person to affected person.