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Rejection sensitivity: offendedness, fear of rejection as a specific ADHD symptom

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Rejection sensitivity: offendedness, fear of rejection as a specific ADHD symptom

Rejection Sensitive Dysphoria (RS) is an increased vulnerability and willingness to expect and accept rejection and to react intensely to actual or perceived rejection. Rejection sensitivity is not characterized by actual rejection by others, but rather by susceptibility to perceived rejection and exclusion as well as an increased sensitivity to criticism
Rejection sensitivity is known as a disorder in its own right and can occur as a primary symptom in various disorders, including borderline personality disorder, narcissism, bipolar disorder, social phobia, depression and anxiety disorders. In the standard literature on ADHD in German-speaking countries, Rejection Sensitivity has not yet been treated as an ADHD symptom, although sensitivity to rejection is often described as a characteristic of ADHD sufferers. However, several studies have shown a clear correlation between the severity of ADHD symptoms and the presence of rejection sensitivity.
Rejection Sensitivity is known to us from many reports from ADHD sufferers. Almost all of the ADHD sufferers we interviewed confirmed the presence of RS.

Rejection Sensitivity is an original ADHD symptom and not just a consequence of negative experiences over time.
The dopamine system plays an important role in the regulation of rejection sensitivity, as it is responsible for the motivation to belong to a group. Stimulants such as methylphenidate have been shown to reduce rejection sensitivity in individuals with ADHD. The use of alpha-2-adrenergic agonists such as guanfacine and clonidine, as well as MAO-A reuptake inhibitors, has also been shown to be effective.

Rejection sensitivity can lead to social phobia, which is characterized by the fear of being judged or rejected in social situations. Treatment with ADHD medication can also reduce the symptoms of social phobia.

1. Rejection Sensitivity (RS)

Rejection Sensitivity (RS) is the predisposition to

  • Anxious expectation of rejection,
  • Willing acceptance of rejection and
  • Intensive reaction to (actual or perceived) rejection.

Rejection sensitivity is known as an independent disorder and occurs as an original symptom in various disorders (decreasing in severity):

  • Borderline: Offensiveness (leading symptom)1
  • Narcissism: narcissistic insufferability (leading symptom)
  • Bipolar disorder
  • Social phobia1
  • Depression1
  • ADHD23
  • Anxiety disorders1

In ADHD, rejection sensitivity has not yet been addressed as a specific ADHD symptom in the standard (German-language) specialist literature on ADHD.

1.1. Rejection sensitivity in ADHD

Offendedness is repeatedly mentioned as a specific and typical characteristic of many ADHD-HI patients45 , e.g. as being easily offended6, as sensitivity to criticism as a subset of a negative hyperfocus7, in a questionnaire (Were you very sensitive and offended as a child?)8 or in other descriptions as a consequence of self-esteem problems910 . Dietrich calls this a low tolerance of criticism from the social environment or a difficulty in accepting criticism and admitting guilt.11

Only rarely, however, is the particular offendedness described as a specific ADHD-I symptom.1213214 In our opinion, the particular significance of the symptom of Rejection Sensitivity as an ADHD symptom is considerably underestimated.

Several larger studies found a clear connection between the severity of ADHD symptoms and the existence of rejection sensitivity1516 An older small study found no connection.17
One of the studies established a connection between the heightened sense of justice of ADHD sufferers and rejection sensitivity.16

Those affected perceive themselves much more as outsiders and “not integrated into the group” than, conversely, the group perceives those affected.

According to a study, the degree of rejection by group members (peer rejection) and the extent to which sympathy for others exceeds the sympathy shown in return are the most reliable parameters for distinguishing children with ADHD from those without ADHD on the basis of group surveys.18
ADHD symptoms and the resulting social rejection (peer rejection) at the age of 4 to 6 years are a mutually reinforcing vicious circle.19 Social rejection causes stress and stress causes current ADHD symptoms. Especially in early childhood, stress manifests the genetic disposition, so that ADHD intensity is also 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 supposed rejection and rejection on the other.

1.2. Differentiation from “Rejection Sensitive Dysphoria” (RSD)

The term “Rejection Sensitive Dysphoria” (RSD) is sometimes used instead of the term Rejection Sensitivity in relation to ADHD.2021

However, the term “dysphoria” does not refer to genuine dysphoria, but rather to rejection sensitivity as such, which is regarded as a special atypical depression.22 Winkler, who was probably one of the first in the German-speaking world to describe rejection sensitivity in ADHD, makes a direct connection between rejection sensitivity and mood dips / dysphoria in ADHD with reference to Dodson23, whereby he considers rejection sensitive dysphoria to be a form of atypical depression.24

We consider Rejection Sensitivity on the one hand and Dysphoria (when inactive) on the other 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 (during inactivity), we use the term rejection sensitivity.

2. Rejection sensitivity as an original symptom of ADHD

The term rejection sensitivity used here as an original symptom of ADHD means that, according to this assessment, rejection sensitivity in ADHD is 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 period of time.
Nevertheless, RS is not exclusive to ADHD. RS is therefore not an exclusive symptom of ADHD. RS alone is by no means proof of ADHD.

2.1. Rejection sensitivity is more than a psychological reaction

First of all, it seems reasonable to attribute the hypersensitivity to rejection in ADHD sufferers to

  • This is 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, and
  • The genetically induced high sensitivity (DRD4-7R, 5-HTTPRs, COMT Met-158-Met, see the aspect of 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-esteem10

A lifetime of rather negative experiences with other people certainly contributes to the development of a fear of rejection.

Videos showing images of people with ADHD compared to those with depression are perceived by third parties as equally unpleasant. However, while videos of depressed people tend to evoke a depressive, tired mood, videos of people with ADHD tend to evoke a hostile mood.25

Although this difference is relevant, it cannot explain the rejection sensitivity of ADHD sufferers alone.

In our opinion, the extent to 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 also have with other people in the course of their lives as a result of their problems. 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 offendedness; borderline: core symptom), we believe that the probability of a learned reaction is further reduced.

A study on healthy individuals showed that the character trait of wanting to belong, but not the trait of rejection sensitivity, caused an increased cortisol response (typical of stress) to exclusion from participation in a group game.26

2.2. Stimulants directly reduce rejection sensitivity

Most of the ADHD sufferers interviewed on this site confirmed an immediate improvement in rejection sensitivity with methylphenidate. (More on this below under 3.5.)

For those not affected, the respective triggers would also be unpleasant, but would not give rise to the intense feeling of being hurt due to perceived rejection described by those affected. From this point of view, the direct effect of medication on the intensity of rejection sensitivity allows no other conclusion than that it is a direct (neurophysiologically mediated) symptom of ADHD.
In view of the modulation of the affiliation motive by dopamine described below under 2.6, it could be conclusive that the dopaminergic stimulants have a positive influence on the symptoms.
On this side, a direct neurophysiological manifestation of RS in the sense of a specific neurophysiological mechanism of action is therefore assumed.

2.3. Early childhood stress experience as a cause of rejection sensitivity

The psychological models of rejection sensitivity attribute this to traumatic experiences in early childhood, which activate the DMS (“Defensive Motivational System” as one of the two behavior-controlling motivational systems according to Gray, which encourages the affected person to actively avoid and fight-or-flight reactions) and develop a defense mechanism (overcaution as protection against unexpected injury), which can no longer be adequately controlled due to inadequate (emotional) self-regulation.2728

2.4. Rejection sensitivity and attachment styles

Different attachment styles clearly predict rejection sensitivity in ADHD.

A secure attachment style is the least affected by rejection sensitivity, while a preoccupied attachment style showed the most ADHD symptoms, even more so than a dismissing attachment style.29 Against this background, rejection sensitivity could be understood as a direct expression of insecure attachment.

This fits in with the picture on this side that even an insecure attachment style can cause enough early childhood stress to activate the genetic disposition to psychological problems (here and in particular in ADHD due to the high sensitivity present there).

More on attachment styles and what parents can do to prevent them: Attachment styles in the chapter ⇒ Prevention.

2.5. Similar symptoms with similar disorders

The symptom of rejection sensitivity does not occur exclusively in ADHD, but is often found as a comorbid disorder in affective disorders such as depression, narcissism (there as narcissistic sickness), bipolar disorders (1 & 2)30 and borderline (there again significantly more severe and determining the disorder pattern).

It is well known that the symptoms of borderline and ADHD partially overlap (Differential diagnosis of ADHD). However, the neurological causes differ considerably. The dopaminergic system is involved in both disorders. While the dopamine level in the PFC and striatum is reduced in ADHD, it appears to be increased in borderline ADHD.

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.31 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.323334 Since ADHD is characterized by a lack of dopamine in the PFC and 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 fear of rejection and criticism.

2.7. Affiliation motive can eliminate procrastination

The particular importance of the affiliation motive in ADHD is also reflected in the fact that ADHD-HI sufferers find it much easier to carry out activities for someone else that they cannot do for themselves (due to pronounced procrastination). This goes so far that Passig and Lobo recommend as a coping strategy for procrastination that those affected do the activities they procrastinate in exchange for someone else.35

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 a key feature of ADHD.

In a test group of n = 82 girls aged 9 to 12, the n = 42 ADHD sufferers overestimated their social skills significantly more than non-affected persons compared to external assessments (teachers, parents and third-party observers). If oppositional defiant behavior was added, this increased even further, as did reduced depression symptoms. Overconfidence only correlated with the tendency of ADHD sufferers to distort responses in the direction of social desirability (socially desirable reporting bias). In ADHD sufferers, the overestimation of social competence was linked to the degree of imbalance. Overconfidence decreased with increasing balance, whereas it increased with balance in non-affected individuals.

This could be interpreted as an effect of the rejection sensitivity typical of ADHD, particularly due to the bias towards social desirability.

3. Social phobia as a possible consequence of rejection sensitivity

Social phobia is characterized by

  • Central:
    • Fear of scrutiny in manageable groups (not in crowds)
    • Appearance of fear
      • Is usually limited to or predominates in certain social situations, e.g.
        • Food
        • Speaking in public
        • Meet people of the desired sex
      • But can also be indeterminate and occur in almost all social situations outside the family
  • Frequent:
    • Low self-esteem
    • Fear of criticism
  • Possible accompanying phenomena:
    • Blush
    • Avoid eye contact
    • Sweating
    • Trembling
    • Palpitations
    • Diarrhea
    • Nausea
    • Urge to urinate
  • Symptoms can intensify to the point of panic attacks.
  • 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.36
In this sense, social phobia, which is quite common in ADHD, could occur as a result of rejection sensitivity, which has already been 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 subside at the same time. We are not yet aware of any evidence for this.

4. Medication for rejection sensitivity in ADHD

4.1. Methylphenidate

Many ADHD sufferers reported that stimulants had a significant and direct influence on their rejection sensitivity. In this context, 90% reported a positive and RS-reducing influence of MPH, 10% reported a rather increasing influence.

One ADHD sufferer reported that his long-standing intense rejection sensitivity had decreased significantly since treatment with MPH. He also reported that he had experienced several relapses of rejection sensitivity when suitable triggers were present and he had also forgotten to take the MPH medication for just a few hours. The intensity of RS triggered by an evening argument with his girlfriend (outside of the daytime MPH medication) was drastically reduced within 10 minutes of taking MPH.

Methylphenidate significantly reduces the feeling of mistrust in ADHD sufferers.37

4.2. Guanfacine and clonidine

According to a single report by an American doctor (Dodson), a combination of the alpha-2-adrenoreceptor agonists guanfacine and clonidine is particularly effective for rejection sensitivity. He reports that at a dosage of between 0.5 and 7 mg guanfacine and between 0.1 mg and 0.5 mg clonidine, one in three patients loses their rejection sensitivity symptoms. He also reported that the effect on quality of life of this treatment was greater than that of treatment with stimulants.20

Dodson also reports from a Harvard University study that increasing the dosage for guanfacine up to 4 mg and for clonidine up to 7-8 mg results in a 40% higher response, although this dosage is 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 therefore responsible for the effects mediated by adrenaline and noradrenaline.38
Agonists increase the effect of the receptors. As a result, guanfacine and clonidine have a noradrenergic effect and reduce the adrenergic effect.

4.3. MAO-A reuptake inhibitors

Dodson20 goes on to describe successes with MAO-A reuptake inhibitors, in particular with Parnate (tranylcypromine), which has been the usual treatment for rejection sensitivity to date. MAO-A reuptake inhibitors have also been used successfully in relation to ADHD symptoms.

4.4. Imipramine, phenelzine

Imipramine and phenelzine are each said to be more suitable (than valproate) for combating rejection sensitivity, depending on the nature of the other symptoms.39.

Imipramine is a conceivable complementary medication to stimulants for ADHD. However, the mutual enhancement of the effects of imipramine and methylphenidate should be taken into account.

4.5. Valproate for BPD

Valproate (250 mg to 500 mg) moderately improved symptoms of irritability, anger, anxiety, rejection sensitivity and impulsivity in 50% of BPD sufferers. The results varied greatly from person to person.40


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