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Rejection Sensitivity: Sensitivity to Criticism, Fear of Rejection as a Specific Symptom of ADHD

Rejection Sensitivity: Sensitivity to Criticism, Fear of Rejection as a Specific Symptom of ADHD

Author: Ulrich Brennecke
Review: Waldemar Zdero, M.A. in Psychology (March 2014)
Completely revised 09/2026

Rejection Sensitivity (RS) refers to a particularly high sensitivity to rejection (E 1a). Rejection is anxiously anticipated, perceived even at the slightest sign, and experienced as deeply hurtful (E 1a). What matters here is not whether rejection actually occurs, but how deeply a potential or perceived rejection affects the individual (E 1a). Criticism is also perceived as significantly more painful than it is for other people (E 4).

Rejection sensitivity is not a distinct disorder in itself, but rather a personality trait that occurs in many mental disorders, such as borderline personality disorder, narcissistic personality disorder, bipolar disorder, social phobia, depression, and anxiety disorders (E 1a). In the case of ADHD, it has been barely mentioned in the literature to date. However, several studies show that the more severe the ADHD symptoms are, the greater the sensitivity to rejection tends to be (E 2b). This applies to children, adolescents, and adults (E 2b). An older, small study found no association (E 3). In experiments involving deliberately induced exclusion, the results were mixed: a stronger psychological reaction was not observed in all studies, and a stronger physical stress response (heart rate, blood pressure) was not found (E 2a).

Rejection sensitivity is very commonly described by people with ADHD (E 4). Nearly all people with ADHD surveyed by ADxS are familiar with it from their own experience (ADxS survey).

On the Internet, the term “Rejection Sensitive Dysphoria” (RSD) is often used to describe the same experience (E 4). This term was coined by the American physician Dodson (E 4). It is not a scientifically recognized technical term, nor is it a diagnosis (E 1a). Experts warn that it can be misunderstood as a congenital, unchangeable trait and that people with ADHD may use it to devalue themselves (E 4). ADxS therefore uses the term “rejection sensitivity,” in part to avoid confusion with the ADHD symptom of dysphoria associated with inactivity.

According to ADxS, rejection sensitivity is an intrinsic ADHD symptom—that is, directly caused by ADHD—and not merely a consequence of many negative experiences. This is supported by the fact that, according to reports from people with ADHD, stimulants such as methylphenidate often noticeably reduce sensitivity shortly after ingestion (ADxS experience). Further support for this comes from the fact that, according to older studies, the need to belong is linked to the neurotransmitter dopamine, which is underactive in ADHD (E 2b). Psychological models, on the other hand, explain rejection sensitivity with early experiences of rejection and an insecure attachment to parents (E 2b). The two are not mutually exclusive: negative experiences likely reinforce an existing predisposition (ADxS assessment).
To date, there have been no controlled studies on the treatment of RS (E 1a). In addition to stimulants, clinical reports also describe guanfacine, clonidine, and MAO inhibitors as helpful (E 4). In a study using atomoxetine, adults with ADHD and social phobia showed improvement in both symptom areas (E 1b).

In everyday life, rejection sensitivity often leads to withdrawal, hiding one’s feelings, strain in relationships, and a tendency to avoid applying for jobs or submitting assignments out of fear of rejection (E 4). As a counterreaction, some people with ADHD overestimate their social skills (E 3).
High rejection sensitivity can contribute to social phobia—that is, the fear of being judged or rejected in social situations (E 3). Since RS can diminish with ADHD treatment, treating ADHD in this case could also improve the social phobia (ADxS assessment).

1. Rejection Sensitivity (RS)

Implications for People with ADHD

Rejection sensitivity describes an increased sensitivity to rejection that occurs in many mental disorders, not just ADHD (E 1a). It is not a diagnosis, but rather a personality trait (E 1a). Therefore, recognizing this trait in oneself does not automatically mean one has ADHD (ADxS assessment). Nevertheless, a high sensitivity to rejection should be noted during the diagnostic process because it is common in ADHD and has received little attention in the literature to date (ADxS assessment).

Rejection Sensitivity (RS) is the predisposition to

  • anxious anticipation of rejection
  • a willingness to accept rejection and
  • an intense reaction to (actual or perceived) rejection

Rejection sensitivity is a distinct psychological construct and appears as a primary symptom in various disorders (in descending order of severity):

  • Borderline Personality Disorder: Hypersensitivity (Key Symptom) (E 4)1
  • Narcissism: narcissistic sensitivity (key symptom)
  • Bipolar Disorder
  • Social phobia (E 4)1
  • (E 1a): Depression (E 4)1, affecting just under 50% of people with ADHD and bipolar disorder (narrative review, E 1a)23
  • (E 2b): ADHD (E 4)4(E 3)5(E 2b)6(E 3)7
  • Anxiety Disorders (E 4)1

A meta-analysis of 75 studies found moderate associations between rejection sensitivity and depression (r = 0.33), anxiety (r = 0.41), loneliness (r = 0.39), borderline personality disorder (r = 0.41), and body dysmorphic disorder (r = 0.43) (meta-analysis, k = 75, E 1a).8

In the case of ADHD, rejection sensitivity has not yet been addressed as a specific ADHD symptom in the standard (German-language) reference works on ADHD (ADxS assessment).

1.1. Rejection Sensitivity in ADHD

Implications for People with ADHD

The more severe the ADHD symptoms are, the greater the sensitivity to rejection tends to be (E 2b). This has been observed in children, adolescents, and adults (E 2b).

In ADHD, it appears that the irritable reaction to rejection is particularly heightened (E 3). When exclusion is deliberately induced in an experiment, no stronger physical stress response is observed (E 2a). This sensitivity therefore primarily concerns perception and evaluation, rather than physiological arousal (ADxS assessment).

Children with ADHD often like other children more than they are liked in return, which can further increase their sensitivity (E 3). In one study, the ability to consciously enjoy pleasant moments weakened this association (E 3).

(E 4): While being easily offended is frequently cited as a specific and typical characteristic of many people with ADHD (E 4)9(E 4)10, e.g., as being easily offended (E 4)11, as sensitivity to criticism—a subtype of negative hyperfocus (E 4)12, in a questionnaire (“Were you very sensitive and easily offended as a child?”) (E 4)13 or in other descriptions as a consequence of self-esteem issues (E 4)14(E 4)15. Dietrich refers to this as a low tolerance for criticism from one’s social environment or a difficulty in accepting criticism and admitting fault. (E 4)16

Adults with ADHD or high levels of ADHD symptoms reported in written accounts that they frequently faced criticism from others, which had negative consequences for their self-esteem and well-being. As coping strategies, they described avoiding criticism, changing their responses, and self-acceptance (qualitative study, n = 162, E 4).17

(E 4): However, heightened sensitivity is rarely described as a specific symptom of ADHD-I. (E 4)18(E 4)19(E 4)20(E 4)21 In our view, the particular significance of rejection sensitivity as an ADHD symptom is significantly underestimated.

Several large-scale studies have found a clear association between the severity of ADHD symptoms and the presence of rejection sensitivity (community sample with a feedback task, N = 391, E 2b)6 (cross-sectional study, N = 1,235, E 3)7. An older, small study found no association (case-control study, n = 78, E 3).22
One of the studies found a link between people with ADHD’s heightened sense of justice and rejection sensitivity (cross-sectional study, N = 1,235, E 3).7

A review of 21 studies that assessed rejection sensitivity using the Rejection Sensitivity Questionnaire found consistent associations with borderline symptoms, depression, social anxiety, and aggression, but found no association with ADHD or psychotic symptoms (systematic review, n = 21, E 1a).23

Among Hungarian students, ADHD symptoms (ASRS) and rejection sensitivity (A-RSQ) correlated with a coefficient of r = 0.46 (p < 0.01). Well-being, creative-executive efficiency, self-regulation, and resilience partially mediated this relationship. The ability to consciously savor positive experiences (savoring) moderated the relationship and nullified it when levels were high. (Cross-sectional study, N = 304, E 3)24 Among U.S. students, ADHD symptoms and rejection sensitivity also correlated positively. High rejection sensitivity weakened the association between ADHD symptom severity and cannabis use as well as cannabis-related problems. (Cross-sectional study, N = 4,150, E 3)25

Among 8- to 12-year-old children with elevated ADHD symptoms, the ADHD symptoms correlated with irritable rejection sensitivity (r = 0.55; p < 0.001), but not with anxious rejection sensitivity. Only angry rejection sensitivity strengthened the association between ADHD and anxiety symptoms. (Cross-sectional study, N = 120 parent reports, of which n = 69 children provided self-reports, E 3)26

Following experimentally induced social exclusion (Cyberball), adults with more severe ADHD symptoms reported a greater threat to their basic social needs (belonging, control, self-esteem, a meaningful existence; r = -0.44; p < 0.001), while heart rate and blood pressure during and after the exclusion did not differ from those of the control group. (Cross-sectional study with experimental exclusion, N = 60, E 3)27 ADHD was assessed only via ASRS screening (61.7% positive, only n = 13 with a reported diagnosis), rejection sensitivity was assessed only indirectly via the Need-Threat Scale and exclusively after exclusion; there were no inclusion criteria serving as a control. The journal is a peer-reviewed publication for student research papers.

Among first-graders, simulated exclusion from a game led to anger, sadness, or anxiety in 96% of cases, with 62% reporting severe distress and 38% reporting only mild distress or none at all. This reactivity to exclusion was associated with hyperactivity (β = 0.27; p = 0.04), but not with inattention, and independently predicted aggression (β = 0.19; p = 0.02). However, it did not mediate the relationship between hyperactivity and aggression (cross-sectional study, N = 171, of whom 107 met ADHD diagnostic criteria and 23 had subclinical ADHD, E 3)28 The authors explicitly leave open whether this early rejection reactivity represents a precursor to rejection sensitivity as measured later. The term “rejection sensitivity” is not used for this age group. Mean age: 5.2 years. Cross-sectional design; therefore, no causal conclusions can be drawn.

Following exclusion in the Cyberball paradigm (only 2 out of 50 balls thrown to the participant), the mood of 10- to 15-year-old adolescents with ADHD symptoms did not deteriorate any more than that of the control group. Only the binge-eating group showed a greater increase in negative mood than the other two groups (Group × Time: F(2,85) = 2.89; p < 0.10; partial η² = 0.06; post hoc p < 0.05). Impulsivity in the stop-signal task increased in the binge-eating group and decreased in the ADHD group following exclusion (Group × Time: F(2,85) = 3.17; p < 0.05; partial η² = 0.07). Before exclusion, the groups did not differ in impulsivity. Mood and impulsivity were not correlated (experimental study, N = 88, of whom n = 33 had ADHD symptoms, n = 23 had binge eating, n = 32 controls, E 2a)29 ADHD group: at least four DSM-IV-TR criteria (inattention and/or hyperactivity/impulsivity), onset before age 7, cross-situational, screening via DISYPS-II, and confirmation in a diagnostic interview (Children’s DIPS). Recruitment via schools and advertisements; not a clinical sample; ADHD medication was an exclusion criterion. Negative mood measured using the six-item short form of the PANAS-C. The group × time effect for mood was only marginally significant (p < 0.10); the post hoc difference between the binge-eating group and the other two groups was p < 0.05. The findings do not support the notion of a generally heightened emotional response to social exclusion among adolescents with ADHD symptoms. The study was not specifically designed for ADHD but used the ADHD group as an impulsive control group for binge eating disorder.

Among adults with mood disorders, retrospectively reported childhood ADHD symptoms correlated with current interpersonal sensitivity (r = 0.31; p < 0.001). When broken down by dimension, the association was strongest for the self-esteem/negative mood dimension (r = 0.37; β = 0.34; p < 0.001), weaker for inattention/school problems (β = 0.15; p = 0.003), while the impulsivity/behavioral problems dimension predicted lower interpersonal sensitivity (β = −0.11; p = 0.016) (cross-sectional study, N = 755, E 3)30 Childhood ADHD symptoms were assessed retrospectively using the WURS-25, and interpersonal sensitivity was assessed using the Interpersonal Sensitivity Measure. All values are from Bonferroni-corrected partial correlations or FDR-corrected path analysis, adjusted for age, diagnosis, gender, education, employment status, marital status, and alcohol and smoking status. Limitations: purely clinical sample (287 with major depression, 468 with bipolar disorder), no ADHD diagnoses, retrospective self-report, cross-sectional study. The opposite direction of the impulsivity dimension suggests that there is no consistent association between ADHD and sensitivity to rejection.

In a large-scale study, children with ADHD showed, on average, significantly more sympathy toward other children than they received from them in return (observational study, MTA sample, E 3).31

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 the condition based on group surveys (observational study, MTA sample, E 3).31
ADHD symptoms and the resulting social rejection (peer rejection) between the ages of 4 and 6 form a mutually reinforcing vicious cycle (cohort study, E 2b).32 From ages 6 to 8, only social rejection influenced ADHD symptoms; the reverse was no longer true (cohort study, E 2b).32 Social rejection causes stress, and stress triggers current ADHD symptoms (ADxS assessment). Especially in early childhood, stress manifests the genetic predisposition, thereby influencing the severity of ADHD throughout one’s entire life (ADxS assessment).

However, actual rejection by others is not a measure of rejection sensitivity (E 1a).
Rejection sensitivity is characterized not by objective rejection by others, but by vulnerability to subjectively perceived rejection. It involves sensitivity to actual rejection on the one hand and the perception of supposed rejection and rejection on the other (E 1a).

1.2. Conceptual Distinction from “Rejection-Sensitive Dysphoria” (RSD)

Implications for People with ADHD

The term “Rejection Sensitive Dysphoria” (RSD), which is widely used on the Internet, refers to the same experience but is not a recognized technical term or diagnosis (E 1a). It stems from the clinical experience of a single American physician (E 4). Reports from people with ADHD confirm this experience: withdrawal, hiding one’s feelings, physical sensations such as nausea or tightness, and avoiding job applications and relationship stress (E 4). Experts nevertheless advise against using the term RSD because it makes sensitivity appear innate and unchangeable, and people with ADHD may use it to devalue themselves (E 4).
ADxS therefore uses the term “rejection sensitivity.”

We consider rejection sensitivity, on the one hand, and dysphoria (during inactivity), on the other, to be two primary symptoms—that is, symptoms directly caused by ADHD (even though they frequently occur together in ADHD) (ADxS assessment). To avoid confusion with the specific ADHD symptom of dysphoria (during inactivity), we use the term “rejection sensitivity.”

(E 4): In some cases, the term “Rejection Sensitive Dysphoria” (RSD) is used instead of “rejection sensitivity” in reference to ADHD. (E 4)33(E 4)19

Dodson and colleagues described four people with ADHD who also had RSD, defined as sudden, physically painful dysphoric episodes following actual or perceived rejection, criticism, or self-criticism, that could not be attributed to any affective, anxiety, or personality disorder. All four responded to guanfacine (0.5 to 7 mg/day). The authors cited clonidine and MAO inhibitors as additional clinically used options. Controlled studies are lacking. (Case series, n = 4, E 4)34

However, the term “dysphoria” does not refer to true dysphoria here; rather, it refers to rejection sensitivity as such, which is regarded as a specific form of atypical depression. (E 4)35 Winkler, who was likely one of the first in the German-speaking world to describe rejection sensitivity in ADHD, establishes—with reference to Dodson—a direct link between rejection sensitivity and mood swings/dysphoria in ADHD (E 4)36, whereby he appears to regard rejection-sensitive dysphoria as a form of atypical depression.(E 4)37

In focus groups with young adults with ADHD, 33 out of 43 participants reported RSD (women: 30 out of 36; men: 3 out of 7). Triggers included perceived social exclusion, negative feedback, and perceived rejection. Some participants interpreted their RSD as a learned consequence of repeated rejections. (Qualitative study, focus groups, N = 43, E 4)38 People with ADHD described rejection sensitivity as a trigger for withdrawal, masking their feelings, and unpleasant physical sensations, even leading to avoiding job applications and submitting assignments out of fear of rejection. (Qualitative study, focus groups, n = 5, E 4).39

Several of the eight female students diagnosed with ADHD in adulthood described RSD as part of their emotional dysregulation, alongside low self-esteem and experiences of stigmatization. (Qualitative study, interviews, n = 8 women, E 4)40 The statement reproduced in the full text—that RSD affects an estimated 99% of adults with ADHD—is not the study’s own finding but rather adopts Dodson’s unsubstantiated clinical estimate. The study’s only original finding is that several participants described RSD.

In an open-ended survey on the negative effects of ADHD on romantic relationships, adults with ADHD identified rejection sensitivity as one of four overarching themes (“Too Much and Never Enough: The Emotional Rollercoaster of Rejection Sensitivity”), alongside the emotional and practical strain on relationship dynamics and the importance of self-understanding. (Qualitative study, N = 355, E 4)41 The authors’ term is “rejection sensitivity dysphoria”; the topic itself is referred to as “rejection sensitivity.”

A critical reflection on the concept of RSD traced its origins: Dodson came across Wender’s description of the sensitivity to criticism among adults with ADHD; he then surveyed his own patients, 99% of whom recognized themselves in this description, and one-third of whom described this sensitivity as the most challenging aspect of their ADHD, and, on this basis, declared RSD to be an ADHD symptom that responds exclusively to the alpha-2 agonists clonidine and guanfacine. The addition of “dysphoria” was intended to distinguish its intensity from that of the established concept of “rejection sensitivity.” However, the Greek word does not mean “unbearable,” as Dodson stated, but rather “discomfort.” As early as the 1960s and 1970s, rejection-sensitive dysphoria had been unsuccessfully proposed as a subtype of depressive disorder. (Discussion contribution, E 4)42
The reflection identified the following risks associated with clinical use: an increase in (self-)stigmatization due to a medicalizing, categorical concept, the framing of these conditions as innate rather than trauma-induced, while neglecting social environmental factors; terminological fragmentation alongside interpersonal sensitivity, rejection sensitivity, and social pain; and the limited empirical evidence: On average, people with ADHD or autism showed only slightly stronger reactions to rejection, which did not differ from other rejection-sensitive groups either quantitatively or qualitatively. For interprofessional communication, the established continuum of rejection sensitivity is recommended; in treatment, adopting the language of people with ADHD is advised. (Discussion contribution, E 4)42The author’s own empirical evidence pertains to autistic adults, not ADHD (stronger reactions to rejection fully explained by lower self-esteem; Social Pain Questionnaire M = 2.33 on a scale of 0 to 4 compared to the clinical cutoff value M = 2.16). Van Asselt explicitly classifies the widely cited figure of approximately 20,000 critical remarks before the age of 12 as an estimate derived from popular media.

A scoping review on RSD identified only 12 relevant studies (four qualitative, six experimental, and two cross-sectional studies) out of 1,285 titles reviewed. The construct definitions and measurement methods varied considerably. Only 2 of the 12 studies defined the construct under investigation at all; the quantitative findings regarding the intensity of the rejection reaction were contradictory; and no study examined reactions to criticism or interventions (scoping review, k = 12, E 1a)43 The included studies focused on adults with autism or adults with high levels of autistic traits, not ADHD.

In individual interviews with seven neurodivergent adults, four of whom had ADHD, the participants had very different understandings of RSD. Their descriptions were clearly influenced by accounts they had read previously. The author concluded that RSD should not be understood as an innate, unavoidable characteristic of neurodivergent people, but rather as something triggered and maintained by environmental factors such as other people and institutions. (Qualitative study, n = 7, E 4)44The researcher is personally affected and explicitly incorporates her own experience into her methodology (Standpoint Theory).

2. Rejection Sensitivity as an Original Symptom of ADHD

Implications for People with ADHD

This section explains why, according to ADxS, sensitivity to rejection is an integral part of ADHD and does not result solely from negative experiences. This is important because it means that ADHD treatment can also improve this sensitivity (ADxS experience). However, sensitivity to rejection alone does not prove ADHD, as it also occurs in many other disorders (E 1a).

The term “rejection sensitivity” as used here to refer to an inherent symptom of ADHD means that rejection sensitivity in ADHD is a symptom directly caused by ADHD itself (just like attention problems or hyperactivity) and is not merely a consequence of negative experiences over a long period of time (ADxS assessment).
However, hyperactivity is not exclusive to ADHD. Hyperactivity is therefore not a symptom unique to ADHD. Hyperactivity alone is by no means evidence of ADHD (according to ADxS).

2.1. Sensitivity to rejection is more than just a psychological reaction

Implications for People with ADHD

People with ADHD are, in fact, rejected more often than others in everyday life (E 2b). This was demonstrated in an experiment in which even simulated ADHD-typical behavior was rejected significantly more strongly than unremarkable behavior (E 2b). Such experiences contribute to the fear of rejection, but, according to ADxS, do not explain its intensity and frequency (ADxS assessment). A study of healthy individuals also showed that the physical stress response to exclusion did not depend on sensitivity to rejection, but rather on the desire to belong (E 2b).

At first glance, it seems reasonable to attribute the hypersensitivity to rejection among people with ADHD to

  • lifelong negative social experiences with one’s environment and the resulting severe impairment of self-esteem,
  • the feeling of being different, of not belonging (E 2b)45, as well as
  • caused by genetically induced hypersensitivity (DRD4-7R, 5-HTTLPR, COMT Met-158-Met; see the section on “Opportunity/Risk Genes” at ⇒ How ADHD Develops: Genes + Environment) (sensitivity and vulnerability due to a stimulus filter that is too open) or
  • generally low self-esteem (E 4)15

Certainly, lifelong, largely negative experiences with other people contribute to the development of a fear of rejection (ADxS assessment).

While this difference is relevant, it cannot, on its own, explain the rejection sensitivity observed in people with ADHD (ADxS assessment).

Videos in which an actress exhibited ADHD-typical behavior as scripted were significantly more strongly rejected by students than a video featuring typical behavior (d = 1.97). Videos depicting depressive behavior were rejected even more strongly (d = 2.76; difference from the ADHD depiction: d = 0.79). The depiction of ADHD triggered a hostile mood among viewers (d = 0.71), while the depiction of depression triggered a depressed mood (d = 0.67) (analog experiment, N = 130, E 2b).46

In our view, the severity with which people with ADHD suffer from rejection sensitivity and its high prevalence among people with ADHD cannot be explained solely by the additional stressful experiences these people encounter throughout their lives as a result of the consequences of their difficulties with others. Since rejection sensitivity also occurs in other mental disorders—where it is not perceived as a “mere” consequence of self-esteem issues (narcissism: narcissistic vulnerability; borderline personality disorder: core symptom), we believe the likelihood of it being a learned response is further reduced (ADxS assessment).

 

A study of healthy participants showed that the personality trait of “need to belong,” but not the trait of rejection sensitivity, predicted an elevated cortisol response (typical of stress) as well as greater perceived stress and negative affect following exclusion from participation in a group game (experimental study involving exclusion, n = 132, E 2b).47

2.2. Stimulants immediately reduce rejection sensitivity

Implications for People with ADHD

Most of the people with ADHD surveyed by ADxS reported that their sensitivity to rejection rapidly decreases while taking methylphenidate (ADxS experience). Controlled studies on this topic are currently lacking (E 1a). An improvement while on the medication suggests that this sensitivity is directly related to ADHD (ADxS assessment). If it remains unchanged while on the medication, this should be discussed with the treating physician (ADxS assessment).

Most of the people with ADHD surveyed here confirmed an immediate improvement in rejection sensitivity following treatment with methylphenidate (ADxS experience).

For people with ADHD, 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 people with ADHD. From our perspective, the direct effect of medication on the intensity of rejection sensitivity leaves no room for any conclusion other than that this is a direct (neurophysiologically mediated) symptom of ADHD (ADxS assessment).
The fact that dopaminergic stimulants have a positive effect on symptoms could be logical in light of the modulation of the affiliation motive by dopamine, as described below in section 2.6 (ADxS assessment).
It is therefore presumed that RS has a direct neurophysiological manifestation in the sense of a specific neurophysiological mechanism of action (ADxS assessment).

2.3. Early Childhood Stress as a Cause of Rejection Sensitivity

Implications for People with ADHD

Psychological models explain sensitivity to rejection as stemming from early experiences of rejection, particularly by primary caregivers (E 2b). This gives rise to a kind of defense mechanism: potential rejection is anticipated with great vigilance, and if it is perceived as certain, intense consequences such as withdrawal, anger, or despair follow (E 2b). The better one is able to regulate emotions, the easier it is to curb these reactions (E 4). Training in emotional regulation can therefore be helpful (ADxS assessment).

 

Psychological models of rejection sensitivity attribute this to early, persistent, or acute experiences of rejection by attachment figures, which activate the DMS (“Defensive Motivational System” according to Lang and Gray: the defensive of the two behavior-regulating motivational systems, which initially leads to vigilance and behavioral inhibition in the face of impending rejection, and to fight-or-flight reactions when rejection is perceived as certain), as well as a defense mechanism (excessive caution as protection against unexpected harm), whose overreactions can only be inhibited with sufficient (emotional) self-regulation. (Overview chapter, E 4)48 (Experimental study, E 2b)49

2.4. Rejection Sensitivity and Attachment Styles

Implications for People with ADHD

A secure attachment in childhood protects against increased sensitivity to rejection (E 3). Adolescents with insecure attachments—particularly those with an insecure-avoidant attachment style—exhibited the highest sensitivity and, at the same time, the most ADHD symptoms (E 3). For parents of children with ADHD or at risk for ADHD, a reliable and sensitive relationship is therefore particularly important (ADxS assessment). Guidance on this can be found in the chapter on prevention.

Different attachment styles are strong predictors of rejection sensitivity (not only in ADHD) (E 3).

A secure attachment style showed the most favorable outcomes and was least affected by rejection sensitivity. An insecure-preoccupied attachment style was associated with the most ADHD symptoms as well as the strongest anxious and angry expectations of rejection, even more so than an insecure-dismissing attachment style. (Cross-sectional study, N = 508, E 3)50 Against this background, rejection sensitivity could be understood as a direct expression of an insecure attachment (ADxS assessment).

This fits with the current understanding that even an insecure attachment style can cause enough stress in early childhood to trigger a genetic predisposition to mental health problems (here, and particularly in the case of ADHD, due to the hypersensitivity associated with it) (ADxS assessment).

Learn more about attachment styles and what parents can do to prevent problems: ⇒ Attachment Styles in the chapter ⇒ Prevention.

2.5. Similar symptoms in similar clinical presentations

Implications for People with ADHD

Increased sensitivity to rejection also occurs in depression, borderline personality disorder, and narcissism, where it is sometimes even more pronounced than in ADHD (E 1a). It is therefore not evidence of ADHD (ADxS assessment). These disorders should be taken into account during diagnosis because the symptoms of ADHD and borderline personality disorder overlap in some respects, even though the underlying brain mechanisms are different (ADxS assessment).

The symptom of rejection sensitivity does not occur exclusively in ADHD, but is also present in affective disorders such as depression (in nearly 50% of people with ADHD and MDD and bipolar disorder) (Narrative review, E 1a)51 as well as—even more prominently and as one of the main symptoms—in narcissism (where it is referred to as narcissistic vulnerability) and borderline personality disorder.

As is well known, the symptoms of borderline personality disorder and ADHD overlap to some extent (⇒ Differential Diagnosis for ADHD). However, the neurological causes differ significantly (ADxS assessment). The dopaminergic system is involved in both disorders. While dopamine levels in the PFC and striatum are reduced in ADHD, a dysfunction of the dopamine system is suspected in borderline personality disorder (E 4).

The efficacy of antipsychotics (dopamine antagonists) in borderline personality disorder suggests increased dopaminergic activity. Direct evidence is lacking. (Hypothesis article, E 4)52

2.6. The motivation to belong is regulated by dopaminergic mechanisms

Implications for People with ADHD

According to older studies, the need to belong is linked to the neurotransmitter dopamine (E 2b). In ADHD, dopamine is underactive in certain areas of the brain (E 1a). This could explain why rejection is experienced as particularly painful in ADHD and why dopaminergic medications can reduce this sensitivity (ADxS assessment). However, the underlying studies are small and outdated, so this remains a hypothesis (ADxS assessment).

Motivation is mediated by different neurotransmitters depending on the type of motive. In terms of motives, motivation can generally be divided into the following groups: the power motive, the affiliation motive, and the achievement motive. (E 4)53 The fear of rejection specifically addresses the affiliation motive, not the achievement motive and not the power motive (ADxS assessment).

 

In McClelland’s studies, activation of the affiliation motive alone was associated with increased dopamine release, whereas the power motive was associated with a urinary marker of norepinephrine turnover (MHPG) and the achievement motive with an indirect marker of vasopressin release (decreased urine flow).(Experimental studies, n = 61 and n = 47, E 2b)54 (Observational study, n = 24, E 3)55 (Experimental study, n = 46, E 2b)56 Since ADHD is characterized by a dopamine deficiency in the PFC as well as in the striatum—the brain’s reward and reinforcement center—it seems plausible from this perspective that people with ADHD are particularly susceptible to fear of rejection and criticism (ADxS assessment).

2.7. A Sense of Belonging Can Help Overcome Procrastination

Implications for People with ADHD

Tasks that people with ADHD repeatedly put off for themselves are easier for them to complete when they are done for someone else (ADxS experience). The desire to belong acts as a motivator in this context (ADxS assessment). As a strategy to combat procrastination, it can therefore be agreed that people will take turns completing each other’s postponed tasks (E 4).

The particular significance of the need for belonging in ADHD is also evident in the fact that people with ADHD-HI find it much easier to perform for someone else the very task they are unable to perform for themselves (due to pronounced procrastination) (Experience ADxS). This goes so far that Passig and Lobo recommend, as a coping strategy for procrastination, that people with ADHD complete the tasks they have been putting off in exchange for having someone else do them. (E 4)57

2.8. Overestimation of one’s own social skills as a possible consequence of RS

Implications for People with ADHD

Some people with ADHD rate their social skills higher than others perceive them to be (E 3). This may be a defensive reaction to the fear of rejection (ADxS assessment). Feedback from trusted individuals can help provide a realistic picture of one’s own impact on others (ADxS assessment).

People with ADHD often overestimate their own social skills (E 3). This symptom is not severe enough to be considered a defining feature of ADHD (ADxS assessment).

 

In a test group of N = 82 girls aged 9 to 12, the n = 42 girls with ADHD significantly overestimated their social skills compared to external assessments (by mothers, teachers, and blinded observers of a social laboratory task) to a much greater extent than people without ADHD. When oppositional defiant behavior was present, this effect was further amplified; the same was true when depressive symptoms were reduced. The overestimation of social competence correlated only among people with ADHD with a tendency to skew responses toward social desirability (socially desirable reporting bias). Among girls with ADHD, overestimation of social competence was also associated with poorer psychosocial adjustment, whereas among girls without ADHD, it was associated with better adjustment. (Case-control study, N = 82, n = 42, E 3)58

This could be interpreted as a consequence of the rejection sensitivity typical of ADHD, particularly given the bias toward social desirability (ADxS assessment).

3. Social Phobia as a Possible Consequence of Rejection Sensitivity

Implications for People with ADHD

A high sensitivity to rejection can contribute to social phobia—that is, the fear of being observed, judged, or rejected in groups (E 3). Social phobia is more common in people with ADHD than in the general population (E 3). Since sensitivity to rejection can decrease with ADHD treatment, social phobia resulting from this sensitivity may also improve (ADxS assessment). In one study, atomoxetine reduced symptoms in both areas among adults with ADHD and social phobia (E 1b). Whether this occurs through reduced sensitivity to rejection has not been investigated (E 1b).

Social phobia is characterized by:

  • Central:
    • Fear of being scrutinized in small groups (not in crowds)
    • The onset of anxiety
      • is usually limited to or predominant in certain social situations, e.g.,
        • Food
        • Public Speaking
        • Meeting people of the opposite sex
      • but it can also be non-specific and occur in almost any social situation outside the family
  • Common:
    • low self-esteem
    • Fear of criticism
  • Possible associated phenomena:
    • Blushing
    • Avoiding eye contact
    • Sweating
    • Trembling
    • Rapid heartbeat
    • Diarrhea
    • Nausea
    • Urge to urinate
  • Symptoms can escalate to the point of panic attacks.
  • Phobic situations are avoided.
  • Often begins during adolescence
  • Pronounced avoidance behavior can lead to complete social isolation

A very pronounced rejection sensitivity is said to be capable of triggering social phobia. (E 4)59

 

In meta-analyses, rejection sensitivity is moderately associated with anxiety (r = 0.41) (meta-analysis, k = 75, E 1a).8

Among adults with social phobia, higher interpersonal sensitivity was associated with ADHD in childhood. Interpersonal sensitivity also correlated positively with the severity of social phobia symptoms and negatively with the age of onset of social phobia (cross-sectional study, N = 125, E 3).60

In this sense, social phobia—which is indeed observed more frequently in ADHD—could arise as a consequence of rejection sensitivity, a symptom already described above as a primary symptom of ADHD (ADxS assessment). Since rejection sensitivity, as an ADHD symptom, can subside with treatment using ADHD medications, a social phobia as a consequence of pronounced rejection sensitivity would, in theory, also subside at the same time (ADxS assessment).

In a randomized, placebo-controlled trial of adults with ADHD and comorbid social phobia, atomoxetine reduced both ADHD symptoms and symptoms of social phobia (LSAS total score: −22.9 vs. −14.4; p < 0.001). Whether this effect is mediated by a reduction in rejection sensitivity was not investigated. (RCT, N = 442, n = 224 receiving atomoxetine 40 to 100 mg vs. n = 218 receiving placebo, 14 weeks, E 1b)61

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