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

Author: Ulrich Brennecke
Review: Dipl.-Psych. Waldemar Zdero

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 so far not been treated as an ADHD symptom, although sensitivity to rejection is often described as a characteristic of people with ADHD. 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 people with ADHD. Almost all of the people with ADHD 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)
  • 1.1. Rejection sensitivity in ADHD
  • 1.2. Differentiation from “Rejection Sensitive Dysphoria” (RSD)
• 2. Rejection sensitivity as an original symptom of ADHD
  • 2.1. Rejection sensitivity is more than a psychological reaction
  • 2.2. Stimulants directly reduce rejection sensitivity
  • 2.3. Early childhood stress experience as a cause of rejection sensitivity
  • 2.4. Rejection sensitivity and attachment styles
  • 2.5. Similar symptoms with similar disorders
  • 2.6. Affiliation motive is dopaminergically controlled
  • 2.7. Affiliation motive can eliminate procrastination
  • 2.8. Overestimation of own social skills as RS
• 3. Social phobia as a possible consequence of rejection sensitivity

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, here in 50% of people with ADHD with severe depression²
• ADHD³⁴
• 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 patients⁵⁶ , e.g. as quick offendedness⁷, as sensitivity to criticism as a sub-case of negative hyperfocus⁸, in a questionnaire (Were you very sensitive and offended as a child?)⁹ or in other descriptions as a consequence of self-esteem problems¹⁰¹¹ . Dietrich calls this a low tolerance of criticism from the social environment or a difficulty in accepting criticism and admitting guilt.¹²

Only rarely, however, is Rejection Sensitivity described as a specific ADHD-I symptom.^13141516 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 correlation between the severity of ADHD symptoms and the existence of rejection sensitivity¹⁷¹⁸ An older small study found no correlation.¹⁹
One of the studies established a link between the increased sense of justice of people with ADHD and Rejection Sensitivity.¹⁸

Persons with ADHD perceive themselves much more as outsiders and “not integrated into the group” than, conversely, the group perceives the people with ADHD.

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.²²²³

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.²⁴ 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 Dodson²⁵, whereby he probably considers rejection sensitive dysphoria to be a form of atypical depression.²⁶

We consider Rejection Sensitivity on the one hand and Dysphoria (during inactivity) 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 formulation 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 period of time.
Nevertheless, RS is not unique 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 people with ADHD 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-esteem¹¹

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

Although this difference is relevant, it cannot explain the rejection sensitivity of people with ADHD on its own.

In our opinion, the extent to which people with ADHD suffer from Rejection Sensitivity and the high frequency of its occurrence in ADHD cannot be explained solely by the stressful experiences that people with ADHD also have with other people in the course of their lives as a consequence of their problems. Since Rejection Sensitivity also occurs in other mental disorders, where it is not perceived as a “mere” consequence of a self-esteem problem (narcissism: narcissistic insultability; 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.²⁸

2.2. Stimulants directly reduce rejection sensitivity¶

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

For people 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 the persons with ADHD. 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.
The fact that dopaminergic stimulants have a positive effect on symptoms could be conclusive in view of the modulation of the affiliation motive by dopamine described below under 2.6.
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 people with ADHD to actively avoid and fight-or-flight reactions) and form a defense mechanism (overcaution as protection against unexpected injury), which can no longer be adequately controlled due to inadequate (emotional) self-regulation.²⁹³⁰

2.4. Rejection sensitivity and attachment styles¶

Different attachment styles clearly predict Rejection Sensitivity (not only 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.³¹ 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 mental health problems (here and especially 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 is not exclusive to ADHD, but can be found as a comorbid disorder in affective disorders such as depression (in 50% of people with ADHD³² and, even more clearly and as one of the main symptoms, in narcissism (as narcissistic sickness) and borderline.

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.

2.6. Affiliation motive is dopaminergically controlled¶

Motivation is mediated by different neurotransmitters depending on the type of motive. In terms of motives, motivation can basically be divided into the groups of power motive, affiliation motive and achievement motive.³³ In the case of fear of rejection, the affiliation motive is specifically addressed, not the achievement motive or the power motive. Only the affiliation motive is dopaminergically controlled.³⁴³⁵³⁶ Since ADHD is characterized by a dopamine deficiency in the PFC and in the striatum, the reward and reinforcement center of the brain, it seems plausible from this point of view that people with ADHD 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 shown by the fact that people with ADHD-HI 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 people with ADHD do the activities they procrastinate in exchange for someone else.³⁷

2.8. Overestimation of own social skills as RS¶

People with ADHD often overestimate their own social skills. This symptom is not so serious that it could be described as a contributing factor to ADHD.

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.³⁸
In this sense, social phobia, which is quite common in ADHD, could occur as a consequence 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.