When Rejection Feels Like a Physical Wound: Understanding RSD
When Rejection Feels Like a Physical Wound: Understanding RSD
A Counsellor’s Perspective
October is ADHD Awareness Month. Awareness is about more than knowing that ADHD exists. It is an opportunity to increase understanding, challenge outdated stereotypes, make space for lived experience, and share accurate, practical information about the many ways ADHD can affect everyday life.
Throughout October, I am sharing a series of blogs exploring some of the less visible parts of ADHD, including emotional dysregulation, rejection sensitivity, masking, perfectionism, relationships, and the ways people may learn to cope and protect themselves.
In this first article, I want to look at an experience that many people with ADHD describe but may struggle to put into words: rejection sensitive dysphoria, often called RSD.
When a Small Moment Feels Anything but Small
In counselling, I sometimes hear people describe a moment that seems ordinary from the outside but feels enormous on the inside.
A supervisor offers constructive feedback.
A friend replies differently than usual.
Someone does not answer a text.
A partner seems distracted.
You realize you made a mistake.
Suddenly, there may be a sinking feeling in your stomach, tightness in your chest, shame, panic, anger, sadness, or an overwhelming sense that you have done something terribly wrong. The emotional reaction can arrive so quickly that there is little time to make sense of what is happening.
Then another reaction often follows:
Why am I taking this so hard?
Why can’t I just let it go?
Why does this feel so much bigger than it should?
These are some of the experiences people may be describing when they use the term RSD.
What Is Rejection Sensitive Dysphoria?
RSD is a term used to describe an unusually intense emotional response to actual or perceived rejection, criticism, exclusion, disappointment, or failure.
It is important to make one distinction early: RSD is not currently a standalone mental health diagnosis. It is not listed as a separate diagnosis in the DSM or ICD. Psychiatrist Dr. James Kustow describes it instead as a clinical description that many people, particularly people with ADHD, strongly recognize in their own experience. He also cautions that research specifically examining RSD is still developing and that important questions remain unanswered. (Kustow, 2026)
The broader concept of rejection sensitivity has a longer research history. It has been described as a tendency to anxiously expect, quickly perceive, and intensely respond to rejection. Research in this broader area suggests that rejection sensitivity can involve heightened emotional reactivity, increased attention to possible social threat, and difficulty regulating distress once it has been activated, including when social cues are ambiguous. (Kustow, 2026)
For me, that distinction matters.
A person does not need another label added to their identity for their experience to be meaningful. We can take rejection sensitivity seriously while also being careful not to claim that the science knows more than it currently does.
Looking at RSD Through the Lens of Dysregulation
In my counselling work, I find it helpful to understand rejection sensitivity through the broader lens of dysregulation.
Something happens.
Your system reacts.
Your body may become activated before you have had much opportunity to think through what the situation means.
Once that activation becomes intense, it can become harder to slow down, tolerate uncertainty, consider alternative explanations, or decide how you want to respond.
Kustow describes a similar sequence: a trigger produces a body response, the response is given meaning or interpreted, emotion follows, and behaviour comes next. When someone is highly dysregulated, even ambiguous situations may begin to feel threatening. (Kustow, 2026)
One idea will be important throughout this series:
The intensity of a feeling is real, but the intensity of the feeling does not necessarily tell us whether our interpretation of the situation is accurate.
Sometimes rejection really happened.
Sometimes criticism was unfair.
Sometimes someone’s behaviour genuinely was hurtful.
Other times, information is missing and our mind is trying to fill in the blanks.
Counselling is not about convincing someone that their feelings are wrong. It is about creating enough space to explore what happened, what the person felt, what they understood it to mean, and what they need next.
Rejection Does Not Always Look Like Rejection
Some triggers are obvious. Others are much more subtle.
A short text such as “okay.”
A change in someone’s tone.
A pause before someone answers.
A friend cancelling plans.
Seeing other people together on social media.
Being corrected at work.
Someone disagreeing with you.
Feeling that you disappointed someone.
Or even disappointing yourself.
Psychoeducational resources on RSD also identify ambiguous responses, overthinking social interactions, reminders of previous rejection, anticipated criticism, unexpected changes in another person’s behaviour, and perceived failure as common situations in which rejection sensitivity may become activated. (NAMI Mercer, RSD Toolkit)
The difficult part is often uncertainty.
When we do not know what another person is thinking or why something happened, the brain may begin creating a story to explain it.
And when rejection is something we already fear, that story can become painful very quickly.
The Ways We Learn to Protect Ourselves
Over time, some people begin changing their behaviour to reduce the chance of experiencing rejection again.
You might become extremely good at keeping other people happy.
You might apologize even when you have done nothing wrong.
You may work twice as hard so nobody can criticize you.
You might avoid asking for help because you do not want to appear incapable.
Or you may stop putting yourself in situations where rejection could happen at all.
Kustow describes three particularly common protective patterns: self-abandonment or people-pleasing, avoidance or withdrawal, and perfectionism. He suggests understanding these responses as attempts to create safety rather than simply viewing them as personality flaws. (Kustow, 2026)
I think that shift is important.
Instead of asking:
What is wrong with me?
We can become curious:
What has this behaviour been trying to protect me from?
And eventually:
Is this protection still helping me, or is it beginning to cost me something?
That cost might be exhaustion, resentment, missed opportunities, difficulty setting boundaries, strained relationships, or gradually losing touch with what you actually want.
We will explore those protective patterns much more closely later in this series.
What Can Counselling Help With?
Because RSD itself is not a formal diagnosis, I do not approach counselling as though there is one standardized “RSD treatment.”
Instead, we can work with the experiences surrounding it.
That might include learning to recognize triggers and early signs of activation, experimenting with regulation strategies, separating feelings from assumptions, developing more flexible interpretations, working with shame and self-criticism, setting boundaries, communicating needs, reducing avoidance, or repairing relationships after a dysregulated response.
Current clinical discussion of rejection sensitivity also emphasizes education, learning personal triggers, pausing before reacting, grounding, developing perspective, strengthening the relationship with oneself, and addressing relationship patterns. (Kustow, 2026)
Different people will need different tools.
My approach is not to decide for a client which strategy should work. It is to help them explore, notice, and choose what works for them.
A Small Place to Begin
The next time you notice rejection sensitivity showing up, try noticing three things before trying to fix anything:
What happened? What did I actually observe?
What did I feel? Notice both the emotion and what happened in your body.
What did my mind decide it meant?
You do not have to challenge the thought immediately.
You do not have to talk yourself out of the feeling.
For now, just begin noticing the difference between what happened, what you felt, and what you understood it to mean.
That small distinction can become the beginning of more choice.
Rejection sensitivity can be deeply painful, but the goal is not to become someone who never feels hurt, criticized, disappointed, or rejected. The goal is to develop more ways of responding when those feelings arrive, without automatically abandoning yourself, attacking yourself, or allowing the fear of rejection to make your decisions for you.
In the next article in this ADHD Awareness Month series, we will look inside the RSD loop itself: what can happen when your body reacts before your mind has had time to make sense of what is happening, and how regulation can help create space between the trigger and what comes next.
Sources
James Kustow, “RSD Coming Into Focus: Rejection Sensitive Dysphoria in ADHD Brains,” ADDitude ADHD Experts Webinar Transcript (2026).
NAMI Mercer, “Understanding Rejection Sensitive Dysphoria (RSD)” toolkit.
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