"Rejection Sensitive Dysphoria"

[Stagg737]

Have an appointment coming up with a patient who just sent me a message about how they watched a video from a psychiatrist about "rejection sensitive dysphoria" and ADHD and that they want to discuss it at our next appointment. I'm very familiar with the concept of rejection sensitivity, but I had never heard of it being used as an actual diagnosis or common co-morbidity of ADHD. Tried to find literature on it but there was almost nothing in PubMed about rejection sensitivity and ADHD and nothing at all about "RSD" alone. Looking into it a little more, it seems like it's relatively new phrasing and that I just found a lot of stories for websites and blogs written by various physicians and psychologists. A couple of them recommended guanfacine/Clonidine or possibly Parnate for "RSD".

Curious if anyone has any actual experience with this or if anyone has even heard of this? I'd love to hear people's thoughts on "RSD" or just non-psychotherapy treatments for rejection sensitivity, as it's not something I have addressed with meds in the past other than patients with atypical depression.

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[splik]

There is zero scientific literature on RSD but it is very big in the ADHD communities and the interwebz. It was coined by psychiatrist William Dodson. you can read more about it here. Not surprisingly alot of narcissists and borderline patients and others who have problems with rejection and emotion regulation have lept upon this as a label that describes their problems, made more attractive by the ADHD context since ADHD is a diagnosis many pts want to have.

That said, difficulties with emotion regulation are definitely part of ADHD as one of our executive functions is related to regulation of emotions and thus executive dysfunction can lead to more intense emotional reactions or emotional dyscontrol in patients with ADHD. Also as a result of ADHD in childhood many individuals will internalize a negative sense of self that may make them more prone to sensitivity to rejection and criticism.

 

[Old&InTheWay]

I agree with splik that many people with ADHD suffer chronic rejection as children which can result in disrupted attachment and negative self-concept. And while perhaps people with ADHD have a genetic/temperamental difference the predisposes them to these symptoms, I don't think there is good evidence that what you describe is not simply a byproduct of the way people with ADHD are treated. I'm curious why you're not interested in psychotherapeutic interventions for this. Mentalization Based Therapy is particularly well suited for these symptoms which I would most likely characterize as BPD traits. Chasing after medications to treat what appear to be psychological/developmental problems feels like a fool's errand and is likely to harm the patient due to the opportunity cost of not pursuing a treatment that is most likely to help.

 

[Fan_of_Meehl]

Have an appointment coming up with a patient who just sent me a message about how they watched a video from a psychiatrist about "rejection sensitive dysphoria" and ADHD and that they want to discuss it at our next appointment. I'm very familiar with the concept of rejection sensitivity, but I had never heard of it being used as an actual diagnosis or common co-morbidity of ADHD. Tried to find literature on it but there was almost nothing in PubMed about rejection sensitivity and ADHD and nothing at all about "RSD" alone. Looking into it a little more, it seems like it's relatively new phrasing and that I just found a lot of stories for websites and blogs written by various physicians and psychologists. A couple of them recommended guanfacine/Clonidine or possibly Parnate for "RSD".

Curious if anyone has any actual experience with this or if anyone has even heard of this? I'd love to hear people's thoughts on "RSD" or just non-psychotherapy treatments for rejection sensitivity, as it's not something I have addressed with meds in the past other than patients with atypical depression.

trait neuroticism?

 

[hamstergang]

I've told some parents who ask about RSD that I'm not discounting what they're seeing their kid experience, but as this is not an "official term," there just aren't good studies telling us how to treat these symptoms differently. Therefore I treat it like I would any other ADHD and all is good enough.

 

[calvnandhobbs68]

Agree with most of the above, most people seem to just be looking for a label for "I feel bad when other people aren't nice to me". Which, as others have alluded to above, is really more associated with borderline personality disorder rather than ADHD, although this has been readily picked up by the ADHD community likely secondary to all the negative school/work interactions people with ADHD have. If you look at any existing papers on "rejection sensitivity", quite a few of them are using this construct as part of a larger sense of personality disorder when this is actually severe and impairing (i.e. borderline personality disorder).

Just like so many people now who think they have "ADHD" though, it gets hard to explain to people that behaviors/emotions/traits fall in a bell curve and just because you feel bad when other people aren't nice to you (as opposed to cutting or trying to kill yourself when other people aren't nice to you) doesn't mean you have some "condition" at the far end of the bell curve. Good thing about this though is that it's not even a real diagnosis, so you can't be convinced to try to use it for accommodations or something....

 

[romanticscience]

Lots of good ideas, thanks!

Any further clinical tips on handling patients, where a therapeutic alliance is threatened, by their rationalized belief that "they had ADHD all along." Someone tells them it's the source of their problems (often these patients already have PTSD and recurrent MDD) and the internet only reinforces such.

So, now, they believe (it often it seems, again, in the traumatized folks [suggestion?]) they have ADHD. How to contend with that without it hurting the therapeutic alliance too much? Some people get my approach (below, based on Goldberg, 2021) and others just leave. The latter are usually only in the consultation phase, thankfully.

I walk them back to appreciate that ADHD is really just one of several syndromes where cognitive symptoms (ie, attention) is impaired. Then, I try to clarify the timing, quality, and course with history and brief cognitive tests (trails, digit span, stroop, etc). Finally, I provide psychoeducation that ADHD is (1) a childhood disorder, (2) remits in ~50% of adults, (3) when symptoms are present in adults, there is very high co-morbidity (eg, bipolar ~45%) and differentiation of cognitive symptoms as primary v. secondary is difficult, (4) if there is a co-morbid affective disorder, we should probably choose agents with known evidence both for that condition, ADHD, or secondary cognitive symptoms of that disorder (eg, wellbutrin).

I'm familiar with the Behavior Rating Inventory of Executive Function (BRIEF-A) and sometimes I throw in the related symptom-validity (negative response bias) questions, just to assess where the encounter may go.

How often has each occurred?
(<1% of respondents in the sample rated 6 or more as "Often")

1. I have angry outbursts
2. I have trouble changing from one activity to another
3. I have emotional outburts for little reason
4. I start tasks (such as cooking, projects) without the right materials
5. I have trouble accepting different ways to solve problems with work, friends, or tasks
6. I talk at the wrong time
7. I have problems waiting my turn
8. I make inappropriate sexual comments
9. I have unrealistic goals
10. I leave the bathroom a mess

Practicing phenomenology-oriented psychiatry in this age is difficult. What would Freud or Kraepelin have done in the age of TikTok.


Goldberg, J. F., & Stahl, S. M. (2021). Practical psychopharmacology: Translating findings from evidence-based trials into real-world clinical practice. Cambridge University Press.

 

[Fan_of_Meehl]

Lots of good ideas, thanks!

Any further clinical tips on handling patients, where a therapeutic alliance is threatened, by their rationalized belief that "they had ADHD all along." Someone tells them it's the source of their problems (often these patients already have PTSD and recurrent MDD) and the internet only reinforces such.

So, now, they believe (it often it seems, again, in the traumatized folks [suggestion?]) they have ADHD. How to contend with that without it hurting the therapeutic alliance too much? Some people get my approach (below, based on Goldberg, 2021) and others just leave. The latter are usually only in the consultation phase, thankfully.

I walk them back to appreciate that ADHD is really just one of several syndromes where cognitive symptoms (ie, attention) is impaired. Then, I try to clarify the timing, quality, and course with history and brief cognitive tests (trails, digit span, stroop, etc). Finally, I provide psychoeducation that ADHD is (1) a childhood disorder, (2) remits in ~50% of adults, (3) when symptoms are present in adults, there is very high co-morbidity (eg, bipolar ~45%) and differentiation of cognitive symptoms as primary v. secondary is difficult, (4) if there is a co-morbid affective disorder, we should probably choose agents with known evidence both for that condition, ADHD, or secondary cognitive symptoms of that disorder (eg, wellbutrin).

I'm familiar with the Behavior Rating Inventory of Executive Function (BRIEF-A) and sometimes I throw in the related symptom-validity (negative response bias) questions, just to assess where the encounter may go.

How often has each occurred?
(<1% of respondents in the sample rated 6 or more as "Often")

1. I have angry outbursts
2. I have trouble changing from one activity to another
3. I have emotional outburts for little reason
4. I start tasks (such as cooking, projects) without the right materials
5. I have trouble accepting different ways to solve problems with work, friends, or tasks
6. I talk at the wrong time
7. I have problems waiting my turn
8. I make inappropriate sexual comments
9. I have unrealistic goals
10. I leave the bathroom a mess

Practicing phenomenology-oriented psychiatry in this age is difficult. What would Freud or Kraepelin have done in the age of TikTok.


Goldberg, J. F., & Stahl, S. M. (2021). Practical psychopharmacology: Translating findings from evidence-based trials into real-world clinical practice. Cambridge University Press.

A) I remind myself that--9 times out of ten--these labels or self-diagnoses are nothing more than empty tautological (circular) reasoning processes and, therefore, non-statements. They are re-descriptions of the problem masquerading as explanations
B) I simply say to myself--and patients, as appropriate--that I do not lie to my patients (or FOR my patients). I may not have all the answers but I know when I'm saying something that I don't actually believe is true. Increasingly (sadly) I have to make myself explicitly clear to patients that, no, I don't believe that 'you have X Disorder made up on Twitter' and you need 'Y Treatment you saw on the internet.' I don't believe I need to prescribe a dog as a 'medically necessary treatment' for your condition. We can agree to disagree. You came to ME for help. Here is what I believe, or don't believe. Here is how I was professionally trained to look for answers and plan treatments for patients. Doesn't work for you? Okay, I can make a referral. This job is hard enough as is.

 

[deleted1100659]

I have literally never heard of this before, lol

 

[ridethecliche]

I'm reading that article on emotional regulation/RSD. The following jumped out at me:

The other most common way of protecting oneself from the extreme pain of RSD is to give up trying anything new unless one is assured of quick and complete success. The notion of trying and failing or being turned down is just too painful to risk. They don’t go on dates. They don’t apply for jobs. They don’t speak in meetings or make their ideas and needs known to anyone.

They don't speak in meetings or make their ideas known? Sounds totally counter to the ADHD 'blurting things out' and being impatient thing we see so much more often. They don't go out on dates? They don't apply for jobs?
I mean... what is this? Sounds almost nonsensical.

I kinda get the gist of what's being said, but some of this is pretty over the top sounding.

Practicing phenomenology-oriented psychiatry in this age is difficult. What would Freud or Kraepelin have done in the age of TikTok.

Freud's tiktok woulda been lit doe.

 

[Fan_of_Meehl]

I'm reading that article on emotional regulation/RSD. The following jumped out at me:



They don't speak in meetings or make their ideas known? Sounds totally counter to the ADHD 'blurting things out' and being impatient thing we see so much more often. They don't go out on dates? They don't apply for jobs?
I mean... what is this? Sounds almost nonsensical.

I kinda get the gist of what's being said, but some of this is pretty over the top sounding.



Freud's tiktok woulda been lit doe.

From a very straightforward behavioral perspective, framing their issue as a 'disease' removes the burden of therapeutic goals or commitment to behavior change. It's one of the serious problems with adopting a 'disease' based model of conceptualizing mental health problems ,(especially in a psychotherapy context). What is being described appears to be overly anxious folks stuck in a cycle of avoidance behavior. Exposure + cognitive restructuring flexibly applied is probably called for. .'I can't speak up in mtgs because I have RSD and I know I have RSD because I can't speak up in meetings' is a profoundly unhelpful and hopelessly inert 'case formulation.'

 

[calvnandhobbs68]

From a very straightforward behavioral perspective, framing their issue as a 'disease' removes the burden of therapeutic goals or commitment to behavior change. It's one of the serious problems with adopting a 'disease' based model of conceptualizing mental health problems ,(especially in a psychotherapy context). What is being described appears to be overly anxious folks stuck in a cycle of avoidance behavior. Exposure + cognitive restructuring flexibly applied is probably called for. .'I can't speak up in mtgs because I have RSD and I know I have RSD because I can't speak up in meetings' is a profoundly unhelpful and hopelessly inert 'case formulation.'

100%
Often ends up getting conceptualized as "the world should change around me because I have this condition" rather than "I need to work to achieve certain goals and overcome these traits". I'm seeing this with teenagers pretty frequently right now (not RSD but the use of disease based conceptualization to drive avoidance). "Accepting mental health" not infrequently becomes "you all should let me avoid whatever I want because I have GAD".

 

[Merovinge]

What would Freud have done in the age of TikTok.

Hopefully capture his patient making some breakthrough and then setting down his cigar down long enough to snort a victory line in a 10 second movie clip with superimposed fireworks firing in the corners of the video!

(In all seriousness, good post though)

 

[Old&InTheWay]

100%
Often ends up getting conceptualized as "the world should change around me because I have this condition" rather than "I need to work to achieve certain goals and overcome these traits". I'm seeing this with teenagers pretty frequently right now (not RSD but the use of disease based conceptualization to drive avoidance). "Accepting mental health" not infrequently becomes "you all should let me avoid whatever I want because I have GAD".

Yes! I have noticed more and more people incorporating mental health diagnoses as components of their identity and expecting unconditional acceptance just as they might expect regarding gender identity (for instance).

 

[Fan_of_Meehl]

Reminds me of a veteran patient with PTSD who quipped that he and his fellow veterans were tempted to start a 'bring back the stigma' campaign. When people are advertising their 'psychiatric disorder' as a source of pride/identity...something's wrong and the pendulum just may have swung too far.

 

[ridethecliche]

Yes! I have noticed more and more people incorporating mental health diagnoses as components of their identity and expecting unconditional acceptance just as they might expect regarding gender identity (for instance).

Legit just had this conversation with a 22YO outpatient and how she was unsure of what to do since her depression was her identity for so long. I was like, isn't it amazing, you get to figure out what you're interested in now!
Not sure what you're referring to re gender identity here so going to sidestep that part of the equation.

100%
Often ends up getting conceptualized as "the world should change around me because I have this condition" rather than "I need to work to achieve certain goals and overcome these traits". I'm seeing this with teenagers pretty frequently right now (not RSD but the use of disease based conceptualization to drive avoidance). "Accepting mental health" not infrequently becomes "you all should let me avoid whatever I want because I have GAD".

I really hope this isn't becoming the norm...
Though I will say that we have a pretty biased sample size given that these are the patients that are referred to us after PCP's have no idea what else to do because they seem so stuck. I've seen this in older patients with anxiety too where they're seemingly incapacitated but have learned helplessness to the point where they can't even fathom taking any sort of action.

 

[Old&InTheWay]

Not sure what you're referring to re gender identity here so going to sidestep that part of the equation.

Just that people (rightly in most circumstances) expect unconditional/unquestioning/unchallenged acceptance of gender identity. And that some people seem to be adopting psychiatric diagnoses as parts of their identities and are expecting a similar type of unquestioning acceptance.

 

[FlowRate]

There is zero scientific literature on RSD but it is very big in the ADHD communities and the interwebz. It was coined by psychiatrist William Dodson. you can read more about it here. Not surprisingly alot of narcissists and borderline patients and others who have problems with rejection and emotion regulation have lept upon this as a label that describes their problems, made more attractive by the ADHD context since ADHD is a diagnosis many pts want to have.

That said, difficulties with emotion regulation are definitely part of ADHD as one of our executive functions is related to regulation of emotions and thus executive dysfunction can lead to more intense emotional reactions or emotional dyscontrol in patients with ADHD. Also as a result of ADHD in childhood many individuals will internalize a negative sense of self that may make them more prone to sensitivity to rejection and criticism.

Interesting, Dodson is a bit infamous around here for his ADHD clinic and the unusual regimen we inherit with his patients now that he's retired.

I do think it's a compelling concept for ADHD as people who are constantly either interrupting or losing track of conversation are aware that other people do not receive them well so they're frequently trying to figure out how to not be rejected/lightly shunned.

They don't speak in meetings or make their ideas known? Sounds totally counter to the ADHD 'blurting things out' and being impatient thing we see so much more often. They don't go out on dates? They don't apply for jobs?
I mean... what is this? Sounds almost nonsensical.

Well, as above, when you have a hammer... you see ADHD and not crippling anxiety.

 

[aim-agm]

Yes! I have noticed more and more people incorporating mental health diagnoses as components of their identity and expecting unconditional acceptance just as they might expect regarding gender identity (for instance).

I wonder how much of this phenomenon is people desperate for acceptance, and modern (esp. youth) society not giving a reasonable path to receive it another way.

 

[Old&InTheWay]

I wonder how much of this phenomenon is people desperate for acceptance, and modern (esp. youth) society not giving a reasonable path to receive it another way.

That's a good thought and I hadn't considered it. My initial thoughts were that it seems related to an incoherent sense of self.

 

[ridethecliche]

Interesting, Dodson is a bit infamous around here for his ADHD clinic and the unusual regimen we inherit with his patients now that he's retired.

I do think it's a compelling concept for ADHD as people who are constantly either interrupting or losing track of conversation are aware that other people do not receive them well so they're frequently trying to figure out how to not be rejected/lightly shunned.


Well, as above, when you have a hammer... you see ADHD and not crippling anxiety.

I mean, right? If you can broaden diagnostic definitions at will because you saw something that no one else does you can combine just about anything. Given some of the timeline for this, I wonder if it's also because ADHD dx is more socially acceptable than saying you have crippling anxiety.

I wonder how much of this phenomenon is people desperate for acceptance, and modern (esp. youth) society not giving a reasonable path to receive it another way.

That's a good thought and I hadn't considered it. My initial thoughts were that it seems related to an incoherent sense of self.

Why not both?

 

[bGMx]

That's a good thought and I hadn't considered it. My initial thoughts were that it seems related to an incoherent sense of self.

Can you expand on this?

 

[calvnandhobbs68]

I mean, right? If you can broaden diagnostic definitions at will because you saw something that no one else does you can combine just about anything. Given some of the timeline for this, I wonder if it's also because ADHD dx is more socially acceptable than saying you have crippling anxiety.

Eh I think ADHD is the "sexy" diagnosis right now...kind of like "I have mood swings so I must have bipolar disorder". It also helps that the treatment is a cognitive enhancer with street value and a pretty favorable side effect profile.

 

[Sushirolls]

Psychology Today has all sorts of labels and descriptions of things.
I at times wonder if they are similar to the news, and generating 'click bait' topics to generate traffic flow and maintain website relevance.
I suspect some of these things come from these online mental health information sources.
My random news feed on my cell phone has all sorts of non-dsm articles popping up. Every so often I have patients coming in stating "psychopathology" in their significant others. Been a while since I've had the rejection sensitivity pop up.

Sadly, this is just another land mind in the field that needs dodging - or time - to devote to disarming.

 

[Old&InTheWay]

Can you expand on this?

I am thinking mainly about the phenomenon of social media contagion around DID, ASD, ADHD, tic disorders, etc. I think some folks who lack a coherent sense of self look for external identities in order to give structure to their self. Social media has allowed people to simultaneously avoid participating in real life (which is important to developing our sense of self) while offering (distorted) lenses through which they may understood themselves. In the examples above, I have seen people identifying with diagnoses, not as illnesses to be treated, but rather as differences which need to be understood and accommodated by others. It's appealing to think that we have an inherrent genetic difference rather than underdeveloped aspects of our character that we have to work to improve. I think this is part of why so many people with BPD cling so strongly to Bipolar diagnoses.

 

[Celexa]

There is zero scientific literature on RSD but it is very big in the ADHD communities and the interwebz. It was coined by psychiatrist William Dodson. you can read more about it here. Not surprisingly alot of narcissists and borderline patients and others who have problems with rejection and emotion regulation have lept upon this as a label that describes their problems, made more attractive by the ADHD context since ADHD is a diagnosis many pts want to have.

That said, difficulties with emotion regulation are definitely part of ADHD as one of our executive functions is related to regulation of emotions and thus executive dysfunction can lead to more intense emotional reactions or emotional dyscontrol in patients with ADHD. Also as a result of ADHD in childhood many individuals will internalize a negative sense of self that may make them more prone to sensitivity to rejection and criticism.

I was reading that article and mainly thinking, eh I'm not sure I buy this as a discrete and adhd related phenomenon, but sure this is a behavior pattern worth addressing.

Then I got to the end of the article where he says it must but neurobiological and therefore not amenable to therapy and I just started laughing.

Appreciate the discussion above, I agree with people noting troubling patterns of mental illness becoming a treasured identity. We'll never be out of work, that's for sure, however much we remain under appreciated and undercompensated.

 

[calvnandhobbs68]

I was reading that article and mainly thinking, eh I'm not sure I buy this as a discrete and adhd related phenomenon, but sure this is a behavior pattern worth addressing.

Then I got to the end of the article where he says it must but neurobiological and therefore not amenable to therapy and I just started laughing.

Appreciate the discussion above, I agree with people noting troubling patterns of mental illness becoming a treasured identity. We'll never be out of work, that's for sure, however much we remain under appreciated and undercompensated.

Oh i love the part where he's just like "oh RSD is biological and of course the simplest treatment is....guanfacine"...without positing any sort of theory as to WHY alpha agonists would even help you not experience "emotional pain" from rejection. I mean, come on, at least have a theory.

Also, the Conners Global Index specifically has an "emotional lability" subscore...and the CGI has been around since the late 90s. So yeah, we get that emotional lability is a part of ADHD, which doesn't necessarily have anything to do with "rejection sensitivity".

 

[hallowmann]

They don't speak in meetings or make their ideas known? Sounds totally counter to the ADHD 'blurting things out' and being impatient thing we see so much more often. They don't go out on dates? They don't apply for jobs?
I mean... what is this? Sounds almost nonsensical.

I kinda get the gist of what's being said, but some of this is pretty over the top sounding.

I mean it sounds pretty typical of individuals with mild to moderate ADHD that have developed anxiety associated with poor performance or social rejection/ridicule. Not everyone with ADHD "blurts things out". Some are just easily distracted and as a result lose their train of thought. One pretty standard behavioral modification to manage this and the associated isolation it may cause in childhood is by not talking.

I have a few patients like this. A whiff of a long-acting stimulant and suddenly they aren't anxious, aren't as self-critical, and are actually doing well in school.

Obviously people with just anxiety or poor self-image may act this way as well. Also this is something that for some could be effectively treated with certain therapeutic modalities alone as I disagree that this response is truly neurobiological, so the paper is a bit problematic as described above.

I've seen this in older patients with anxiety too where they're seemingly incapacitated but have learned helplessness to the point where they can't even fathom taking any sort of action.

I actually have multiple older patients like this (people in their 50s-60s). There's typically a healthy dose of cluster B or C PD along with it.

 

[cara susanna]

So I actually used rejection sensitivity in my thesis. RS is a real construct, but it's not dysphoria so much as easily perceiving rejection. So, it refers to a bias that people with high RS will often interpret something as rejecting even if it's neutral. I'm mostly familiar with the research on it with BPD.

I haven't seen anything about rejection sensitivity dysphoria outside of the internet. I actually posted a thread about it in the Psychology forum a while back. There is an SDNer who apparently researches RS and also hadn't seen anything with it related to ADHD.

 

[Liquid8]

I have occasionally heard the term RSD used by patients when conducting ADHD assessments, and it appears many have picked this up from TikTok and other social media.

The first time I heard it, I remember that after doing some further reading and it seemed that only one psychiatrist was pushing the term as something that was exclusively associated with ADHD and nothing else. Aside from gross generalisations and absolutes being philosophically problematic, my natural inclination was that the emotional deregulation and symptoms associated with the term had much more in common with Borderline PD so when it gets brought up I will look at evaluating that too. For me it is probably one of the buzzwords along with “executive dysfunction” that annoy me the most, as it means I have to spend more time unpacking exactly what patients mean. As with all phenomenology, one needs to explore jargon carefully – if a patient says they are “manic” or “psychotic” what they then describe has to match my clinical understanding of the term and the same applies. However, with terms like “RSD” I don’t find that it has much in the way of clinical utility with regards to ADHD.

On specific problems that come under the RSD banner, some of my adult patients with ADHD describe resisting the urge to blurt things out immediately in order to confirm to social norms, but have to expend a lot of energy to control themselves. I don’t feel the term RSD is a useful descriptor that accurately captures that experience.

While some ADHD patients trying complex tasks and challenges due to past attempts and failures, I have seen plenty who have often tried repeatedly but with limited success. Often they may give up on tasks like homework or assignments at a high school level, but make repeated attempts at tertiary studies but end up dropping out after 6-12 months and change courses repeatedly. Again, RSD doesn’t logically fit with this pattern of behaviour either, and a more obvious explanation is that the primary pathology that is limiting them is related to inattention difficulties, poor time management or procrastination, often worsening in less structured environments.

 

[watto]

Well there is some research that those with ADHD have inattention paid to the eye regions when interpreting facial emotional signals, sometimes misinterpreting things like fear for anger. I saw a grand rounds on this a couple of weeks ago - most of the citations come out of OHSU if you search for them. This would explain poor reading of facial signals leading to rejection sensitivity.

 

[Merovinge]

I am thinking mainly about the phenomenon of social media contagion around DID, ASD, ADHD, tic disorders, etc. I think some folks who lack a coherent sense of self look for external identities in order to give structure to their self. Social media has allowed people to simultaneously avoid participating in real life (which is important to developing our sense of self) while offering (distorted) lenses through which they may understood themselves. In the examples above, I have seen people identifying with diagnoses, not as illnesses to be treated, but rather as differences which need to be understood and accommodated by others. It's appealing to think that we have an inherrent genetic difference rather than underdeveloped aspects of our character that we have to work to improve. I think this is part of why so many people with BPD cling so strongly to Bipolar diagnoses.

When you think about how social media is categorized and pushed down the consumer's throat via algorithms this is the inevitable consequence. There are clear communities you can be immediately accepted into if you report ASD, DID, ADHD, etc, in contrast I have never heard of any for "teenager with well adapted friend circle exploring identity in a healthy manner".

Not to insult anyone, but this is a bit like joining a frat at the start of college. It artificially creates a a sense of identity and belonging without any pre-existing basis. Obviously there's a big difference when everyone agrees to do so without identifying as having a disorder in the case of frats/sororities, but I only bring this up to note how long people at the developmental stages of identity have been doing this. The pull for human's to feel part of a tribe is tremendous and is now just amplified by the social media algos. I think we are only starting to see the tip of the iceberg of this issue, I expect it to be a hot topic in CAP moving forward.

 

[Desired Member]

I am thinking mainly about the phenomenon of social media contagion around DID, ASD, ADHD, tic disorders, etc. I think some folks who lack a coherent sense of self look for external identities in order to give structure to their self. Social media has allowed people to simultaneously avoid participating in real life (which is important to developing our sense of self) while offering (distorted) lenses through which they may understood themselves. In the examples above, I have seen people identifying with diagnoses, not as illnesses to be treated, but rather as differences which need to be understood and accommodated by others. It's appealing to think that we have an inherrent genetic difference rather than underdeveloped aspects of our character that we have to work to improve. I think this is part of why so many people with BPD cling so strongly to Bipolar diagnoses.

Agree.
To add to this, I am very disillusioned with the practice of psychiatry. I think I would enjoy it more if I was exclusively/almost exclusively seeing patients for whom medications would be helpful. I find that patients meet criteria for MDD and GAD, and I prescribe the usual medications but surprise, they don't work, because these people really just need social/economic support which I can't provide. But they continue to meet criteria for MDD and GAD so I have to continue this charade of medication management. They can't afford therapy and medicaid therapists are booked 1 year or more in the future. 90% of people I see grew up with one or both parents not invested in their life or abusive in some way and I routinely give the MSI BPD to patients.
And as far as the ADHD thing -- Kids are passing public school with minimal effort/knowledge because no child can be left behind. Parents are working long hours to be able to survive and support their kids, American kids are glued to their devices and their attention spans deteriorate as a result. Cannabis and alcohol are extremely prevalent which I'm sure don't help with focus.

 

[Username2015]

I suspected that RSD is a new label to make borderline patients feel validated while avoiding the discomfort of having a personality disorder label/diagnosis.

 

[futureapppsy2]

When you think about how social media is categorized and pushed down the consumer's throat via algorithms this is the inevitable consequence. There are clear communities you can be immediately accepted into if you report ASD, DID, ADHD, etc, in contrast I have never heard of any for "teenager with well adapted friend circle exploring identity in a healthy manner".

Not to insult anyone, but this is a bit like joining a frat at the start of college. It artificially creates a a sense of identity and belonging without any pre-existing basis. Obviously there's a big difference when everyone agrees to do so without identifying as having a disorder in the case of frats/sororities, but I only bring this up to note how long people at the developmental stages of identity have been doing this. The pull for human's to feel part of a tribe is tremendous and is now just amplified by the social media algos. I think we are only starting to see the tip of the iceberg of this issue, I expect it to be a hot topic in CAP moving forward.

I also think some (a lot of?) people use it as a way to avoid responsibility--"you can't blame me for not turning in my homework because I have ADHD," "it's not my fault I got mad at you--I have ASD and don't understand neurotypical social communication, "you shouldn't make me work--I have depression/anxiety," etc. Ironically, most people I know who actually have these diagnoses get really bothered when people try to use them in these ways, especially people who try to use autism to excusive rude or abusive behavior.

 

[clausewitz2]

I also think some (a lot of?) people use it as a way to avoid responsibility--"you can't blame me for not turning in my homework because I have ADHD," "it's not my fault I got mad at you--I have ASD and don't understand neurotypical social communication, "you shouldn't make me work--I have depression/anxiety," etc. Ironically, most people I know who actually have these diagnoses get really bothered when people try to use them in these ways, especially people who try to use autism to excusive rude or abusive behavior.

Sometimes I fantasize about going full on old-school confrontational style and getting a bell that I ring every time a patients says 'anxiety' until they start describing it with words that convey substantive meaning. Same with adults with ADHD who seem to feel that if they don't experience intrinsic motivation to do something it is physically impossible for it to happen.

'Great, when was the last time you were able to just decide to motivated to do something? You mean that's never happened? So what will you do if you never feel motivated to do thing X? I wonder if it makes sense to explore ways you could make it more likely you will be able to do it even if you never feel a burning desire to do it for it's own sake.'

Your ADHD makes it more difficult to get things done, sure. But you know, now that you're diagnosed and getting treated, you have to figure out how you're going to compensate for that to do whatever it is you want to be doing. If you're a brittle Type I diabetic, are of normal intelligence, are well-educated in how to take care of yourself, and access to insulin and appropriate monitoring equipment isn't a problem, it's kind of on you if you become hypoglycemic because you just failed to take any steps to make sure you had some appropriate source of sugar on hand as you went about your day. When you know you have a particular challenge or difficulty and there exist ways of circumventing or ameliorating it that you have access to, you need to use them, and if you don't, you are responsible for that choice and whatever comes with it.

 

[mistafab]

Social media algos are especially predatory for persons with mental illness. I suspect more of these "diagnosis" will pop up in the future. A stance to validate the distress leading to the presentation is always going to be a good strategy, while avoiding validating their maladaptive schema (like a delusion). I'm not sure how psychiatry as a whole will fare in the battle of good vs bad information in the current era. With mental health becoming more of a public concern (as it rightfully should), we will be facing the same battles of snake oil vs "evidence-based" that will forever be fought, but this time we will fight with platform size, marketing, and hashtags. Hopefully we build some trust with the public in the process. The fight between "experts" and "influencers" is occurring at all fronts in medicine, and always has.

 

[futureapppsy2]

Eh I think ADHD is the "sexy" diagnosis right now...kind of like "I have mood swings so I must have bipolar disorder". It also helps that the treatment is a cognitive enhancer with street value and a pretty favorable side effect profile.

In my experience, ASD is "sexier" right now than ADHD, especially among women. I've seen people legit argue that BPD is actually just female ASD, which... doesn't make a ton of sense, as someone with a fair amount of clinical expertise with both populations.

 

[calvnandhobbs68]

In my experience, ASD is "sexier" right now than ADHD, especially among women. I've seen people legit argue that BPD is actually just female ASD, which... doesn't make a ton of sense, as someone with a fair amount of clinical expertise with both populations.

lol I concur that this absolutely does not make sense. Wonder what Leo Kanner would have thought of that

 

[calvnandhobbs68]

Social media algos are especially predatory for persons with mental illness. I suspect more of these "diagnosis" will pop up in the future. A stance to validate the distress leading to the presentation is always going to be a good strategy, while avoiding validating their maladaptive schema (like a delusion). I'm not sure how psychiatry as a whole will fare in the battle of good vs bad information in the current era. With mental health becoming more of a public concern (as it rightfully should), we will be facing the same battles of snake oil vs "evidence-based" that will forever be fought, but this time we will fight with platform size, marketing, and hashtags. Hopefully we build some trust with the public in the process. The fight between "experts" and "influencers" is occurring at all fronts in medicine, and always has.

100% I was just talking to a family member about this. They actually totally got rid of Instagram and TikTok because of how much they were being bombarded with "ADHD" and "anxiety" recommendations after watching some video about ADHD once....it's ridiculous.

These algorithms just pummel you with anything and everything they think you'll be even tangentially interested in and then feed as much of it as possible to keep eyeballs on the screen= money. People way way underestimate the impact this has on your sense of overall wellbeing when you spend so much of your time on this.

 

[Fan_of_Meehl]

Sometimes I fantasize about going full on old-school confrontational style and getting a bell that I ring every time a patients says 'anxiety' until they start describing it with words that convey substantive meaning. Same with adults with ADHD who seem to feel that if they don't experience intrinsic motivation to do something it is physically impossible for it to happen.

'Great, when was the last time you were able to just decide to motivated to do something? You mean that's never happened? So what will you do if you never feel motivated to do thing X? I wonder if it makes sense to explore ways you could make it more likely you will be able to do it even if you never feel a burning desire to do it for it's own sake.'

Your ADHD makes it more difficult to get things done, sure. But you know, now that you're diagnosed and getting treated, you have to figure out how you're going to compensate for that to do whatever it is you want to be doing. If you're a brittle Type I diabetic, are of normal intelligence, are well-educated in how to take care of yourself, and access to insulin and appropriate monitoring equipment isn't a problem, it's kind of on you if you become hypoglycemic because you just failed to take any steps to make sure you had some appropriate source of sugar on hand as you went about your day. When you know you have a particular challenge or difficulty and there exist ways of circumventing or ameliorating it that you have access to, you need to use them, and if you don't, you are responsible for that choice and whatever comes with it.

I work for the VA as a psychotherapist. As you may imagine, I have LOTS of clients who (over)use the term 'anxiety' at every turn (without elaboration). Besides generic Socratic questions (which are very useful, especially as a 'first pass' examination), I often break out the whiteboard and try to engage them in a collaborative exercise of simply exploring what the term 'anxiety' (which goes in the 'emotion' column) goes along with in the other columns (situation, thoughts/beliefs/images, physiological symptoms, and behavior [or behavioral urges]). Most of the time this is an informative exercise (and really helps move the case formulation forward). Some of the time, they have no answers for any of this, even after intensive questioning, requesting examples of situations in which they felt 'anxiety,' or even rating (0-100) how much of this 'anxiety' did they feel while anticipating the session? Now? Last night lying in bed? This morning in the shower? 1 hour ago in traffic? For clients who will play along, it is often interesting to ask, 'How is anxiety different from anger?'

 

[bGMx]

I work for the VA as a psychotherapist. As you may imagine, I have LOTS of clients who (over)use the term 'anxiety' at every turn (without elaboration). Besides generic Socratic questions (which are very useful, especially as a 'first pass' examination), I often break out the whiteboard and try to engage them in a collaborative exercise of simply exploring what the term 'anxiety' (which goes in the 'emotion' column) goes along with in the other columns (situation, thoughts/beliefs/images, physiological symptoms, and behavior [or behavioral urges]). Most of the time this is an informative exercise (and really helps move the case formulation forward). Some of the time, they have no answers for any of this, even after intensive questioning, requesting examples of situations in which they felt 'anxiety,' or even rating (0-100) how much of this 'anxiety' did they feel while anticipating the session? Now? Last night lying in bed? This morning in the shower? 1 hour ago in traffic? For clients who will play along, it is often interesting to ask, 'How is anxiety different from anger?'

Based off this, I'd love to work with you and learn. Could you expand in your Socratic questions?

 

[Fan_of_Meehl]

Based off this, I'd love to work with you and learn. Could you expand in your Socratic questions?

Essentially, they are variations of the question, 'Why?' Basically, open-ended questions where the questioner tries to maintain the discipline of not making assumptions about the answer.

 

[bGMx]

****, I've been doing that since I was 3... looks like I'm in the right place.

 

[Stagg737]

Based off this, I'd love to work with you and learn. Could you expand in your Socratic questions?

TBH this isn't really particularly unique or hard and is something you should be learning regardless of where you go to residency. It's just something a lot of attending psychiatrists don't do because it's more time-consuming and likely won't change the medication plan. If you're interested in therapy, it's a very helpful approach to understanding the underlying mechanisms of a patient's anxiety though.

I used an abridged form of this and ask "If I weren't a psychiatrist and had never heard of anxiety before, how would you describe it to me? What does anxiety mean to you?" The response can be very telling, even if it is just "I don't know".

For clients who will play along, it is often interesting to ask, 'How is anxiety different from anger?'

This is an interesting perspective that I've rarely encountered. How often do you find yourself pursuing that line of questions and when are you typically seeing it? BPD and PTSD or do you see it with primary anxiety disorders as well?

 

[Stagg737]

Thanks for the responses everyone, sounds like my intuitions about this were pretty in line with what everyone else is thinking. I'm certainly familiar with rejection sensitivity, but the idea of "RSD" specific to ADHD and that there's data to treat it primarily with medications was foreign to me and seems mostly unfounded.

To update, I basically told the patient that I wasn't going to address this with medications but recommended he discuss it in therapy as that would likely be the most beneficial. Also discussed that this likely wasn't d/t his ADHD and but supported his concerns with rejection sensitivity overall. Turns out his wife had brought this up to him and said it seemed to fit him perfectly after she saw a TikTok video from a psychiatrist named Melissa Shepherd. No idea what her angle/game is as I didn't watch the video, but seems like a way to publicize her practice or promote herself as someone specializing in ADHD.

 

[Fan_of_Meehl]

TBH this isn't really particularly unique or hard and is something you should be learning regardless of where you go to residency. It's just something a lot of attending psychiatrists don't do because it's more time-consuming and likely won't change the medication plan. If you're interested in therapy, it's a very helpful approach to understanding the underlying mechanisms of a patient's anxiety though.

I used an abridged form of this and ask "If I weren't a psychiatrist and had never heard of anxiety before, how would you describe it to me? What does anxiety mean to you?" The response can be very telling, even if it is just "I don't know".




This is an interesting perspective that I've rarely encountered. How often do you find yourself pursuing that line of questions and when are you typically seeing it? BPD and PTSD or do you see it with primary anxiety disorders as well?

When I have a veteran whose clearly predominant affective presentation is anger/irritability but he's blathering on about his 'anxiety' whilst posturing, with spread/animated arms and hand gestures, in a loud voice and is clearly not a shrinking violet. Of course, it doesn't mean he isn't experiencing anxiety (or doesn't, outside of the office setting), but it raises red flags whenever anyone's presentation doesn't appear to match their (repeatedly) reported emotion. I can't say that I've literally used that exact question a whole lot (if ever), but it was an attempt to summarize the angle of approach here. I guess it would be one of the important things to explore (via a line of questions) with a veteran who is consistently reporting 'anxiety,' who doesn't actually appear to be anxious, who cannot tell me much (if anything) about what having the 'anxiety' is like for him, the last time he felt this 'anxiety,' what thoughts he has when he is 'anxious,' what he typically does (or feels like doing) when he is 'anxious,' etc (you get the point). I think folks who work in outpatient settings at VA have come across this scenario a time or two. On the other end of the spectrum of presentations, I've run across some male veterans (mostly younger folks) who appear to have a double-whammy of a social anxiety diathesis + combat trauma exposure and subsequent PTSD and many of these young men (who DO present/appear as quite anxious, by the way) have a very difficult time describing their internal states, elaborating beyond brief responses, or generally even keeping the conversation going in therapy. They just clam right up and some of them are very challenging to deal with because they just....won't.......talk.... . I usually have one of these right after a client who just.....won't.....stop.....talking... LOL. Fun practice environment to get conversational whiplash in.

 

[hallowmann]

****, I've been doing that since I was 3... looks like I'm in the right place.

It annoys me so much that seeing the asterisks made me think, "how were they able to finish their post without dealing with the wildcard?" Damn you EPIC

 

[clausewitz2]

When I have a veteran whose clearly predominant affective presentation is anger/irritability but he's blathering on about his 'anxiety' whilst posturing, with spread/animated arms and hand gestures, in a loud voice and is clearly not a shrinking violet. Of course, it doesn't mean he isn't experiencing anxiety (or doesn't, outside of the office setting), but it raises red flags whenever anyone's presentation doesn't appear to match their (repeatedly) reported emotion. I can't say that I've literally used that exact question a whole lot (if ever), but it was an attempt to summarize the angle of approach here. I guess it would be one of the important things to explore (via a line of questions) with a veteran who is consistently reporting 'anxiety,' who doesn't actually appear to be anxious, who cannot tell me much (if anything) about what having the 'anxiety' is like for him, the last time he felt this 'anxiety,' what thoughts he has when he is 'anxious,' what he typically does (or feels like doing) when he is 'anxious,' etc (you get the point). I think folks who work in outpatient settings at VA have come across this scenario a time or two. On the other end of the spectrum of presentations, I've run across some male veterans (mostly younger folks) who appear to have a double-whammy of a social anxiety diathesis + combat trauma exposure and subsequent PTSD and many of these young men (who DO present/appear as quite anxious, by the way) have a very difficult time describing their internal states, elaborating beyond brief responses, or generally even keeping the conversation going in therapy. They just clam right up and some of them are very challenging to deal with because they just....won't.......talk.... . I usually have one of these right after a client who just.....won't.....stop.....talking... LOL. Fun practice environment to get conversational whiplash in.

I have definitely worked with that first guy outside of the VA in CMHC. The kind of 'anxiety' someone who just got out after a five year bit from armed robbery experiences when they come close to beating an acquaintance half to death for making fun of them. Actually, this was the kind of 'anxiety' experienced by the couple people I've worked with who had a mostly positive reaction to being diagnosed with ASPD. Fits the classic phenomenological descriptions of their interior emotional life being either boredom or vague aversive sensations I suppose.

 

[birchswing]

Saw this in the Journal:

TikTok Diagnosis Videos Leave Some Teens Thinking They Have Rare Mental Disorders

When teens decide they have a personality disorder or other mental-health affliction based on information they found in TikTok videos, it can fray family relationships and pose a treatment challenge.

www.wsj.com

They make it sound like an indictment of TikTok (I have honestly never seen TikTok).

But I think it's more the state of understanding of mental health/illness.

I've long said when you read a list of personality disorders and their descriptions, it's a bit like reading a list of horoscopes: It can be easy to find yourself in many of them.

Perhaps, like language, mental health diagnoses will be collaboratively created?

I found myself in a confusing place on Reddit recently, linked from TwoXChromosomes (a forum for women) to various transgender communities and found terms I had never heard of before—subgenres of transgenderism. There were two new terms to me: truscum and tucute. These are new identities.

And the truth is that scientists don't have the answers. They are following what people are experiencing, and maybe what people experience within any particular social setting and time is more true than what has already been written down. I was trying to trace down the biological origins of sexual orientation and gender, and it was amazing what a mystery it still is. The most I could find is that they think it has to do with gene expression affected by exposure to hormones in the womb resulting in various brain "types." If you combine something that vague with ever-changing social configurations and environmens, whatever is in the DSM is going to be outdated and becomes more prescriptive than descriptive IMO. Pretty soon I think telling people they are gay or transgender will be considered trying to fit them into a box rather than considered the progress it once was.

And what a seachange the BPD diagnosis has been. I think Pete Davidson had a lot to do with turning that around. It wasn't many years ago I was hearing that psychiatrists wouldn't even give that diagnosis because of how poorly it would be received. And now, at least from what I can tell, it seems pretty well accepted.