Menachem M. Kiwak Ph.D, LMHC

In working with adolescents, a clinical psychologist encountered terms in psychological reports that were new and perplexing. Among these, Rejection Sensitivity Dysphoria (RSD) stood out. Reports would note, “As part of her ADHD, Amelia also has RSD,” or “Bethan’s RSD makes it hard for her to establish friendships and she is socially isolated.” Despite its frequent mention, RSD was absent from any diagnostic manuals, raising questions about its origins and validity.

Discovering RSD

Parents seemed to regard RSD as familiar as ADHD or Generalized Anxiety Disorder (GAD). They explained that it was why their child got so upset when friends didn’t text back; it was neurological, they insisted. Intrigued, the psychologist turned to Google for answers.

A Lightbulb Moment

The term RSD was introduced in the 2010s by psychiatrist William Dodson, who noticed that many of his adult clients with ADHD were highly sensitive to rejection. Dodson asked, “For your entire life, have you always been much more sensitive than people you know to rejection, teasing, criticism, or your own perception that you failed or have fallen short?” Many responded affirmatively, and Dodson coined the term Rejection Sensitivity Dysphoria (RSD). His articles resonated widely, leading to a surge of online content about RSD, including symptom checklists and self-help books.

The Rise of RSD

RSD quickly gained traction, validating the experiences of many who felt their emotional reactions were now understood. It offered an explanation for why life seemed harder for them. However, it’s crucial to note that Dodson’s observations were based on clinical anecdotes rather than empirical research. His clients’ heightened sensitivity to rejection was self-reported, and it wasn’t clear whether this was unique to those with ADHD.

Gaining Credibility

Despite the lack of robust research, RSD resonated with many people and began to be viewed as a credible explanation for certain emotional experiences. Articles and medical websites started to claim that RSD might be due to brain structure differences and recommended medication. Dodson even suggested that RSD should be seen as a core feature of ADHD, especially in adults.

A Cultural Context

The philosopher Ian Hacking described this phenomenon as a “looping effect” – as more people identified with RSD, the classification itself evolved. Psychologists began to include RSD in their reports, reflecting its growing acceptance as a cultural phenomenon. This shift underscores the influence of culture in shaping our understanding of mental health.

Peri-Psychiatric Terms

Researchers like Haltigan et al. (2023) refer to terms like RSD as “peri-psychiatric.” These terms bear similarities to psychiatric diagnoses but are not officially recognized in diagnostic manuals. They often emerge from lived experiences shared in online communities rather than academic research. This does not diminish their reality for those who identify with them; it highlights the deep connection between mental health and culture.

Dissociative Identity Disorder and Online Culture

The evolution of Dissociative Identity Disorder (DID) exemplifies how online culture can redefine psychiatric diagnoses. Traditionally, DID was considered a rare and severe mental health issue linked to developmental trauma. However, an online culture has emerged around DID, creating a new taxonomy that includes people identifying as “plural” without trauma histories or considering themselves disordered. This phenomenon illustrates how diagnoses can evolve beyond their conventional definitions.

Uncharted Lands

Mental health professionals now navigate an uncharted landscape where clients use the language of psychiatric and peri-psychiatric diagnoses to understand their experiences. Social media has played a significant role in spreading symptoms and shaping these new understandings. Diagnoses have become cultural identities, aiding personal transformation and self-forgiveness. However, this raises questions about the role and meaning of diagnoses in this new context.

Conclusion

Diagnoses, whether conventional or peri-psychiatric, are descriptions rather than explanations. They do not always reliably describe distinct entities, and there is considerable overlap. As these concepts evolve, especially in the age of social media, mental health professionals must grapple with their implications. Understanding these new cultural contexts is essential for providing effective and empathetic care.

Naomi Fisher’s Psychology of Mental Health, an undergraduate primer, was published by the Oxford University Press in May 2024.