Is It Social Anxiety? Or Something Far Deeper?

Dr. Andrea Bonior: Almost all of us care about being liked. But for some of us, the potential upset of rejection is so painful, it might as well be an electric shock coursing through our body. Today I'm talking about a condition you might not know about, but you should. Today we're going deep into rejection sensitive dysphoria, a seemingly common set of symptoms that many people struggle immensely with without realizing there's even a name for it. This episode is a must listen for anyone whose fear of rejection is holding them Welcome. I'm Dr. Andrea Bonior, and this is Baggage Check, mental health talk and advice with new episodes every Tuesday and Friday. Baggage Check is not a show about luggage or travel, incidentally. It is also not a show about the return of the revolutionary rhinestone setting tool, the bedazzler. So let's get into it. Today, I want to talk about a condition that affects many more people than maybe aware. So many of us know about depression or anxiety, although, of course, there's still a lot to learn. That's why we're here. But we've likely been exposed to those, or to substance abuse or eating disorders, or the idea of a phobia. We've seen movie or TV series portrayals for all of that stuff, typically for better or for worse, often worse. All these various disorders under the sun, they get a lot of airplay. But have you heard of rejectionsensitive dysphoria? And do you know? It's different than social anxiety, and it very commonly goes along with ADHD. I've got to start with the context for this, so I became really interested in this myself. Rejection sensitive dysphoria, uh, probably about five years ago. By wave background, I am m an anxiety disorders specialist, which means that my research back in graduate school was related to anxiety. Both my master's thesis and dissertation were based on facets of anxiety, and I promised never to do a dramatic reading of either of those documents. That would be some hate mail the likes of that male probably never seen before by humankind. Anyway, my clinical training was in treating anxiety and related disorders, which means I had a lot of experience in treating panic disorder or generalized anxiety disorder, phobias, and also some of the related disorders like OCD, or the repetitive body focus disorders like trichotillomania, which is hair pulling, and excoriation disorder, which is skin picking. But I also had a particular interest in social anxiety disorder. Now, the hallmark of social anxiety disorder is a, uh, fear of being judged negatively by other people. The research calls this FME fear of negative evaluation. And it is so, so painful in people with social anxiety disorder. For some folks, it's most prevalent in performance situations, like, I'm going to blow this free throw and lose the game for my team. Or the stage fright that comes before performing in a recital or a concert or a dance performance, or the dreaded public speaking, which apparently many people would rather be lit on fire than experience. But for other people with social anxiety, it's about simple chitchat. Am I making too much eye contact? What did I say? Did I not laugh enough? Was I being stupid? Am I blushing? Will this person think I'm annoying? All these worries are most certainly on a spectrum, right? Not everyone who suffers with social anxiety as a symptom also truly has a diagnosable disorder. But for some people, it really gets in the way of their life. So social anxiety disorder, which used to be called social phobia, it's been around as a diagnosis for a long time, and there's so much to say about it. And we definitely will devote some future episodes to it and talk to some folks who experience it. And there are some excellent treatments available that are quite effective for it. So if that's you with social anxiety, definitely talk to someone, specifically, a cognitive behavioral therapist with expertise in anxiety disorders. But that's not what today's episode is about. Today's episode is about something distinct from social anxiety disorder, though it does overlap in certain ways. Today's episode is once again about rejection sensitive dysphoria. So bringing you back to my interest in this, I'd been studying social anxiety, treating it, I taught about it, and I really enjoyed helping folks who experienced it. But I started to notice some patterns in certain clients and certain people who wrote to me through my media work. Some patterns that looked a little different than classic social anxiety. But I didn't yet have a good way of conceptualizing what I was seeing. For these folks, it wasn't just the nervousness of potentially being negatively judged by other people. It was about something deeper, something more cutting, something more profound, something that spoke to their sense of connection with others, that spoke to their attachment to others, that spoke really to their identity. These were folks who were very, very sensitized to the idea of being rejected or left out or excluded, even by people that they knew well and were not classically anxious around. I didn't really know at the time how to view it. Was it a personality thing? Did it have something to do with their self esteem? Did it stem from issues with attachment and childhood? Was it actually social anxiety, but just in a different form? In doing some research and looking at the established literature, I came across rejection sensitive dysphoria or RSD, and it really fit what I was seeing these individuals go through. I ended up really getting deep into the existing research and writing about it for Psychology Today, and the piece was explosive. So many people recognize themselves in this, and I still hear from folks, uh, all the time more than three years later. Folks who see themselves in this piece, who felt like something clicked when they learned about this. Nearly 700,000 people have read this piece. Maybe a few of those were bots who knows? Can bots develop rejectionsensitive Dysphoria someday? That's a whole artificial intelligence conversation that might be interesting. But anyway, so many people read this and said, this is me. I feel seen, I feel understood. There's a name for what I'm going through. And I think that's really, really powerful. So I wanted to take that a step further and talk to you today about it. I really want to paint a picture for you of what rejection sensitive Dysphoria is like for folks. And if you see yourself or a loved one in this portrayal, there is hope and you are not alone. Now, most of us are concerned with being liked. And for some people, even without social anxiety or rejection sensitive dysphoria, this concern with being liked can preoccupy them at times. It's often thought of as ideal to simply not care at all what other people think. But it's virtually impossible for most of us not to care at least a bit. And if we truly don't care at all, uh, sometimes that might lead us down a problematic path in its own right. It probably even stems back to evolution when we were all walking around with loincloths. I m don't know if there's a gender neutral term for loincloths anyway. When we lived in caves, we needed others in trying to survive. It was a matter of life or death. If we were being shut out of our group or our tribe, we'd be in physical danger. And so it made sense as a species for us to develop negative reactions to rejection, for us to find it aversive. That was probably conditioned in us to want to belong in order to keep ourselves safe. And so it's likely built in for us for rejection to be a fundamentally stressful and negative and somewhat upsetting experience. I'd say that's true for almost all of us. And when I say stressful and negative and upsetting, I really mean physically as well as mentally being rejected. Socially, it activates the same part of our brains as does physical pain. I mean, you can literally look at a brain scan and somebody being socially rejected and somebody experiencing physical pain, and you see the similar pathways light up. It's the anterior cingulate cortex for anyone keeping neurophysiological score at home. But isn't that striking, physical pain and social rejection really making us feel awful in so similar of ways? But for some of us, we are off the charts sensitive, and the experience is absolutely excruciating. So maybe it's the difference between the physical upset of touching a hot pan versus having an electric shock course throughout your whole body. And if we are in this group, we also likely perceive that we're being rejected far more often than we actually are. This is at the heart of rejectionsensitive dysphoria. It's pretty new as a label, and it's only really now starting to be researched in depth. And so it's not currently in the DSM five which is the Diagnostic and Statistical Manual of Mental Disorders, the Bible. That's Bible with a lowercase b of psych disorders. But we know that rejection sensitive Dysphoria is there. It's not in the DSM, but it's there in the world. I mean, people who have rejection sensitive Dysphoria, they respond extremely negatively to the idea of being rejected, far beyond the typical discomfort that most of us would experience. For people with RSD, the idea of being excluded or criticized or ousted from a group brings such a strong reaction to people who are observing from the outside, these reactions, they might look like anger or somebody turning on you, or somebody flipping out. But inside, these folks that are experiencing this, uh, they are in a tail spin, they are in so much pain. They are just blindsided by the idea of being excluded. And so they start ruminating, they start thinking about it non stop. They might feel physically ill, they might feel like their whole life is a failure. So you have some allorn thinking too often times with this rejection being experienced, there could be rage, there could be extreme shame, and there could just be agony, mentally and physically. So for some of these folks, they might look almost explosive in their reactions. Some people might adopt an offense is the best defense strategy, and push people away first and decide they dislike them before letting themselves be rejected by them. Other, um, people may see those with RSD as being overly perfectionistic or oversensitive or overly reactive to even the mildest types of criticism. Some people with RSD may just keep bending over backwards and attempting to keep on people's good sides. They're on this treadmill of making everyone happy. They're so desperate to not be rejected. So they might let other people walk all over them because it's much more important to them that those other people like them than it is whether or not they themselves are getting taken advantage of. So what does this mean? And is it an actual diagnosis? Well, as I mentioned, the DSM five doesn't really recognize it. And so many people say, well, is it even real? Well, lots of things are real that are not in the DSM. Mayonnaise is real. It's not in the DSM. M even mental health things, uh, they don't have to be listed in the DSM to be real. There are mental health characteristics, even fundamentally unhelpful or dysfunctional ones, that aren't necessarily yet diagnosable as disorders. So RSD is most definitely real in the sense that the cluster of symptoms exists and it causes great distress to folks. But it's not an official condition with its own code label. Certainly we might see it in an upcoming edition of the DSM. The DSM is always changing. It morphs from one thing to the next. It's like some sort of diagnostic hulk, I guess. But as of now, RSD is not labeled on its own as a disorder, but we actually see it often associated with some other conditions, conditions that might surprise you, and one of them is ADHD or ADT. But before we get to that, let's explain more about the differences between social anxiety and RSD. As I mentioned, at uh, its core social anxiety disorder is about being preoccupied by that fear of other people judging you badly, that fear of negative evaluation. Social anxiety often comes across as shyness, though not always. Social anxiety and introversion may sometimes go together too, but they're not exactly the same thing. In fact, we'll have a future episode on how much we misunderstand introverts. So introverts, talk to me. If you're actually willing, you can be on that episode. But with social anxiety, we've talked about how for some folks, it's in any kind of chit chat situation, whereas for other folks it's more based on performance situations. In either case, the anxiety about that potential of negative judgment by others might cause them to avoid these interactions. You know, they run away from the recital or the championship game. This can happen to even the most talented of athletes and musicians. Or somebody cancels going out to that party at the last second because it's just too much. They know they'll be too uncomfortable. Of course, a lot of people with social anxiety might turn to substances they'll drink before they go out, specifically so that they'll feel a little bit less anxious and feel more loosened up. So sometimes you see an issue on the surface, like alcohol abuse or opioid addiction or chronic reliance on sedatives, when in reality there's something very important going on under the surface. And that could be social anxiety. A lot of people come across as flakes too. They bail at the last minute, and oftentimes that's social anxiety too. So being sensitized to other people's reactions to you can be very true in both social anxiety and RSD. And so social anxiety and RSD can definitely exist together in the same person. But here are the key differences between social anxiety and RSD. With social anxiety, people may feel worse around people they don't know well, or people they're meeting for the first time, or who they don't have the comfort level with. They may be preoccupied with the fear of embarrassing themselves around strangers, for instance. But when people with social anxiety get together with people that they can be themselves around people they know a little bit better and trust, there's a lessening of this. They're not as fearful of negative evaluation among their closest friends or their partners. With RSD. This looks different. Somebody with RSD doesn't necessarily ever get to that point of comfort. The idea of a close person rejecting them is still a tremendous and potentially debilitating fear. It's that rejection that's their main concern. So it's the idea that someone in my life might push me away or exclude me. Not just the idea that a random person on the subway thinks I'm a Klutz, by the way, I am a klutz. Lots of random people on, um, the subway know that I'm a klutz. But another difference with social anxiety versus RSD is that someone with social anxiety often gets really nervous before an interaction. They overanalyze everything that they're going to say or do or whereas someone with RSD may not have this to the same extent, but it's afterwards, man. That's where the pain begins. Especially if they think the interaction went badly. They ruminate about how maybe people don't like them anymore, or how they might have upset someone, or how they were somehow not really part of the group in the first place. There might be shame or guilt or sadness or even anger about what they perceive as rejection rather than what we see with social anxiety, which is that more debilitating nervousness beforehand, before the interaction. Now, to throw another complication in here, we don't run from complications here at baggage tech. We embrace them. Some folks have something called avoidant personality disorder. This is a trickier one, because I'll tell you a terribly kept secret, which is that, uh, the personality disorder diagnoses are riddled with issues. Psychologists scream about them all the time, even those psychologists without personality disorders themselves. But anyway, for shorthand, you can think of avoidant personality disorder as being social anxiety on steroids to the point where someone really is so anxious that they're cut off and disconnected from daily life and relationships because they're so terrified of people judging them negatively. And it's gone on since childhood. So you can see some connections between avoidant personality disorder and rejection sensitive dysphoria as well, but, uh, some distinctions. So this brings us to attention deficit hyperactivity disorder or attention deficit disorder. So ADHD with the hyperactivity being a big issue, and Ad d without the hyperactivity messing with somebody's life so much. Many folks who are diagnosed with Add as adults, they're probably not climbing on chairs anymore, but they still struggle with inattention and inability to focus and disorganization that restless mind. The mind that's constantly searching for the next new thing. So it turns out a lot of the attention that RSD rejectionsensitive dysphoria has gotten has stemmed from the community of people who have ADHD. Because it seems there's a big connection here. Having ADHD appears to raise your risk of RSD significantly. Honestly, it's not super clear why this is. They don't immediately seem all that related. ADHD is about the way your mind thinks and processes information, even in everyday tasks. Whereas RSD seems much more about emotional reactions and sense of self and judgments about relationships. But maybe for one, it's about the nervous system. Some research has suggested this, that perhaps the nervous system of folks with ADHD is triggered in very specific ways, ways that might overlap with that same over sensitized triggering of rejection. Something physical. Interesting stuff. Maybe there's a genetic predisposition that people have that makes them vulnerable to both. And here's another thing. Folks with ADHD may sometimes experience rejection more in their early years, especially, like the kid who interrupts their friends or can't wait for their turn, or the adult who veers off track at meetings or doesn't keep organized. That could, in turn, trigger reactions in other people, reactions that are negative, which might make people with ADHD start to view themselves as the other, you know, being rejected, being not part of the group. And maybe that makes them really sensitized to it going forward because it has such negative effects. And impulsivity could be another connection. Folks with attention deficit disorder, especially the type with the h in it, uh, attention deficit hyperactivity disorder, ADHD, that includes a lot of impulsivity. So these folks, they might be really sensitized to reaction, first off, because they have sudden impulsive reactions to a lot of things. And again, that might have negative effects where they do get rejected. And also if they get extremely upset with what they believe is rejection, they might be prone to doing something that really will get them rejected, especially as kids, like if they quit a game suddenly or they run away from a situation abruptly, or they go off on someone. And so you can really empathize with how, if these patterns develop at an early age, they are prone to rejection and they're feeling the pain of it. And unfortunately, it becomes a self perpetuating cycle, because that impulsivity makes it really hard for them to take the time before responding for them to pause. And maybe they could have mitigated the damage if they were able to take that time, but they can't create that pause before reacting strongly to their emotional upset. And so that could be another way that ADHD and rejectionsensitive dysphoria are connected. Now, let's think of how this plays out in relationships, because it could be that maybe you don't recognize this in yourself, but you recognize it in somebody that you love or somebody that you work with, or maybe both. Maybe we love the people we work with a more power to you. But RSD has a significant impact on relationships or even your ability to seek out relationships. Can you imagine dating when you're hyper focused on whether it means that they're not interested anymore because they didn't text you back right away? Someone can be their own worst enemy because they assume disaster about a relationship, or they ruminate on what they think they did wrong, or they isolate themselves and actually drive the other person away. And so they can self sabotage pretty easily with an existing relationship. So we're talking past the scary dating phase. All kinds of things can happen. A person might always be secondguessing their own actions. They might need frequent reassurance from their partner that everything is okay with the relationship. Or maybe they start hiding their fears because they're embarrassed of them and they think they're supposed to be stronger, and so it pops up in other ways. Maybe they're irritable or depressed or avoidant. The truth is, some people who are controlling partners may be acting out of underlying rejectionsensitive dysphoria, and it makes them desperate to keep their partner controlled and on a tight leash because they're terrified that their partner will leave. Now, make no mistake, controlling behavior is damaging and dangerous and toxic. So I'm in no way condoning it. But I think it's important to highlight and understand where some controlling behavior comes from so that if a person wants to make changes and be less controlling, that they can get some support in doing so. There's so much to say about controlling relationships in general, and we'll definitely have an upcoming episode on them. In the meantime, if you want to see signs of controlling relationships, you can look in the episode notes for a link to some resources on that. So now let's get you a reality check about whether or not RSD might be affecting you or someone you know. The truth is that I would never claim to be able to diagnose you through a podcast. Podcasts are many things. They can teach you a lot. They can teach you how to snake out your clogged bathtub. Yeah, that's, uh, probably more YouTube, I guess. But anyway, podcasts are wonderful, obviously. I believe so. But podcasts can't give you a reliable medical or psychiatric diagnosis, so let's keep that in mind. And I can't diagnose from afar or in the abstract, but I figured that listing out some signs and symptoms, well, that's probably why you're here, right? That might be really helpful to give you an idea of whether RSD is something that you should look into further, ideally by talking to a mental health practitioner who has some experience in it. Remember, there's no diagnostic label in the DSM, so these are not quantifiable criteria that are official. Nor is this some sort of test like what I used to do in college in the back of all the women's magazines. Hey, that's how I found out that Sagittariuses are super adventurous. But we're going to give you some signs and symptoms so that you can see how many of them might resonate with you or with someone you love first. You have a very high sensitivity about the possibility of rejection. Well, yeah, that's kind of in the title of this pattern, right? Rejection sensitive dysphoria. But you might have overly high standards for yourself. You feel easily triggered towards guilt and shame. You often isolate yourself and a preemptive strike so as to not be rejected. You have aggressive or rageful behavior towards those who have been perceived to have slighted you. You frequently feel an uncomfortable physical reaction due to not fitting in or feeling misunderstood. You have self esteem that's almost entirely dependent on what others think and which rises and falls accordingly. And you frequently ruminate after an interaction where you think that you said or did something wrong or where somebody seemed to potentially be rejecting you. So think about those things and whether or not they strike a chord. I know they have with so many of my readers over at Psychology Today. Now let's think about what might cause RSD. Of course, no two people are exactly alike in what made them have a certain condition. I can have two folks whose depression symptoms, for example, are as matchymatchy as they could possibly be, and yet, uh, they might have each arrived at depression for entirely different reasons or patterns of reasons. So keep that in mind. But people with RSD probably have a genetic predisposition as part of it. It could be that their HPA axis, which is part of the stress response, is really highly sensitive and easily triggered. Genetics might have set the stage for that, but it's certainly not the whole answer. There's so much that happens in our environment, and it interacts constantly with our genetics. Maybe you grew up with really perfectionistic standards, or a high sense of shame was put on you, or you had an extremely upsetting rejection at a young age that really set the stage for you to be upset by anything having to do with rejection. Maybe you were made to feel overly guilty about even normal behavior as a kid. Or maybe there was some sort of attachment issue in terms of parents or caregivers. Or maybe your early romantic relationships in adulthood were full of sudden rejection or being blindsided by betrayal or loss. It could be any number of things. Of course, if we also imagine situations with abuse or trauma or neglect, we can imagine how that would sensitize not just someone's stress response and HPA axis, but also sensitize somebody to the idea of being wronged or harmed by somebody to the point where they're really looking out for it and they're on guard for it all the time. But here is the most important thing. There is help. There is treatment. And the treatments are going to vary depending on the intensity of your symptoms and how they overlap with other disorders. Certainly if you've got underlying depression or underlying trauma or ADHD, that's going to need its own treatment. And of course, those treatments can work together with RSD treatment. But what do we know about RSD treatment on its own? First, we know that some medications seem to be very helpful because there is most definitely a physiological component here. So you're looking at meds that can potentially calm that physiological reaction. And some of them have really shown promise for RSD, including some that are typically meant to treat blood pressure problems. Now, I think I'm not going to get in the habit of listing specific medications by name on the show for a few reasons. First is I am a clinical psychologist, not a psychiatrist. So I do not prescribe these meds or have firsthand oversight of things like side effects. But there are other problems I don't want to contribute to as well. Well, first, I don't want to contribute to the problem of my getting sued by a pharmaceutical company. That doesn't seem like a good way to spend, I don't know, 47 Tuesdays of my life. But also, I don't want to contribute to the idea that somebody just hears a medication name and goes to the doctor and asks for it without being able to get a fuller picture of what's going on for them. Everybody, uh, deserves to get that full picture, and I don't want somebody to prematurely get the medication first. But anyway, medication might be quite helpful. And again, if you have underlying depression, antidepressants might be helpful for that. If you have underlying ADHD, other medication might be helpful for that. That's all very important to keep in mind. But therapy is what I'm all about. And what therapy is going to do is work on improving your understanding of those emotional reactions in the moment, giving you insight into how to pause and how to think about a strategy to manage those uncomfortable feelings and to calm yourself down and move forward and not jump to conclusions or damage the relationship or your own beliefs about yourself. Therapy can be really helpful with challenging some of those cognitive distortions, as we call them. Those are those inaccurate, invalid thoughts that contribute to these hyper triggered reactions, these exaggerated, off the charts, painful reactions, all those times that you assume the worst or that you think you're being rejected when you're not. Cognitive Behavioral Therapy, otherwise known as CBT, and also Acceptance and Commitment Therapy, also known as act. That's my particular specialty and the framework for my book, Detox Your Thoughts anyway, they both can be really helpful for this. Therapy can also help with increasing your overall coping mechanisms and supporting you and handling your stress better, helping you take better care of yourself, and building the resilience for the natural ups and downs of life and relationships. Because, like, uh, almost all psychological symptoms and challenges, having high sustained stress makes them worse. And interpersonal psychotherapy, also called IPT, and something called DBT or Dialectical Behavioral Therapy. I know this is like alphabet soup today. Anyway, those two therapies are really important to keep in mind, too. DBT is very helpful for managing intense interpersonal reactions. And all these therapy techniques are related to Mindfulness. ACT is as well. That gentle and curious awareness of what you're experiencing in the current moment when we put Mindfulness to use in genuine practice, not just to some buzzword or the beautiful canvas that you have above your desk that says something about living in the moment, but really, really just in a simple way, putting it into use. I've really seen it change people's lives. So there you have it. Hopefully, this built you a pretty strong foundation of understanding about the basics of rejection, sensitive dysphoria and. How it can affect lives. Remember, you are not alone in this. Truly, there is hope and there is treatment available. Thank you for joining me today. Once again, I'm Dr. Andrea Bonior, and this has been Baggage Check with new episodes every Tuesday and Friday. Submit your voice memos@baggagecheckpodcast.com, and if you have that quirky friend who likes podcasts about thought-provoking issues, please let them know where to find us. Our original music is by Jordan Cooper, cover art by Danielle Merity, and my studio security is provided by Buster the dog. Until next time, take good care.