The Biological Causes of Mental Illness Cannot Be Separated From the Social Ones
The Biological Causes of Mental Illness Cannot Be Separated From the Social Ones
Case in point: Rejection Sensitive Dysphoria in kids with ADHD or Autism.
This piece was originally published to Medium on August 17, 2022. Why I’m leaving Medium for Substack.
When children struggle socially or emotionally, many parents are strongly motivated to believe the struggle must have some biological cause. This makes discussing the interpersonal and cultural roots of many mental illnesses very difficult and fraught.
For example, if a kid has a very powerful emotional reaction to rejection, and cries and flails on the ground for half an hour after getting a bad grade on a test, many parents will find it compelling to explain this as a case of “rejection sensitive dysphoria” (or RSD) — a supposed ‘symptom’ of ADHD — and to see rejection sensitive dysphoria as being rooted in a kid’s neurology.
Under this point of view, all that crying and flailing is a disproportionate response to receiving mild negative feedback, but the kid can’t help that they’re reacting this way, because they have a disorder that makes them perceive any small slight as catastrophic. This explanation offers up a tidy-enough seeming solution: you treat and medicate the kid’s ADHD, which is supposedly the biological source of the issue, and hopefully their big crying flailing meltdowns and oversensitivity will end.
This approach is exactly what the inventor of the term rejection sensitive dysphoria, William Dodson, was hoping people would take. Dodson was the first person to describe RSD as a ‘symptom’ of ADHD, based on his observation that many of his ADHDer patients were overly reactive, in his point of view, to negative social feedback. Dodson has long advocated for professionals to find some effective way of medicating RSD away.
RSD was not formally documented in peer-reviewed clinical studies, and there is no objective measure of what qualifies as RSD. It’s merely the invention of a single high-profile psychiatrist who believed that his patients were feeling the pain of rejection too strongly. And it’s in the subjectivity and anecdotal nature of this definition that we begin to see the cracks in RSD as a concept.
What does it mean to be too sensitive to rejection? Who gets to decide that on another person’s behalf? And how might life experience and vulnerability lead a person to become more attuned to signs of rejection than other people are? And if a person is already disabled, and thus already in a more marginal position in society, doesn’t being more careful about avoiding rejection simply make sense? What’s disordered about recognizing that you need human support, and freaking out when you’re facing the risk of losing it?
The term “dysphoria” comes from the Greek dusphoros, which means “hard to bear.” As a medical term, it was first coined in the 1840s, to refer to patients that doctors viewed as being “impatient” with their own physical pain or emotional anguish. In other words, the dysphoric patient has always been the one who is willing to complain about the suffering they’re enduring, and to actually make it their doctor’s problem. I think I like the original Greek meaning better than it’s modern usage.
Today we mostly talk about dysphoria as if it’s just an internal feeling of profound despair that must be some sign of mental sickness. Gender dysphoria, for example, is often described as an interior feeling of gender-wrongness or body-wrongness that is so unpleasant it might lead a trans person to self-injure or worse. But calling dysphoria “impatience under anguish” instead reveals the external judgement that doctors and psychiatrists are making when they say it.
Some patients don’t just dwell quietly in their suffering. They take action, and kick and snarl and cry out for help, forcing others around them to grapple with the enormity of what they’re going through. That doesn’t sound disordered to me. That sounds like killer self-advocacy. It’s sitting around, glumly compliant, being patient with your pain that strikes me as dysfunctional.
Some trans people will not endure living in a gender role they never consented to be forced into. Even if the state or the medical system does not grant them the freedom to live as they truly are, they’ll take that freedom for themselves, no matter the risks necessary. That impatience with anguish — that willingness to fight for a better life — is gender dysphoria. It’s being unwilling to bear the pain that society created for you anymore, and taking your own body, endocrinology, identity, and future existence into your own hands.
Similarly, some children who have repeatedly been mocked, condescendingly corrected, ostracized, and judged throughout their lives find the pain of rejection too much to bear. They refuse to hold society’s punishing social standards within themselves anymore. They freak the fuck out when they’re told, in so many words, that they’re being too dumb, too loud, too annoying, too clueless, too immature, too needy, too much themselves — and in so doing, they communicate that it’s wrong for a society to ever tell children those things. That’s rejection dysphoria. An unwillingness to accept the negative things you’ve been told about yourself all your life.
I think it’s very easy for an adult to look at the meltdowns and freak outs of a RSD child and to conclude that they’re reacting to small dismissals we believe “should not” hurt them at all. But when we judge children like this, we forget what an incredibly weak and confusing social position that they are in, and how extremely high stakes every experience of exclusion really can be for them.
Is It Rejection Sensitive Dysphoria or Complex Trauma?
There’s a new pathological term picking up speed in the ADHD community: Rejection Sensitive Dysphoria. It describes…
When you’re a powerless kid, not one single fuck-up is small. Your security and emotional wellbeing hangs entirely on the acceptance of the adults and social systems that surround you. And you really don’t know what misstep will lose you their support and protection. You have no idea whether this failing grade will be the one that gets you kicked out of school, if that unintentionally rude comment will be the one that loses you all your friends, if this mess you made in your room will get you kicked out of your house.
In the eyes of the law, as a child you are your parent’s property, and when you are mistreated you have nearly zero recourse. The world is guided by a series of laws and rules that you are not privy to, with incarceration, starvation, homelessness, and loneliness all waiting for you on the other side. Kids are tiny unmoored aliens thrust into a menacing world that they do not understand, and they have to spend the first two decades of their lives messily putting together an understanding of that world’s rules.
Usually, when we’re kids, we only learn about a social rule after it’s too late and we’ve violated it. And who knows how bad the consequences for violating it will be. I remember that once when I was about eight years old, my dad took me out to buy an ice cream. When I stepped up to the counter and ordered an elaborate milkshake with all kinds of fruit toppings, my father fumed at me and pulled me outside. He’d told me I could order an ice cream, he said, by which he meant one single scoop. Our family couldn’t afford those expensive specialty items. Didn’t I understand that? Why would I do that to him? He was furious with me, and we went immediately home, with no ice cream at all, and for hours he sat with his arms folded and stewed.
I was young, with no conception of money or unspoken implications, but that all changed in me after that day. I painstakingly reviewed the costs of all items from then on. Said no to offers that I thought might actually be traps. At restaurants I always ordered the cheapest option on the menu. If someone did notice or make a comment on the cost of something I wanted, I would completely and utterly lose my shit. Because experience had taught me that severe consequences were on the horizon.
No wonder kids fear rejection. No wonder neurodivergent children, who are more prone to a certain kids of ‘mistakes,’ would be particularly panicked about doing “too much” wrong and losing everything. That’s not disordered. But it is dysphoric. Who among us wouldn’t find the threat of constant rejection to be too much to bear?
Unfortunately, many well-intentioned parents of kids with rejection sensitive dysphoria take a social interpretation of the “symptom” as a personal attack. If you suggest that instead of being caused by their biology, a child might be very attuned to signs of social failure because of their experiences, many parents think you’re calling them abusive and neglectful. See how the replies and quote tweets on this twitter thread wound up playing out.
My own white-hot panic in the face of rejection is tied in part to past parental abuse. My dad was an explosive, unpredictable person and he left me believing that social land mines lay beneath me everywhere that I go. But even in my case, that’s not entirely where it originated. As an awkward Autistic kid who said and did weird stuff constantly, I got socially spurned and chided for behaving “incorrectly” just about everywhere that I went.
I was held down and beaten by girls at a church slumber party for no explicable reason. A close, trusted friend of mine covered my chair in the lunchroom with lipstick in order to ruin the white pants I was wearing. I once lost an entire years-long friendship over a single differing opinion about music. I’m sensitive to rejection because I have been rejected a lot — often for simply being me. And I’ve been dismissed and disposed of by other people so frequently that the fear of dying completely alone with zero support is baked into my bones.
I might strike a non-disabled person as being filled with irrational social panic, but really, I’m just accurately recognizing a pattern in my life. Why would I expect anything but ostracism? Noticing a real-life pattern of social disposability is not a disorder on my part. If anything, that’s my biology and my psychology working correctly, adapting and trying to protect me.
In the twitter thread that I mentioned above, one person replied to me saying that RSD is a mental illness “symptom” because it often involves spiraling out in overwhelming sadness after being rebuffed in a totally ‘mundane’ way, such as being passed over for a job. But being jobless isn’t actually mundane, is it? We all require money in order to have housing, healthcare, and food. If we are passed over for enough jobs, we’ll no longer be able to survive. And neurodivergent people are unemployed & under-employed at far greater rates than our non-disabled peers. So why the hell wouldn’t we be freaked out by the prospect of not finding work?
Calling the fear of unemployment ‘rejection sensitive dysphoria’ is just another instance of psychiatry assigning a negative value judgement to a very logical conditioned response. If you can’t find work, you might die, and if you have a disability it’s extra hard for you to find work. Of course you’d feel dysphoric when you get rejected for a position that could have put food on the table, yet again. Of course a kid who is their parent’s legal property fears a parent’s coldness and mockery like it’s a death sentence. It could actually be one.
Many of the realities of living under capitalism are horrifying — we’ve just all been taught to act like they’re mundane. When disabled people refuse to pretend that our exclusion isn’t a life and death matter, we get punished further for it. We are told we are over reacting. We’re said to be too sensitive. We get labeled as disordered. But really, we are just dysphoric — we are naming a pain that society expects us to silently bear, and with our loud, defiant responses of anguish, we are telling society we refuse.
This pins EXACTLY what issues I have but couldn’t articulate about RSD. Not its existence as a phenomenon, but how we use it to seemingly delegitimize real fears many of us have in response to being rebuffed in so many ways by the systems and people around us. I can work my at through my reaction, temper it, soothe it in all my therapized ways. However I cannot make the world around me understand me enough to not pose a real threat, only hope to create a network of people who do.
Thank you for your work that so often makes me feel seen and accepted, that advocates for a kinder, more just world <3