One of the toughest parts of ADHD is left out of the diagnosis

October 9, 2026

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5 min read

One of the toughest parts of ADHD is left out of the diagnosis

When psychiatrist Sasha Hamdani was a medical student, she walked to her attending's door hoping for a letter of recommendation to become a pediatrician. She was stopped cold. "You cry all the time," the attending told her. "You cry during patient interviews, you cry when you're checking out, you stick around with the families, you make them cry more." The attending warned she would burn out. Hamdani wanted to defend herself but could already feel the tears building. In hindsight, as a psychiatrist who also has ADHD, she recognizes that moment as a textbook case of rejection-sensitive dysphoria—a condition that is arguably the most disabling part of ADHD for many people, yet remains entirely absent from the official diagnostic criteria.

What RSD actually is

Rejection-sensitive dysphoria was popularized in the 1990s by psychiatrist William Dodson, who noticed it frequently in his ADHD patients. It is not ordinary sensitivity or hurt feelings. Hamdani describes it as "an incredibly robust emotional, sometimes physical, but mostly emotional response to rejection or criticism"—and the rejection can be real, perceived, or even just the threat of it. The response is neurological, not a character flaw.

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What you'll learn

1 (00:21) **Sasha Hamdani's Story: The "You Cry All the Time" Moment** - The host introduces Dr. Sasha Hamdani, who recounts the pivotal moment in med school when an attending told her she would burn out as a pediatrician because she cried too much.
2 (01:24) **Defining Rejection-Sensitive Dysphoria (RSD)** - Dr. Hamdani defines RSD as a robust emotional (and sometimes physical) response to real or perceived rejection or criticism, even the mere threat of it.
3 (04:21) **The Brain Wiring Behind RSD: Amygdala vs. Prefrontal Cortex** - Sasha explains the neurological mechanism of RSD, focusing on two key brain areas and their weak connection.
4 (05:53) **Why Emotional Dysregulation Fell Off the ADHD Radar** - Sasha explains why this aspect of ADHD was historically overlooked in favor of observable symptoms.
5 (07:07) **How Likely is a Mental Health Professional to Know About RSD?** - Sasha discusses the variability in awareness among different types of clinicians.
6 (08:25) **The "Sneaky Agenda" to Get RSD into the DSM** - Sasha reveals her motivation for writing her book and the strategy for changing the diagnostic criteria.
7 (09:39) **Treatment Landscape: Pattern Recognition First** - Sasha outlines the first step in diagnosis and treatment, emphasizing pattern recognition over single incidents.

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Show Notes

ADHD diagnoses are on the rise in the United States, but what if professionals are missing a key part of the disorder? In the 1970s, some clinicians recognized a lot of their ADHD patients had trouble with emotional regulation. But because it was easier to measure behavior rather than emotions, the criteria eventually fell off the radar. Today in the U.S., emotional dysregulation is not a part of the ADHD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Dr. Sasha Hamdani thinks that needs to change. In today’s episode, she talks about her book Too Sensitive, and explains what is going on in the brains of people with Rejection Sensitive Dysphoria.

Interested in more mental health science? Email us your question at [email protected].

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Wender, P. H. (1971). Minimal Brain Dysfunction in Children. Wiley-Interscience. https://pubmed.ncbi.nlm.nih.gov/4581984/

Barkley, R. A. (2015). Emotional dysregulation is a core component of ADHD. In R. A. Barkley (Ed.), Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (4th ed., pp. 81–115). Guilford Press. https://www.guilford.com/excerpts/barkley2.pdf?t=1

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Faraone, S. V., et al. (2019). Emotional dysregulation in adults with attention deficit hyperactivity disorder: Validity, aetiology, and clinical implications. Neuroscience & Biobehavioral Reviews, 107, 132–142.https://doi.org/10.1016/j.neubiorev.2019.08.021

Bondü, R., & Esser, G. (2015). Justice and rejection sensitivity in children and adolescents with ADHD symptoms. European Child & Adolescent Psychiatry, 24(2), 185–198.https://doi.org/10.1007/s00787-014-0560-9<