Rejection Sensitive Dysphoria (RSD): Part 3 - Autism, RSD and Mental Health

Table of Contents

• Background and Introduction
• Mental Health in the Autism Community
• RSD and Mental Health
• Autism, Trauma, and RSD
• What This All Means for Autistic Mental Health
• RSD and Social Pain
• RSD and the Physical Pain Connection
• Summary
• References

Background and Introduction

This is the third part of a five-part series on Rejection Sensitive Dysphoria (RSD):

• Part 1 - An Introduction
• Part 2 - Understanding RSD Triggers
• Part 3 - Autism, RSD and Mental Health
• Part 4 - Impact on Daily Life
• Part 5 - Managing RSD

In this section, we consider how an Autistic identity with co-occurring RSD can impact mental health.

While RSD can deeply affect our relationships, education, work, and school, its impact doesn’t stop there. In part 2, we learned that for some Autistic people, emotional regulation struggles, past experiences of exclusion, rejection, and core Autistic traits can work together to create a keen sensitivity to social threat. This combination of contributing factors seems to create just the right conditions in which RSD can take hold.  (Part 2 - Understanding RSD Triggers)

Research seems to be confirming a connection between RSD, anxiety and depression. Similarly, Autistic people have higher rates of anxiety and depression than the general population. What’s more, compelling research shows people with high rejection sensitivity are more likely to experience anxiety, depression, and other mental health conditions. Let’s add one more to the mix. From children to adults, Autistic people are more vulnerable to victimization – including from repeated or ongoing experiences of social injury – which can lead to trauma-based conditions like PTSD or Complex PTSD.

Before we get into the research, let’s take a step back and remember that autism is not a mental health diagnosis. A review of the Diagnostic and Statistical Manual (DSM-5-TR) confirms this: mental illness is not part of the diagnostic criteria for autism.¹ However, many Autistic people do live with co-occurring mental health conditions, and these conditions often have a significant impact on the person’s quality of life. As yet, researchers have not empirically stated why there is such a high prevalence of mental health conditions in autism. It could make a positive difference if they did. The evidence that is available seems to connect much of the blame on the way we are treated within society.

The way we are supported (corrected, rejected, invalidated) appears to have a profoundly negative impact on our lives. Autistic people who are fortunate to avoid the constant hum of rejections, negative feedback, and trauma may be the ones who enjoy good mental health. We don’t know for sure, but it makes sense to this Autistic writer. Now, let’s take a look at some research and the data.

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Mental Health in the Autism Community: Let’s Look at the Data

Depression

A 2019 paper by Hudson et al. that analyzed findings from 7,857 papers found that Autistic people are “more likely to experience depression in their lifetime” when compared to the general population.² And in other news, the sky is blue ** sarcasm**.

In other words, this study confirms what most in the Autistic community already knows.

• Autistic adults are much more likely to experience depression than non-Autistic adults. A meta-analysis (a large study that combines and reviews data from several smaller studies) indicated that 37% of Autistic adults have experienced depression in their lifetime, and 23% currently meet criteria for a formal diagnosis. In comparison, the general population shows a lifetime depression rate of about 5%, much lower that the Autistic population.^3,4

   

• Depression also disproportionately affects autistic youth. A study by Longmore et al.⁵ found that 37% of Autistic youth exhibited elevated depressive symptoms at baseline, with 35% continuing to show elevated symptoms four years later. Consider the following for comparison: “Today, approximately 5% of male youth and 12% of female youth aged 12 to 19 have experienced a major depressive episode.”⁶

Anxiety

• A Swedish population study of over 220,000 people including 4,049 Autistic people aged 18 to 27 found that Autistic people without an Intellectual Disability were nearly three times more at risk for an anxiety disorder than the general population. As well, Autistic people with an Intellectual Disability were 1.71 times more likely to have an anxiety diagnosis.⁷

   

• Anxiety disorders are very common among Autistic adults, with 27% experiencing symptoms currently and 42% reporting a lifetime history of anxiety. These rates are much higher than the 4% of those in the general population who have an anxiety tal-healthdisorder.^3,8
• Anxiety disorders are very common in Autistic children—much more so than in the general population. A meta-analysis found that about 40% of Autistic children and teens meet criteria for an anxiety disorder.⁹ In contrast, around 5% of Canadian children aged 5 to 17 have been diagnosed with anxiety.¹⁰

Together, these studies show that Autistic people experience anxiety and depression at much higher rates than the general population. But this raises an important question: could rejection sensitivity be part of the reason why? The next section takes a closer look at that connection.

Learn More here:

• An Introductory Overview of Some Mental Health Challenges and their ‘Co-Occurrence’ with Autism
• INSAR 2025: Anxiety Diagnoses in Autistic Preschoolers
• Autism and Anxiety Webinar
• Anxiety's Toll on Autistic Individuals

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RSD and Mental Health

Large data review of several studies may shed some light on the question of RSD and mental health. This meta-analysis, conducted in China, examined 75 different studies representing over 21,000 people.¹¹ Each study used a questionnaire to measure rejection sensitivity and mental health symptoms such as depression, anxiety, and loneliness. These were not formal diagnoses but self-reported symptoms expressed, at the time of the survey.

The researchers¹¹ found that people with high rejection sensitivity were notably more likely to report symptoms of five mental health conditions than those with low rejection sensitivity. The results showed an association between rejection sensitivity and the likelihood of experiencing the following conditions. Although these ranges might seem small, these findings are considered meaningful.

• Depression: A moderate association
• Anxiety: A moderate to strong association
• Loneliness: A moderate association
• Borderline Personality Traits: A moderate to strong association
• Body Dysmorphic Disorder (body image issues): A moderate to strong association.¹¹

These figures show what researchers call a ‘moderate’ association between rejection sensitivity and these specific mental health conditions. This means that people with high rejection sensitivity are more likely to have symptoms that suggest depression, anxiety, borderline personality disorder, body dysmorphic disorder, and loneliness. These results tell us that rejection sensitivity plays a role, but it is not the only factor. Could Autistic traits be another reason?

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Autism, Trauma, and RSD

For many Autistic people, trauma is a key part of their lives. A 2020 study of Autistic adults found that in the previous month, over 40% of research participants showed PTSD symptoms significant enough for a probable diagnosis. Also of interest: the participants reported trauma resulting from a larger variety of life events than those listed for PTSD diagnostic purposes.¹² The DSM-5-TR stipulates that to be diagnosed with PTSD, the person must have been exposed to or threatened with death, serious injury, or sexual violence.¹

In contrast, according to Statistics Canada,¹³ 8.4% of Canadian adults reported moderate to severe PTSD symptoms in the month prior to being surveyed. That is a big difference.

When people think of trauma, they often picture one life-altering event. But for many Autistic people, trauma doesn’t set in with a single tragic event—it accumulates across time and from repeated social injuries: being rejected, excluded, misunderstood, and/or shamed for being who we are. It can escalate when forced into therapies that aim to erase the Autistic identity, or when people deny and/or gaslight us about our needs. The trauma is compounded by the feeling of being trapped in situations where the trauma keeps happening. Repeated ‘social injuries’ that occur over a period of time where the person feels they cannot escape, reflect, in brief, the broad range of life experiences that can cause trauma. The gravity and extensive human cost of relentless social injuries are revealed in the data.

These experiences aren’t just upsetting. They impact the nervous system of the Autistic person and can change the way we respond to threats. In a paper discussing how the brain reacts to these events, the author says that the body responds to these with a “…nervous system locked into states of defence that limit access to calming pathways.” ¹⁴

In other words, after many challenging experiences, the nervous system can get stuck in high alert — constantly scanning for danger like rejection or correction, even when nothing is actually happening. When this occurs repeatedly, the brain adapts. It starts anticipating emotional harm in every interaction, like the kind that comes from not being accepted. Porges¹⁴ also explains that this nervous system change can make attempts at self-regulation unsuccessful as the body skips over them entirely.

Though statistics vary from study to study, results all seem to indicate that Autistic people suffer from trauma much more frequently than non-Autistics. In an online article, Dr. Freya Rumball suggests the rates are even higher. While about 4 to 4.5% of the general public might meet criteria for PTSD, studies show that 32% to 45% of Autistic people report symptoms strong enough to suggest a probable diagnosis. That means Autistic adults are living with PTSD at rates that are 7 to 11 times higher than the general population.¹⁵

It seems clear that as Autistic people, we are much more likely to experience trauma. While we can expect that much of this trauma comes from the wide range of life experiences that find us being excluded, rejected or invalidated, we are also at very high risk for serious harm from being victimized by others.

Researchers in a UK-based review looked at 34 studies involving Autistic children, teens, and adults. The result of this meta-analysis shines a light on the very high rates of victimization in the Autistic community. Harm from victimization came from many sources – physical or verbal attacks, online bullying, hate crimes, domestic abuse, child abuse, and sexual abuse. This is what they specifically found among the many Autistic people of all ages:

• 44% had been victimized
• Among those victimized, 84% reported more than one type of harm or abuse
• 40% reported sexual victimization
• 16% experienced child abuse or neglect.¹⁶

Researchers have noted the toll that victimization takes on Autistic individuals, including mental health concerns and self-harm.¹⁷ The blurry connections between anxiety, trauma, rejection, RSD and mental health come into sharper focus when we look at the numbers.

These numbers reflect more than isolated incidents—they point to a pattern of disregard for the consequences of social rejection for Autistic people. The emotional cost of victimization is not temporary discomfort. It can deepen rejection sensitivity, increase the risk of anxiety and depression, and make it harder to feel safe in everyday life.

Learn more here:  Becoming More Trauma Informed Collection

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What Does This All Mean for Autistic Mental Health?

Taken together, these findings help us understand an important pattern. Autistic people are more likely to experience anxiety, depression, and trauma than the general population. We are also more likely to be victimized by others, especially through experiences like bullying, exclusion, abuse, and social rejection. These patterns are not random, and they are not caused by autism itself.

Rejection sensitivity appears to play a role in this. It may make some Autistic people more emotionally affected by the negative treatment we experience. But rejection-sensitive traits are not the only factor. Studies also show that when people live in environments where they are often misunderstood, corrected, or excluded, they are more likely to develop symptoms of mental health conditions.

It is important to recall that autism is not a mental illness, yet so many Autistic people do have mental health conditions. Based on what the research shows, these conditions seem to develop not because of autism, but because of how Autistic people are treated. That includes how often we are rejected, scrutinized, have our needs ignored, and are forced to hide who we are in order to be accepted.

These issues are serious. They affect our mental health, our quality of life, and sometimes even our ability to survive. Moving forward, mental health research and services a must reflect the experiences of Autistic people. This includes recognizing the significant role of rejection in our lives, understanding the impact of social trauma, and listening to Autistic voices to determine a way forward. Understanding how RSD interacts with our Autistic traits and lived experience can help make sense of why mental health struggles are so common in our community.

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RSD and Social Pain

People who experience the loss of emotional control that accompanies RSD know all too well that the pain is real. Fortunately, researchers are slowly catching up to what we have known all along. Emotional pain really does hurt.

Research carried out in the UK included 20 Autistic university students and 40 non-Autistic students.¹⁸ Each of the participants were asked to look at photos of strangers and guess whether or not the person liked them. After each guess, they were given feedback—either “yes” (the person liked them) or “no” (the person did not like them). However, they did not know that the feedback was completely random--no one was judging them. The whole exercise was conceived and designed to measure how much each person expected to be liked or rejected.

Participants also completed questionnaires that measured their levels of autistic traits, social anxiety, and depression. This let researchers see how mental health and identity might be involved in someone’s expectation of rejection.

The results showed that Autistic participants were far more likely to expect rejection and to guess “they don’t like me” than their non-Autistic peers. The most significant finding was that social anxiety—not Autistic traits or depression—was the strongest indicator of expecting rejection. In simple terms, the more socially anxious a person was, the more they braced for rejection, regardless of their diagnosis.

There’s more. Autistic students in the study also showed much higher anxiety and stress levels than non-Autistic students. Their anxiety scores were more than double, and stress levels were nearly twice as high. These results are important. They show the emotional weight that many Autistic people are carrying as they react to a lifetime of rejection, misunderstanding, and emotional harm.

These results provide important information that has the potential to increase our understanding of what it can mean to be an Autistic person. This research shows the emotional weight many Autistic people carry as they interact with or simply cross paths with others. They’re responding to a lifetime of rejection, misunderstanding, and emotional harm.

This research reminds us that anticipating rejection develops over time and often is shaped by experience, anxiety, and how people have treated us in the past. Supporting Autistic people means treating that reality with the seriousness it deserves.¹⁸

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RSD and the Physical Pain Connection

Read any lived experience blog on the topic of RSD, and it is the hard-hitting descriptive language that will catch your attention first.

“It feels like your chest is caving in.”
“An invisible sharp knife stabs right in your gut.”

“A sudden burn behind your eyes and tears are rising…”

“The ache in your heart pulses.”

They often describe overwhelming emotional pain—sharp, intense, and sometimes even physical. What’s jolting is the vivid physical descriptions used to explain something emotional.

What is that all about?

Well, reality, it turns out.

In a groundbreaking 2011 study, Kross and colleagues¹⁹ asked participants to remember a painful rejection—like a romantic breakup—while their brains were scanned in an fMRI machine. What lit up on those brain scans surprised even the researchers.

The same brain regions that handle physical pain lit up when people experienced emotional pain.

Specifically, two key areas turned on: the secondary somatosensory cortex and the dorsal posterior insula. These sound like fancy medical words, but here’s the plain-English version:

• The secondary somatosensory cortex is like your brain’s pain translator. It figures out where something hurts and what kind of pain it is—burning, stabbing, pressure, etc.
• The dorsal posterior insula is like your pain volume dial. It processes how intense the pain feels—mild twinge or full-body scream.

These two aren’t in the frontal "thinking" part of the brain. They live in the parietal and inner side regions—close to each other in what you could call the brain’s "pain-processing neighborhood." They’re not twins, but they’re neighbors who work closely together to process physical hurt.

And here’s the twist: these brain areas don’t usually light up when people feel emotional distress. They’re usually activated when your body gets physically injured—burns, cuts, bruises. But in this study, they reacted to rejection. Just rejection. That’s how powerful the experience was.

As the researchers put it:¹⁹

“Intense social rejection activated somatosensory regions that are strongly associated with physical pain, which are virtually never associated with emotion as typically studied.” ¹⁹

So what does that mean for those of us who live with RSD?

• It means we’re not imagining it.
• It means the pain is real.
• It means the brain treats rejection like a punch to the gut or a hand on a hot stove.

To quote the study again:

“Social rejection and physical pain are similar not only in that they are both distressing, they share a common representation in somatosensory brain systems as well.” ¹⁹

For Autistic people—many of whom experience RSD regularly—this matters. It validates what we’ve been saying all along. We’re not too sensitive, we’re not overreacting, and we don’t need to "toughen up." Emotional pain is physical pain in our brains.

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Summary

This part of the series explored RSD triggers and risks that seem to make us more vulnerable. We hope this section has helped Autistic people to know that their RSD is of course valid and real, and for others, to accept as real how painful the Autistic experience of RSD can be.

Click here for more resources on RSD

Next: Rejection Sensitive Dysphoria (RSD): Part 4  - Impact on Daily Life

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References

1. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
2. Hudson, C. C., Hall, L., & Harkness, K. L. (2019). Prevalence of depressive disorders in individuals with autism spectrum disorder: A meta-analysis. Journal of Abnormal Child Psychology, 47(1), 165–175. https://doi.org/10.1007/s10802-018-0402-1
3. Hollocks, M. J., Lerh, J. W., Magiati, I., Meiser-Stedman, R., & Brugha, T. S. (2019). Anxiety and depression in adults with autism spectrum disorder: A systematic review and meta-analysis. Psychological Medicine, 49(4), 559–572. https://doi.org/10.1017/S0033291718002283
4. World Health Organization. (2023, March 31). Depressive disorder (depression). https://www.who.int/news-room/fact-sheets/detail/depression
5. Longmore, A., Anagnostou, E., Georgiades, S., Jones, J., Kelley, E., & Baribeau, D. (2025). Predictors of depressive symptoms in autistic youth—A longitudinal study from the Province of Ontario Neurodevelopmental Disorders (POND) Network. The Canadian Journal of Psychiatry, 70(5), 372-381. https://doi.org/10.1177/07067437241259925
6. Pearson Canada Inc. (2025). Special awareness days: Mental Health Week. Pearson Canada School. https://www.pearsoncanadaschool.com/special-days-calendar/national-child-and-youth-mental-health-day.html
7. Nimmo-Smith, V., Heuvelman, H., Dalman, C., Lundberg, M., Idring, S., Carpenter, P., Magnusson, C., & Rai, D. (2020). Anxiety disorders in adults with autism spectrum disorder: A population-based study. Journal of Autism and Developmental Disorders, 50(1), 308–318. https://doi.org/10.1007/s10803-019-04234-3
8. World Health Organization. (2022, June 8). Anxiety disorders. https://www.who.int/news-room/fact-sheets/detail/anxiety-disorders
9. van Steensel, F. J. A., Bögels, S. M., & Perrin, S. (2011). Anxiety disorders in children and adolescents with autistic spectrum disorders: A meta-analysis. Clinical Child and Family Psychology Review, 14(3), 302–317. https://doi.org/10.1007/s10567-011-0097-0
10. Statistics Canada. (2022, May 6). Youth mental health in the spotlight again, as pandemic drags on. Government of Canada. https://www.statcan.gc.ca/o1/en/plus/907-youth-mental-health-spotlight-again-pandemic-drags
11. Gao, S., Assink, M., Cipriani, A., & Lin, K. (2017). Associations between rejection sensitivity and mental health outcomes: A meta-analytic review. Clinical Psychology Review, 57, 59-74. https://doi.org/10.1016/j.cpr.2017.08.007
12. Rumball, F., Happé, F., & Grey, N. (2020). Experience of trauma and PTSD symptoms in autistic adults: Risk of PTSD development following DSM‐5 and non‐DSM‐5 traumatic life events. Autism Research, 13(12), 2122–2132. https://doi.org/10.1002/aur.2306
13. Statistics Canada. (2024, May 27). Survey on mental health and stressful events, August to December 2023. The Daily. https://www150.statcan.gc.ca/n1/daily-quotidien/240527/dq240527b-eng.pdf
14. Porges, S. W. (2022). Polyvagal theory: A science of safety. Frontiers in Integrative Neuroscience, 16, 1-15. https://doi.org/10.3389/fnint.2022.871227
15. Rumball, F. (2022, March 30). Post-traumatic stress disorder in autistic people. National Autistic Society. https://www.autism.org.uk/advice-and-guidance/professional-practice/ptsd-autism
16. Trundle, G., Jones, K. A., Ropar, D., & Egan, V. (2023). Prevalence of victimisation in autistic individuals: A systematic review and meta-analysis. Trauma, Violence, & Abuse, 24(4), 2282–2296. https://doi.org/10.1177/15248380221093689
17. Cappadocia, M. C., Weiss, J. A., & Pepler, D. (2012). Bullying experiences among children and youth with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42(2), 266-77. https://doi.org/10.1007/s10803-011-1241-x
18. Gurbuz, E., Riby, D. M., South, M., & Hanley, M. (2024). Associations between autistic traits, depression, social anxiety and social rejection in autistic and non-autistic adults. Scientific Reports, 14, 1-8. https://doi.org/10.1038/s41598-024-59532-3
19. Kross, E., Berman, M. G., Mischel, W., Smith, E. E., & Wager, T. D. (2011). Social rejection shares somatosensory representations with physical pain. Proceedings of the National Academy of Sciences of the United States of America, 108(15), 6270–6275. https://doi.org/10.1073/pnas.1102693108

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