The ever-changing psychology of mental health

A couple of years ago, I noticed something new in the reports I was reading about the adolescents I worked with. 'As part of her ADHD, Amelia also has RSD', a typical report might say. Or 'Bethan's RSD makes it hard for her to establish friendships and she is socially isolated'. RSD? RSD was not something I'd been trained in, nor could I find it in the diagnostic manuals. Yet it was being written about in the reports as if it was something that all professionals would know about.   

I asked parents, and they were confused by my question. Didn't I know about RSD? To them, it was no different to ADHD, or GAD (Generalised Anxiety Disorder), or any other diagnosis their child had been given. They described it to me as an integral part of ADHD – that was the reason their child got so upset when their friends didn't text them back, they said. One of them told me that this was the way their child was wired and always would be – it's neurological. 

I went away and I Googled it. What I discovered intrigued me. 

A lightbulb moment

Back in the 2010s, a psychiatrist called William Dodson observed something in his adult clients with ADHD. They had, he suggested, a heightened sensitivity to rejection from others.  He assessed this by asking them this question.

'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 of his clients said yes to this question, and Dodson gave it a name. Rejection Sensitivity Dysphoria or RSD. He started writing articles about it. The concept resonated with many. Before long, there were people posting TikTok or Youtube videos about RSD and how to identify it. The list of ways in which RSD manifested itself spread way beyond the original question. It was said to include sensitivity to failure, to arguments, to not having your ideas responded to in meetings. Therapists wrote articles about how important it was to understand RSD and how they saw it in their clients with ADHD (and experienced it themselves). Books were written explaining RSD (and offering self-help). Symptom checklists were published in online magazines. 

The idea of RSD spread like wildfire. It was a lightbulb moment for many and they said it helped them to understand why life had always been harder for them than for other people. It validated their experiences and emotional reactions. To them, it meant that no longer were they over-sensitive or too emotional – they had RSD. The name made all the difference. It was the reason they had been looking for.

Gaining credibility

The only problem was, of course, that it wasn't actually a reason. Dodson described something he saw in his clients, but that didn't mean that he had discovered the reason why they felt that way. Because the question asked was based entirely on self-perception, it wasn't clear whether his clients really were more sensitive to rejection, or whether they just perceived themselves to be. It's common for people compare their insides to the outsides of others – and to assume on that basis that everyone else finds life easier than they do. It also wasn't clear whether RSD was specific to those with ADHD – Dodson specialised in ADHD, so he asked people with ADHD about their rejection sensitivity. He didn't compare them with a control group of those with a different diagnosis – perhaps social anxiety, or depression. RSD was based on clinical anecdote rather than research. 

This didn't matter to the many people who felt that RSD described them and their children. It resonated. The idea spread. Articles on medical websites claimed that RSD is likely to be 'due to differences in brain structure' despite the lack of research. They recommended medication as a frontline treatment. Dodson himself now argues that RSD should be seen as a core feature of ADHD and that it may be more important in adults than the official diagnostic criteria.  

The more people talked about it, the more RSD gained credibility. The more it gained credibility, the more likely it was that people would hear about it, and identify with the term. And by doing so, they would change the way that they understood themselves and that other people understood them. 

A cultural context

Classifying people (including self-classification) is not a neutral act. The philosopher Ian Hacking called this a 'looping effect'. We define a group of people, and then more and more people come to define themselves in that way, and as they do so, the nature of the classification changes to include them. 

That is why RSD was showing up in the reports I was reading by psychologists. RSD was becoming an explanation for why people felt the way that they did. It validated their experience and connected them with others. It was a cultural phenomenon, and psychologists exist in a cultural context. 

I've always been interested in culture. I lived in four different countries when growing up, and attended schools where most of the students and teachers had a very different cultural background to my own. As a newly qualified clinical psychologist, I worked in GP surgeries in London where it wasn't unusual to see clients from six different cultures in a single day.  Perhaps the thing which interests me most is how we are often blind to our own culture. Our own culture is 'just how things are' whilst the culture of others is, well, 'culture'. Psychiatric classification manuals such as DSM-5 define some 'culture-bound syndromes', but these are usually only defined for non-Western cultures. Yet one way to see the whole psychiatric system is as a culture-bound model for understanding mental distress and unusual behaviour. Emerging ideas such as RSD could be seen as new cultural concepts, spreading and changing through the medium of social media. 

Haltigan and colleagues (2023) refer to terms such as these as 'peri-psychiatric'. They bear some of the hallmarks of a psychiatric diagnosis (and are often used as if they were a diagnosis), but they are not defined by the diagnostic manuals and are usually based on lived experience (as described in online communities) rather than on academic research. 

This doesn't mean that they aren't 'real' to the people who describe themselves this way. The way that we understand mental health is deeply embedded in culture. The medical historian Edward Shorter explains this through the idea of the 'symptom pool'. He suggests that within a culture, there are a range of different ways in which people can and do express their distress. These symptom pools are fluid and change over time. In the UK, our symptom pool has in the last 50 years been largely defined by diagnostic manuals such as ICD-11 and DSM-5 but this has been changing in recent years due to the ease by which information spreads over the internet.  

Dissociative identity disorder

As I explored this world more deeply, I discovered that not only are new peri-psychiatric terms such as RSD emerging on the internet, but official diagnoses are being redefined. Dissociative identity disorder (DID), for example, is understood by mental health professionals to be a rare and severe mental health problem, usually caused by prolonged developmental trauma. Individuals may feel as if they have different distinct personality states and have gaps in their memory. People with DID have great difficulty in functioning and their symptoms usually cause intense distress. 

An online culture has developed around DID which, whilst including some elements of the conventional definition, goes far beyond it in scope. Those who identify with it have developed a new taxonomy, including people who define themselves as 'plural' (i.e., having multiple personalities) with no history of trauma and without considering themselves to be disordered. Online content creators post videos of them switching between different personalities and gain millions of followers. The culture which develops is, in the words of Haltigan et al. (2023), 'liberated from conventional psychiatric nosology'. 

In other words, people self-identify as having DID without fitting the diagnostic criteria. Colleagues who work with DID tell me that over the last decade they have noticed a significant change – previously, almost no one came to mental health services wanting a diagnosis of DID or having even considered the possibility. Now, many people (including teenagers) arrive having already strongly identified with DID. They are often upset and angry if told that they do not meet criteria, or offered an alternative explanation. 

This raises the intriguing question of what a diagnosis means if it is no longer tied to the diagnostic criteria. A fundamental part of the medical model is that a person is only given a diagnosis if they are in serious distress or having significant problems functioning, and therefore need intervention. Symptoms alone are not enough to confer a diagnosis. If that is no longer necessary, then we have no idea how many more people would come under any particular diagnostic umbrella. Research shows that even symptoms such as hearing voices (which are usually considered to be a sign of serious mental health problems) are surprisingly widespread in the general population. Differences between people are dimensional and this is increasingly recognised by researchers. This means that there will be large numbers of people who have similar symptoms to those who meet full diagnostic criteria, but to a lesser degree or without causing impairment. There is also evidence that symptoms can be spread by social media, with Kirsten Müller-Vahl and colleagues in Germany coining the phrase 'mass social media-induced illness' to describe an outbreak of young people developing verbal and motor tics after watching a highly successful YouTube creator who made videos showing a wide range of 'Tourettes-like' tics. 

Uncharted lands

All of this leaves mental health professionals facing an uncharted landscape. Clients are understanding their experiences in new ways, but are often doing this using the language and framework of psychiatric (or peri-psychiatric) diagnosis. Symptoms are both identified and spread via social media. Many clients are asking for a validation (meaning a diagnosis) of something which they have already decided for themselves. Diagnoses have become cultural identities, and as such have taken on a life beyond DSM and ICD. They have become tools for personal transformation for many who say that getting a diagnosis allowed them to forgive themselves 'and finally start healing'. But are these new understandings less pathologising, or is, as Allan Frances, psychiatrist and chair of the DSM-IV taskforce argues, our concept of 'normality' shrinking as psychiatric concepts stretch to include ever more of the population?

For psychologists working in mental health, this raises complex questions on a daily basis. Is our role to reflect this new culture and to give diagnoses whether or not a person fits the criteria? Should we use peri-diagnostic terms because they have significance to our clients, or should we maintain a distinction? If a diagnosis is a route to healing and self-forgiveness and is not tied to criteria, then it's hard to justify why one should be denied to anyone who wants one. In that case, we might reasonably ask ourselves what a diagnosis means at all.  

Psychiatric (and peri-psychiatric) diagnoses are, after all, descriptions and not explanations, something which is rarely acknowledged in the online communities. Even when defined by the diagnostic manuals, they don't reliably describe separate entities and there is considerable overlap. There is strong evidence that diagnostic groups do not map onto structural brain differences, despite the websites which will tell you otherwise. Boundaries have always been fuzzy, and the further a concept moves away from the diagnostic criteria, the fuzzier they become. Once a diagnosis is 'liberated from conventional psychiatric nosology', then it will mean very different things to different people. As psychologists, we will need to grapple with that.