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What role does the prefrontal cortex play in RSD and ADHD? 

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Updated
ByMy Patient Advice
Author: Dr. Rebecca Fernandez, MBBS

The prefrontal cortex (PFC), the part of the brain just behind your forehead, plays a central role in how we manage emotions, focus attention, and make decisions. In people with ADHD, this region often functions differently, which can help explain why Rejection Sensitive Dysphoria (RSD) feels so intense for many. 

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How the prefrontal cortex regulates emotions and attention 

According to research in Frontiers in Molecular Neuroscience (2022), the dorsolateral (dlPFC) and ventromedial (vmPFC) areas of the PFC work together to regulate emotional reactions and maintain control over impulses (Frontiers, 2022). Findings reported in Frontiers in Integrative Neuroscience (2025) suggest that medication can enhance activity within prefrontal circuits involved in reward evaluation and attention control, supporting the PFC’s role in executive and emotional regulation (Frontiers, 2025). 

RSD and disrupted prefrontal limbic balance 

Although Rejection Sensitive Dysphoria is not a formal diagnosis, it describes an experience many people with ADHD recognise: overwhelming emotional pain in response to perceived rejection or failure. A growing body of imaging and neurocognitive research links RSD-like sensitivity to overactive limbic regions (for example, the amygdala) combined with reduced top-down regulation from the prefrontal cortex. This imbalance can make emotional cues feel more threatening and reactions more intense (Frontiers, 2022; Frontiers, 2025). 

What NHS and NICE say about emotional dysregulation in ADHD 

NICE guideline NG87 (updated 2025) recognises emotional dysregulation as a common and impairing feature of ADHD and recommends structured psychological interventions, such as cognitive-behavioural and emotional control strategies, when appropriate (NICE NG87). NHS advice also notes that heightened emotional sensitivity and mood swings can be part of ADHD rather than a separate condition (NHS — ADHD overview). 

Getting help and support 

If emotional regulation difficulties are affecting daily life, professional assessment and support can help. Alongside NHS pathways, private services like ADHD Certify provide ADHD assessments and post-diagnostic reviews with qualified clinicians in the UK. 

Takeaway 

Emotional sensitivity and rejection distress in ADHD likely arise from prefrontal–limbic circuit dysregulation, where the brain’s emotional brakes struggle to keep up with its emotional drive. Understanding this neurobiological basis can reduce self-blame and point to targeted therapies and structured support that make a meaningful difference. 

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Dr. Rebecca Fernandez, MBBS
Author

Dr. Rebecca Fernandez is a UK-trained physician with an MBBS and experience in general surgery, cardiology, internal medicine, gynecology, intensive care, and emergency medicine. She has managed critically ill patients, stabilised acute trauma cases, and provided comprehensive inpatient and outpatient care. In psychiatry, Dr. Fernandez has worked with psychotic, mood, anxiety, and substance use disorders, applying evidence-based approaches such as CBT, ACT, and mindfulness-based therapies. Her skills span patient assessment, treatment planning, and the integration of digital health solutions to support mental well-being.

All qualifications and professional experience stated above are authentic and verified by our editorial team. However, pseudonym and image likeness are used to protect the author's privacy. 

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