ADHD and Anxiety

By Roberto Olivardia, Ph.D.

Attention Deficit Hyperactivity Disorder (ADHD) can often be overlooked, complicated or made harder to treat when an anxiety disorder is also present. Approximately 30%-40% of people with ADHD have an anxiety disorder such as obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD)/excessive worry, agoraphobia, panic disorder or other anxiety issues. Not surprisingly, genetic research suggests that ADHD and anxiety may share similar genetic underpinnings. Studies from Massachusetts General Hospital found that approximately 30% of people with OCD also have ADHD, and that there is a common link between the two.

Anxiety Can Exacerbate ADHD

Anxiety has a profound effect on a person’s ability to attend to information in a clear and mindful way. If someone is obsessing about whether touching a doorknob will lead to a life-threatening disease or having intrusive thoughts that they are going to hell (as with OCD), it becomes very difficult to pay attention here and now. Anxiety often takes us out of the present moment, attending to something in the past or anticipating a threat in the future instead of living in the now. Anxiety exacerbates pre-existing challenges with attention and organization. Anxiety creates extra noise in the brain that makes it difficult to organize information productively. People with anxiety disorders often find themselves assessing any possible threat in their environment, leading to a lack of awareness of “bigger picture” details in the environment.

A Vicious Circle

ADHD symptoms often lead to much stress and anxiety. If you’ve missed a flight in the past, you may worry excessively about missing future flights. You may have trouble sleeping the night before your flight, which could lead to more anxiety and increasing ADHD symptoms, which leads to yet more anxiety, and the cycle continues.

One individual I spoke with was housebound with agoraphobia (fear of any situation where it is perceived to be difficult or embarrassing to escape) due to his ADHD symptoms. Subjected to such ridicule at his job due to forgetfulness, distractibility and impulsivity, his embarrassment was so painful that his home became his only “safe” place. Another individual, a college student, expressed severe social anxiety primarily due to ADHD. His verbal interruptions of other people and his inability to follow conversations often caused him to “miss the boat” in social gatherings, leading to social alienation and feeling socially ineffective.

People with ADHD often find themselves in situations where others may react to them in negative ways, which can increase their self-consciousness and anxiety. In addition, people with ADHD tend to be sensitive. This can be a positive trait, but it also makes them more vulnerable to negative situations and emotions.

Treating ADHD and Anxiety

It is imperative to understand and treat both ADHD and any anxiety disorder simultaneously. If either disorder is undiagnosed or clinically neglected, treatment will unsuccessful. Treating ADHD requires thinking outside the box, using unconventional methods to gain mastery of the ADHD brain. Anxiety can make this difficult since trying new things implies the risk of failure, which can be very threatening to someone struggling with anxiety. For this reason, co-existing anxiety cannot be ignored.

Similarly, ADHD cannot be left out of the picture. Anxiety disordered individuals are often very self-critical, and treating ADHD successfully requires self-acceptance – a challenging goal for those with constant critical thoughts. If you are dwelling on thoughts of not being like everybody else, you are not going to get anywhere. ADHD symptoms might lead to forgetting to do therapy homework, being distracted in session, and unintentionally missing appointments. Anxiety and ADHD symptoms interact in ways that must be addressed simultaneously. Seeking help with expertise in both anxiety and ADHD is important.

Psychopharmacological Issues

Medications that treat anxiety disorders can boost energy, improve mood and free up cognitive space, which can have an indirect impact on treating the ADHD. Two classes of medications are most often used to treat anxiety: selective serotonin reuptake inhibitors (SSRI’s such as fluoxetine, paroxetine, and sertraline), and benzodiazepines (such as lorazepam and alprazolam). Neither seems to have any negative effect on the ADHD.

Stimulant medications are highly effective in treating ADHD, but can sometimes exacerbate anxiety symptoms. One patient with ADHD and OCD discontinued his dextroamphetamine prescription because, while it dramatically helped his ADHD symptoms, it also made his compulsive rituals far worse. In such cases, another stimulant or a non-stimulant medication may be clinically indicated, although non-stimulants may be less effective than stimulants for treating ADHD. Some patients take both an SSRI and an ADHD medication. Patients who prefer taking one medication may choose to treat the more impairing disorder pharmacologically and the other disorder behaviorally. Working closely with a psychiatrist who understands the nuances of ADHD and anxiety is extremely important.

Treatment Strategies

Despite potential complicating factors, the good news is that treatment can be highly effective for people who struggle with both ADHD and anxiety disorders if done right. The following strategies will help improve your odds of a successful outcome.

• Understand how ADHD and anxiety relate to each other. If most of the anxiety was a consequence of ADHD symptoms, focus of treatment on the ADHD. If they are independent but affecting each other, give each the attention it deserves.

• Cognitive therapy, which focuses on thinking patterns, is indicated for both anxiety and ADHD. People who are anxious often fall into common cognitive distortions, such as all or nothing thinking, where they might believe, for example, you need to get an “A” on an exam or you’re a failure. Cognitive therapy works at correcting any inaccurate assumptions and overcoming negative self-talk, which does nothing to help one’s anxiety or ADHD symptoms.

• Behavioral therapy is essential in treating almost every anxiety disorder, as well as ADHD. Effective treatment for ADHD/Anxiety demands a therapist with expertise in behavioral therapies. For example, exposure therapy can help reduce people and situation avoidance by introducing feared situations or stimuli to help develop a tolerance for anxiety.

• Developing relaxation techniques, like diaphragmatic breathing and progressive muscle relaxation is very helpful in clearing one’s mind of “mental clutter” as well as reducing physical tension in the body.

• Attending to the basic elements of health are important. Eating a well-balanced, nutritious diet, getting adequate amounts of sleep and regular exercise all aid in both anxiety and ADHD. There is substantial research about the effects food, sleep, and exercise habits have on anxiety, as well as ADHD.

• Practice mindfulness. Anxiety worsens when you try to avoid an anxious thought. You cannot prevent a thought, and in fact, the more you try to push it away, the more intrusive it becomes. Instead, accept the thought and know that the thought is just a thought; it is not necessarily accurate or truly indicative of danger. Notice your thoughts and recognize that you do not need to react to them.

• Surround yourself with supportive, positive people. Negative, cynical and judgmental people only add to your stress. People with ADHD are, unfortunately, used to feeling criticized and judged. Create a social circle of warm, affirming people.

• Accept both the anxiety and ADHD. You are not a weak person because you have these issues. There is nothing to be ashamed about. There are millions of people who struggle with ADHD and anxiety. Have a sense of humor about it when you can. Without acceptance there can be no progress.

Having both ADHD and anxiety is not a death sentence. The key is to accept the so you can engage in effective treatment that will lead to a productive, fully-lived life.

Roberto Olivardia, Ph.D. is a Clinical Psychologist and Clinical Instructor in Psychiatry at Harvard Medical School. He is co-author of “The Adonis Complex”, about body image and eating disorders in boys and men, and has a private practice specializing in treating ADHD, eating disorders, obsessive-compulsive disorder, and body dysmorphic disorder.