Attention Magazine August 2023

For many individuals, ADHD AND ANXIETY go hand in hand. The anxiety often comes from worry about performing, about forgetting things, about missing appointments, not following through on plans, and making careless errors to name a few triggers. But could it be that it’s not just ADHD. Up to twenty-five percent of people with ADHD also have anxiety as a separate condition, not simply in response to ADHD.

Let’s look at a few stories of people who are facing some of the difficulties of ADHD combined with anxiety.

Three different but common scenarios
Sam has had anxiety for as long as he could remember, but he had just recently figured out, at age thirteen, that not everyone experiences this internal discomfort. He becomes anxious about what will happen tomorrow. He gets anxious about whether he can do what it takes to keep his grades up. He gets anxious about the impulsive statement he made to his teacher that got him in trouble—and would he do it again tomorrow? He becomes anxious about whether he will have enough time to get ready for school in the morning. There seems to be no end to what he gets anxious about; he has major internal stress.

In addition, Sam has always had great difficulty getting things done. He has trouble remembering things he has learned. It takes him a long time to read his school assignments, because he must reread every page in order to really have it register in his mind and to remember what it says. If he forgot his calculator for his math test, he worried about the grade he is going to make on it.

Sam’s parents noticed his stress level only recently, though they knew about his problems with school for a long time. He was close to giving up on school. So, his mom made an appointment with his pediatrician to talk about school problems. Of course, he became very anxious about the upcoming appointment, too.

Sam’s mother brought the doctor questionnaires with information from his teachers. They discussed the criteria for ADHD during the visit, and Sam identified with these symptoms, which he thought everyone had. He realizes now that he has been struggling much more than his friends. His anxiety level remained high, but he felt someone understood him far more than ever before. That helped.

He was given a trial of a stimulant medication. Sam and his mom titrated it to the best level with the help of his doctor, and it made a huge difference. Over the next several weeks he started to relax, and the anxiety really started to fade. He still experienced it with minor situations that would probably make anyone anxious. He found he not only worried less about his school performance, but he worried a lot less about other things. For the first time in his life he had long periods during each day with no anxiety at all. “Wow! This is great!” he told his doctor.

Sam had ADHD and perhaps a tendency to respond to stress with more generalized anxiety, but the driver of his anxiety was the ADHD that had not been recognized since he had high normal intellectual ability. When his ADHD was treated optimally, his anxiety dissipated enough that it became almost the same as any average thirteen-year-old without ADHD. This is an example of ADHD-induced anxiety and no further treatment is needed at this point.

Emily felt much the same as Sam prior to her first visit to the doctor. But when her ADHD was properly treated, she did not notice much improvement in her anxiety. So her mom and her primary care provider sent her to a therapist. The therapist helped her through cognitive behavioral therapy techniques, and she gradually felt much better. She was given ways to deal with the anxiety and disarm it. She did not require medication for the anxiety directly. In Emily’s situation, she has ADHD with a tendency toward anxiety which she has been able to overcome with learning coping skills.

Jasmine felt much the same as both Sam and Emily. But when she was treated for ADHD, she found that even though the ADHD symptoms decreased and her school performance and absentminded tendencies improved, her anxiety did not get better. She went to a therapist, but it did not seem to normalize her anxiety.

Jasmine then went to a specialist who was able to identify her anxiety as a separate entity that was not the product of ADHD symptomatology and that was not responsive to psychotherapy alone. She required medication that would help her system to boost serotonin in the parts of the brain that help anxiety. When she began taking the medication for anxiety, it got very much better. She began to relax and feel like she could enjoy things more and breathe easily again.

Responses to treatment—and another scenario
These are three different scenarios that are common when ADHD and anxiety intersect. Sam did not really have a separate anxiety disorder, but untreated ADHD was causing him to have greatly increased anxiety due to his feeling of not being able to function at a level to which he knew he should be able to function.

Emily had anxiety that was not simply responding to ADHD symptomatology in her life. And she had a type that is more responsive to her own intervention strategies as taught to her by a therapist.

Jasmine had a type of anxiety that is not as responsive to therapy, but once the medication has the anxiety at a level that is more manageable, she may then benefit from psychotherapy in order to maintain the anxiety at a normal or near-normal level. The combination of medication and therapy has been shown to be of greater benefit than medication alone, especially for maintaining the anxiety at a low level.

Now twenty-three years old, Karen has experienced anxiety all of her life. After graduating from college and becoming a teacher, she married and now has a small child. Her anxiety has been treated since late high school, but whatever medications she tried worked for a while and then stopped working—even with titration of doses upward. She has been through almost all of the usually very effective serotonin reuptake inhibitors (Prozac/fluoxetine, Zoloft /sertraline, Lexapro/ecitalopram and others like Buspirone), but her anxiety level eventually returned to significantly high and disruptive levels.

Karen’s primary care provider was perplexed, but decided to ask her about ADHD symptoms. She had symptoms of inattentiveness, poor task completion, poor efficiency in work productivity, and poor memory organization as well as disorganization throughout her school career. But being highly motivated she was able to achieve a higher education degree. But with the complexity and demands of her job, her family, and “adulting,” she was just having more and more difficulty. So a trial of medication for ADHD was begun with remarkable benefit.

She remained on the anxiety medication she had been on at the time, until she learned coping skills through therapy. In time she no longer needed the antianxiety medication. She had tried therapy before, but sometimes there is difficulty with internalizing the therapeutic principles and putting them into practice routinely if the person doesn’t have the internal organization needed to do so.

Effective treatment for coexisting ADHD and anxiety
In the distant past it was thought that treating ADHD with stimulant medications in anxious individuals made anxiety worse. This is not typically true, according to many studies on anxiety with ADHD. Anxiety is a potential side effect of starting at too high a stimulant dose initially. That’s why it is best to start low in all individuals (with anxiety or not) and titrate up to the lowest dose that works optimally. Then it is important not to exceed that dose unless ADHD symptoms return. It is also really important to take medication regularly. For most individuals, if medication is stopped for two or more days in a row and then restarted at full dose, side effects will be present that are normally only seen when starting at too high a dose.

The general principle here is that in someone who meets criteria for ADHD, the ADHD should be treated well first. Most often this will decrease the anxiety and/or depression symptoms if they are not too severe. ADHD is a brain function problem—focus, memory organization, and task completion—in most individuals. Impulsiveness and over-activity (including over-talkativeness) occur in others. Executive function difficulty emerges as adulthood is reached. As a baseline, having those symptoms optimally improved leaves a better platform on which to start building the best management program for the anxiety.

Working to simplify life by organizing and arranging school, work, and home to avoid the most anxiety-provoking components will help as well. Some things that constantly provoke anxiety may be restructured so that they are not causing daily anxiety. Setting aside time to do certain tasks at certain times so that decisions don’t have to be made every day can be very helpful. Organizing so that what is needed is ready and available to complete tasks like doing homework or paying bills or managing other daily or weekly activities of life will reduce the anxiety as well. Routine helps both ADHD and anxiety. Routines take work to get established, but are well worth working for and maintaining.

Both medication and psychotherapy, especially cognitive behavioral therapy, can be very helpful for anxiety. Sometimes the decision on which one you take advantage of first may have to do with what is most readily available. For many types of anxiety, medication or therapy may be equality effective, at least initially. Looking at the longer-term remission rates in many studies, therapy is generally more effective. For many individuals, medications that target improvement of anxiety symptoms will be more effective initially and will give symptom relief sooner. For both ADHD and anxiety disorders, modifying challenging life situations can improve quality of life, too. But knowing that there is help available gives hope that anxiety does not have to be a problem forever; nor do the symptoms of ADHD.

Earl J. Soileau, MD, FSAHM, specializes in treating ADHD in children, adolescents, and adults, and has treated co-occurring conditions as well. Dr. Soileau is an assistant professor at the family medicine residency based at Lake Charles Memorial Hospital in Lake Charles, Louisiana. He authors articles on ADHD for textbooks and medical journals and speaks nationally and regionally.