ADHD and Anxiety: The Connection and What it Means for Treatment

By Hailey Perez, LMFT

Octave Therapist

What do ADHD and anxiety have to do with each other? On the surface, the two conditions are unrelated, the former being a developmental disorder and the latter a mood disorder. However, studies have found that at least 50% of people with ADHD also suffer from an anxiety disorder.

The reality is that, for a person with ADHD and anxiety, the connection is easy to understand. While anxiety isn’t a primary symptom of ADHD, it is an indirect consequence of years of struggling to succeed in a world that expects neurotypical thinking.

How Does ADHD Lead to Anxiety?

To see how ADHD leads to anxiety, it is necessary to understand what underlies ADHD. Attention-deficit/hyperactivity disorder (ADHD) is a developmental disorder characterized by a deficit in executive functioning. Executive functioning refers to the ability to plan, organize, and complete tasks. It is responsible for working memory, which allows a person to retain and recall information over short periods of time.

In other words, it is not related to what is colloquially called intelligence, nor is it a matter of a lack of knowledge. A child with ADHD therefore struggles to understand why certain tasks seem so difficult when others can perform them with ease. Parents and teachers might often explicitly make these comparisons, believing that the child is simply not trying or purposefully not following directions.

For many, this experience happens over and over again throughout childhood – in their performance in homework assignments and tests, their completion of family responsibilities, and their ease in social interactions. They lose confidence in their abilities.

Day-to-day tasks become fraught with uncertainty. The person worries that they might do something wrong or misunderstand directions. They may misplace an important item or forget a responsibility altogether. This is compounded by a sense of perfectionism, despite not knowing what ‘perfection’ might mean.

The uncertainty they experience, both in their own capabilities and the potential outcome, creates anxiety even when it comes to everyday tasks. Since this anxiety is rooted in so much historical experience, individual successes can each feel like a fluke, making only a small dent in what can be a powerful inferiority complex.

The ADHD and Anxiety Feedback Loop

Anxiety is not only caused by the expectations felt by people with ADHD. Many of the symptoms of ADHD actually resemble those of anxiety, leading to a feedback loop.

For example, a physical symptom of both ADHD and anxiety is restlessness and fidgeting. When expressed as a symptom of ADHD, it can trigger or increase anxiety if it is perceived as such.

ADHD can also cause racing thoughts, impulsivity, hypervigilance, and emotional dysregulation. Each of these symptoms mirrors an experience of anxiety, heightening existing anxious feelings and triggering further anxiety.

What Does Anxiety Linked to ADHD Look Like?

Although anxiety disorders are distinct from ADHD and have their own characteristics, they present in specific ways for people with ADHD.

There are certain common characteristics present in anxiety linked to ADHD.

Sensory Overload

People with ADHD are often hypersensitive to sensory input. Loud noise may lead to a feeling of claustrophobia. Strong odors can cause physical and psychological distress. In certain environments, the person may experience sensory overload, leading to a sense of generalized anxiety. The overwhelming nature of the experience can also trigger anxiety surrounding any number of things. These may be related, such as trying to continue a conversation in a noisy environment, or unrelated, such as further fixation on already-present anxious thoughts.

Perfectionism and Procrastination

As I mentioned, people with ADHD are often perfectionists. However, this is most often not expressed through overworking but rather through procrastination. The sense that they need to do everything ‘right’, in combination with the belief that they will get something ‘wrong’, makes it difficult to find the motivation to start the task.

Their struggles with organization also play a role in this. It makes preparation necessary just to get to the task itself.

Hyperfixation and Overthinking

It’s a common misconception, not helped by the name of the disorder, that people with ADHD always struggle with focus and attention. However, a common symptom of ADHD is hyperfixation, the tendency to focus intensely on a subject or activity that is particularly interesting or rewarding. Someone with ADHD might struggle to pay attention to a lecture for five minutes while easily spending hours reading fiction, playing a musical instrument, gaming, or learning something novel.

Hyperfixation can lead to overthinking when the person’s focus shifts day-to-day matters. For most people, overthinking happens in unfamiliar or stressful situations. Someone with ADHD, on the other hand, may hyperfixate on whatever is on their mind, whether an upcoming deadline, a meeting, a social interaction, or any number of matters. The mind throws up countless potential challenges, often irrelevant and unlikely, making realistic problem solving difficult. The uncertainty about a resolution leads to heightened anxiety.

Masking and The Fear of Being Found Out

Masking, a coping mechanism stemming from fear of rejection, makes social situations loaded for people with ADHD. Rather than learning to embrace their idiosyncrasies and express them in healthy ways, the person tries to act ‘like everyone else’. But, even when this tactic ostensibly succeeds, the person continues to fear being ‘found out’, believing that one misstep can topple the whole edifice.

Not only can this make social situations feel draining, but it also strips them of some of their appeal. When masking, social interactions inevitably lack authentic validation or connection.

Gnawing Anxiety: What Have I Forgotten?

Ever had the following experience? You’re about to leave the house for work, feeling overburdened by responsibilities. Suddenly, you get the feeling that you’ve forgotten something important. You search your mind but can’t find anything and, at the end of the day, realize there was nothing to worry about.

Many people with ADHD feel this gnawing anxiety every single day. However, it’s not a fleeting experience, as it is borne of personal experience. Forgetfulness is a symptom of ADHD that can affect every aspect of the person’s life. They may forget small things, like where they just put their phone, and big things, like important jobs or taking their passports to the airport.

The anxiety therefore has a solid foundation. Without the skills to manage this symptom, it remains hard for the person to tell if they really have forgotten something.

Impulsivity

Impulsivity is another common symptom of ADHD and it is made worse by anxiety. One reason for this is that the person wishes to alleviate the anxiety by acting immediately. Another reason is that with the mind already crowded by anxious thoughts, taking time over a decision feels too exhausting.

Treating ADHD-Linked Anxiety

There are many great treatments available for anxiety disorders. However, when the anxiety is linked to ADHD, treatment needs to be adjusted. Specific treatments are well-suited to ADHD, while others have been developed for this purpose.

Cognitive-Behavioral Therapy (CBT)

Cognitive-behavioral therapy has rightly become a mainstay of treatment of anxiety. It provides skills to counteract the unhealthy thoughts and behaviors engendered by anxiety.

But for someone with ADHD, CBT will not necessarily be effective in the same way. Strategies like testing one’s thought processes can help assuage anxious thoughts. However, as people with ADHD have the tendency to overthink, using these tactics too often can backfire, with the mind finding new ways to justify the anxiety.

Mindfulness

Mindfulness has become ever present in the discussion of mental health treatment. People struggling with anxiety disorders find it particularly useful. Breathing meditations, for example, provide an easy and effective way to calm the body and mind.

However, some people with ADHD struggle with meditation. Focusing on the breath for ten minutes can feel extremely boring and, even after weeks of trying, the person might find meditation no easier.

For the above reasons, one of the most effective types of treatment for ADHD combines aspects from both CBT and mindfulness.

Dialectical Behavior Therapy (DBT)

Initially developed as a treatment for borderline personality disorder, DBT is now often used to treat many mood and personality disorders. It has also been found to be effective for many people with ADHD who struggle with anxiety.

DBT makes use of some of the most effective CBT techniques, but mindfulness is at the core of the treatment. Therefore, it doesn’t overly rely on CBT strategies, nor is its success dependent on one’s ability to meditate.

The mindfulness practiced in DBT is about acceptance – of oneself, one’s thoughts, and one’s feelings. The techniques are very practical, training the person to experience their reality without judgment. An important mantra is that ‘pain is inevitable, suffering is optional.’ This refers to the understanding taught by DBT that it is the thoughts and judgments that accompany difficult feelings which make them seem unbearable.

For example, a person with ADHD may start to feel anxious about an upcoming event. Their instinctual response to that anxiety is to try to get rid of it. They begin overthinking everything that could go wrong in an attempt to control the future. The initial anxiety balloons.

DBT teaches the person to pause before reacting to the feeling. It provides skills to let go of judgment in that moment, allowing it to come and go without holding onto it. When the person feels the anxiety as it happens, they find that it’s actually manageable and doesn't need to be ‘fixed’.

This is just one example of how DBT can be effective in treating anxiety for people with ADHD. There are many other skills in the DBT toolbox, helping the person with distress tolerance, emotional regulation, and interpersonal effectiveness.

Medication

Medication can help lessen anxiety and is especially effective when used in combination with therapy. It is important to keep in mind that people with ADHD are at higher risk of addiction. Non-addictive medication including antidepressants like SSRIs, rather than addictive sedatives, are often prescribed for this reason.

ADHD Coaching

Certain symptoms of ADHD are likely to trigger anxiety even when therapy and medication are working. Forgetfulness and disorganization can make it difficult for a person to feel ‘on top of things’ on a day-to-day basis, especially if they are working in a high-pressure environment.

ADHD coaching can help in this regard. There are alternative skills many people with ADHD use to manage tasks and responsibilities. Through coaching, the person learns to structure and schedule their time in a way that is sustainable for them. They learn to counter the negative impact of forgetfulness, lessening the sense of foreboding that comes along with it.

Therapists who specialize in ADHD can help with ADHD coaching. Alternatively, ADHD coaches can provide services which complement the therapy process.

The Upside of the Link Between ADHD and Anxiety

For many people with ADHD who suffer from anxiety, the realization that they are linked is a huge relief. It provides validation of what they’ve always known: many of their symptoms of anxiety have an underlying cause. It gives insight into how anxiety can be more effectively treated, even when other methods haven’t had the desired effect.

If you have ADHD and suffer from anxiety, Octave will connect you with an experienced therapist who understands your unique challenges. Get in touch today to start your journey towards a greater sense of balance, clarity, and calm