Why ADHD and Anxiety Occur Together

There is a phone call coming up. In forty minutes. In those forty minutes you cannot do anything; you sit, you stand, you open something, you close it. The call takes two minutes and does not go badly either. Then you get angry at yourself: was it worth all that?

For years this picture stood in my mind under the name of "tension." What I noticed after the diagnosis was that anxiety was not the only thing I was living through in those forty minutes. The anxiety was there, but under it there was also being unable to start, and not being able to feel time. When I began to separate the three, I also began to know what to do with each.

How often

In adult ADHD, having another mental health condition alongside it is more the rule than the exception. The community-sample study by Kessler and colleagues (2006) shows that anxiety disorders are markedly more common in adults with ADHD. Katzman and colleagues (2017) emphasize that this co-occurrence is almost an expected situation in the clinic.

This is called comorbidity: two conditions being present together in the same person. Comorbidity does not mean "one is the cause of the other"; it only means "both are there in the same person."

Where the anxiety comes from

There is an important distinction here, and making it changes the treatment.

Primary anxiety. The anxiety stands on its own. It would have been there without ADHD. Uncertainty, health, catastrophic scenarios; the subject is independent of the practical problems ADHD brings.

Secondary anxiety. The anxiety has developed as a result of ADHD. For someone who has forgotten, been late and left things half done for years, becoming anxious is a reasonable thing learned. This is called anticipatory anxiety, and its content is very concrete: I will forget again, I will not keep up again.

The two feel the same. But in secondary anxiety, when the ADHD side is addressed, part of the anxiety eases by itself, because the cause beneath it lessens.

Someone who keeps missing things learns to expect that they will miss them. This is called anxiety, but it is actually a prediction that works well.

How it looks in me

Let me describe my own pattern, because the description in the book did not help me for a long time; its everyday form did.

Overpreparation. For a thirty-minute meeting I prepare for hours. Preparation looks like a good thing, and so no one objects to it. Yet a sentence is hidden inside: if I do not prepare, my gap will be seen.

Rechecking. I reread a message I have sent. Then once more. Not to find an error; to be sure there is no error. The two are the same movement but different jobs.

Avoidance disguised as procrastination. This is the sneakiest one. For months I say "my turn hasn't come" about a task. The turn actually always comes, and I walk past it. There is a small uncertainty inside that task and my mind pushes it to the bottom of the list each time.

Silence once I have started. I noticed that once I sit down to the task, the anxiety disappears. So what frightens is not the task itself but the emptiness before starting it.

Why it is hard to tell apart

The symptoms of the two overlap. This is called symptom overlap:

• Being unable to focus. It is there in both ADHD and anxiety. In anxiety attention locks onto one place; in ADHD it settles nowhere.
• Restlessness. It is in both. In ADHD it is bodily and constant; in anxiety it is tied to a trigger.
• Being unable to sleep. In ADHD the mind jumps from one subject to another; in anxiety it circles around the same subject.
• Procrastination. In ADHD it is task paralysis, in anxiety it is avoidance. From the outside it looks the same.

For this reason the work of differential diagnosis belongs to a specialist. The developmental history is decisive here: ADHD symptoms need to have been present in childhood too, while anxiety may have started later. I laid out the direct comparison of the two separately in the article ADHD or anxiety.

Anxiety can hide ADHD

This is one of the reasons for late diagnosis, and it is not talked about much.

An anxious person usually arrives early, checks the list twice, finishes the work before the deadline. From the outside they look organized. The attention problems are there underneath, but the compensation system built on top covers them.

At some point this compensation is not enough: when the load increases, when the job changes or when life gets more complicated. Then the question "why did this person suddenly fall apart" comes up. Actually nothing is falling apart; the system that kept it invisible is collapsing. I described the cost side of this in the article on masking.

Order matters. The European consensus statement (Kooij et al., 2019) recommends determining the order of treatment by looking at which of the co-occurring conditions causes the heavier loss of functioning. Starting ADHD treatment while there is severe anxiety can increase anxiety in some people. The decision on diagnosis and medication belongs to your doctor; the order is also a subject to talk through with them.

What helps day to day

Solve the concrete part of the anxiety. The antidote to the "I will forget again" anxiety is not to instill self-confidence in yourself; it is to build a system. When you set up an external reminder, the subject of the anxiety narrows: the chance of forgetting really does decrease, and the mind notices this.

Separate procrastination from avoidance. If you cannot approach a task, ask yourself a single question: when I think of this task, what is inside me, an emptiness or a tightness? If it is emptiness, the matter is the threshold of starting. If it is tightness, there is a fear underneath and that fear needs to be named. The details are in the article procrastination or avoidance.

Do not let avoidance grow. Everything avoided gets a little bigger the next time. Approaching in small steps is the logic at the center of anxiety treatment. I wrote about how this works in a concrete example, making a phone call, in the article why is making phone calls hard in ADHD.

Put uncertainty into writing. A small movement that works for me: writing down not what the task that is inflating the anxiety is, but which part of it is uncertain. Usually a single unknown comes out, and that unknown can often be solved with a question.

Review the caffeine. Caffeine affects both sleep and anxiety, and in ADHD it is often used as a form of self-medication. Quitting is not necessary; knowing the amount and the time helps.

A common mistake

The mistake I see most often is treating anxiety as a character trait on its own: saying "I am an anxious person" and leaving it there.

That sentence is comforting because it offers an explanation. But it leaves nothing to do. Yet when you solve the concrete leg of the anxiety, the remaining part shrinks too, and working on that part becomes more possible.

The second mistake is the opposite: writing everything off to ADHD. Building only organization systems while there is severe anxiety leaves you under the very system you built.

The unknown side

There is a question in this area without a clear answer: there is no test that measures how much of the anxiety in someone with ADHD is secondary and how much is primary. The distinction is understood through the history, the course and the response to treatment. So in some cases you learn the answer only with time.

This bothered me at first. It bothers me less now, because a plan that addresses both does not have to wait for an exact distinction to move forward.

I covered the fact that medication can affect anxiety in both directions in a separate article.

What is left

When ADHD and anxiety walk together, you need to see both. Addressing only the anxiety leaves in place the cause that feeds it. Looking only at the ADHD side sometimes is not enough either.

My forty-minute wait for the phone call did not disappear entirely. It got shorter. Because I now know what is what inside that emptiness, and I can choose what to do about which. I described how the diagnostic process works in the article adult ADHD diagnosis.