By Sarah Ludwig Rausch
When you have ADHD, it’s likely that anxiety plays at least a small role in your daily life. Just think about some of the worry-inducing mini-crises that, if you’re like me (someone with ADHD), happen on a fairly regular basis: You’re rushing to get out the door on time for an appointment. Or you’re attempting to focus on the task at hand as a deadline looms closer and closer. Maybe you can’t stop yourself from worrying about what you blurted out in the last company meeting. Or you just realized you forgot you were supposed to send treats to school with your kid.
The Relationship Between ADHD and Anxiety
Up to 80% of adults with ADHD have another psychiatric disorder too, such as depression, anxiety, substance use disorder or a personality disorder. Not surprisingly, the most common condition to co-occur with ADHD is anxiety disorder, which affects about 50% of people with ADHD.
What’s more, there are several overlapping symptoms between ADHD and anxiety, including:
- Difficulty concentrating
- Sleep issues
- Difficulty relaxing and/or feeling restless
It’s pretty clear that ADHD and anxiety are closely intertwined. This is especially true when ADHD is untreated, says Edward Hallowell, MD, a child and adult psychologist, author of multiple books on ADHD and founder of The Hallowell ADHD Centers.
“Pretty much everyone with untreated ADHD has anxiety because ADHD leads you to make a lot of mistakes — you forget or overlook things, misspeak, misplace, fall behind, lose track of time,” Dr. Hallowell says. “It’s an anxiety generator.”
Sometimes people with ADHD feel labeled or their teachers or co-workers get frustrated with them, which can cause anxiety symptoms, says Christine Sauer, MD, ND, a certified holistic brain and mental health professional and founder of DocChristine Coaching Inc.
“People can set themselves up for failure by believing that because they have ADHD and tend to get distracted easily, they’re going to fail,” she says. “They get anxious and uptight with all the symptoms of anxiety, and it becomes a self-fulfilling prophecy.”
While you may have ADHD, anxiety and depression at the same time, it’s possible that your symptoms are actually from ADHD. Dr. Hallowell says untreated ADHD is like untreated nearsightedness. “If you have untreated nearsightedness, you bump into things. With untreated ADHD, you overlook and forget things and you underachieve, so what can look like depression and anxiety can be the wake of the untreated ADHD,” he says.
Medication for ADHD and Anxiety
There are medications for anxiety and medications for ADHD. But they don’t always work well together. In fact, medications for anxiety can sometimes exacerbate symptoms of ADHD, or even cause new issues, experts say.
Many adults with ADHD are given medications for depression and anxiety first, Dr. Hallowell says. “Most doctors start by putting you on a selective serotonin reuptake inhibitor, or SSRI — which is a big mistake because that’s not what you need,” he says.
Dr. Hallowell — like many other experts — says he seeks to first prescribe treatment for people’s ADHD symptoms. “I start with treating the ADHD and see if that doesn’t take care of the anxiety and the depression,” he says.
There are two categories of medications typically used to treat ADHD — stimulants and non-stimulants.
Stimulants are the most common type of medication used to treat ADHD and they work for about 70% of people. There are two types that are FDA-approved to treat ADHD: amphetamines such as Adderall, Vyvanse, Dexedrine and Adzenys; and methylphenidate, such as Ritalin, Focalin and Methylin. Dr. Hallowell and other mental health professionals also prescribe modafinil, with the brand name Provigil, which is another stimulant that’s used off-label to treat ADHD symptoms.
“When they’re used properly, stimulant medications are safe and effective,” Dr. Hallowell says.
He points out that amphetamines were first used to treat ADHD in 1937 and methylphenidate has been in use since around 1950. “Nothing lasts that long unless it’s safe and effective,” he says. “We’ve got over 70 years of experience with both of these stimulants, yet there is so much misinformation about them.”
If none of the stimulants work, Dr. Hallowell prescribes a non-stimulant next. However, non-stimulants are less effective than stimulants and can take several weeks to treat ADHD symptoms. “When they work, the non-stimulants are preferable because they work around the clock and they’re not controlled substances like stimulants,” Dr. Hallowell says.
Non-stimulants used to treat ADHD include:
- Selective norepinephrine reuptake inhibitors, including atomoxetine (brand name Strattera), and viloxazine (brand name Qelbree)
- Blood pressure medications, including guanfacine (brand name Intuniv), and clonidine (brand name Kapvay)
- A norepinephrine-dopamine reuptake inhibitor called bupropion (brand name Wellbutrin)
- Tricyclic antidepressants, including desipramine (brand name Norpramin), imipramine (brand name Tofranil) and nortriptyline (brand name Pamelor)
- An antiviral drug called amantadine (brand name Symmetrel)
The three non-stimulants Dr. Hallowell prescribes regularly are amantadine, bupropion and atomoxetine. He says guanfacine is known to be helpful for treating rejection-sensitive dysphoria, a common issue in people with ADHD. That’s when people feel unusual and intense emotional pain related to rejection or the perception of rejection.
Antidepressants and ADHD
Antidepressants aren’t approved by the U.S. Food and Drug Administration to treat ADHD, but sometimes mental health professionals prescribe them either alone or with a stimulant. If you have an anxiety disorder and ADHD, you may need to take both a stimulant and an anti-anxiety medication, “though you usually don’t need to,” says Dr. Hallowell.
But Dr. Hallowell believes SSRIs — one type of antidepressant — should be a last resort for treating ADHD.
“SSRIs are safe, but there are two side effects that I think make them particularly not worth going on unless you really need them,” he says. The first, he says, is that they’re cognitively dulling. The second, he says, is that they reduce libido, “a natural, affirming, joy-producing life force.”
Stimulants’ Effect on Anxiety
You may have heard that stimulants can make anxiety worse. While this is true, Dr. Hallowell says, “that’s no reason not to try them. So what if they make you more anxious? You’re already anxious.”
In his experience, it’s more common that a stimulant will make a person less anxious because their ADHD symptoms will improve, which is why he prescribes a stimulant first.
And if a stimulant continues to make you more anxious, you can switch to another medication.
“A trial of medication is just that — it’s a trial. You may continue to use it, or you may not,” Dr. Hallowell says. “It’s just a shame that people are afraid of using a stimulant because whatever it does, good or bad, it only lasts for a matter of hours.”
One big reason for stimulant failure is not using a high enough dose, according to Dr. Hallowell. “The beauty of stimulants is they give you an automatic feedback reading — your body will tell you if you’re taking too much,” he says.
There are five variables to watch when you’re using a stimulant, according to Dr. Hallowell: weight, heart rate, blood pressure, sleep and how you feel. As long as these are all stable, your mental health provider should keep increasing the dose until your target symptoms — usually focus and organization — have improved. You should also have no side effects other than reduced appetite without unwanted weight loss.
Non-Medication Treatments for ADHD
Both Dr. Hallowell and Dr. Sauer are proponents of non-pharmaceutical options to treat ADHD. Dr. Hallowell prefers to try medication right away “because it makes all the non-medication interventions work so much better.” He says waiting to try medication is similar to squinting without glasses. “Why not the proven intervention first? It makes everything else so much easier,” he says.
“Mental health is going through the dark night of the soul,” says Dr. Sauer. “It’s a wakeup call to think about and develop a better path forward.”
Her practice focuses on non-medication treatments to improve ADHD symptoms, though she says medications “can be a very valuable bridge,” especially for kids.
Here are the interventions Dr. Sauer and Dr. Hallowell recommend:
“Love is the most powerful force in the world for pretty much everything good,” says Dr. Hallowell. “And lack of love, or disconnection, is the force for everything bad. We’re living in an absolute epidemic of disconnection.”
He says it’s essential for good mental health to create positive connections with people in your life, whether it’s family, friends, community or organizations.
Psychotherapy, also known as talk therapy, can be helpful in treating ADHD. Two types that may be especially beneficial for ADHD include:
- Cognitive-behavioral therapy, or CBT, helps you change unhelpful thinking and learn helpful behaviors to improve your life.
- Eye movement desensitization and reprocessing therapy,
or EMDR, helps you
heal traumatic memories.
Research shows that exercise boosts your mood, improves focus and sleep, and decreases anxiety and depression. Both Dr. Sauer and Dr. Hallowell highly recommend exercise for treating ADHD. A shining example of its effectiveness is swimmer Michael Phelps, who has 23 Olympic gold medals. “He was diagnosed with ADHD when he was a child, and he treated it with intense aerobic exercise,” says Dr. Sauer.
• Mind-body interventions
You might try some mind-body interventions to see if they improve your symptoms. Some examples include:
- Yoga and tai chi: These practices help lower stress and increase self-esteem and positive feelings.
- Mindfulness: Practicing mindfulness can have multiple benefits for your body and your mind, including reduced stress and anxiety, happiness, lower blood pressure, decreased chronic pain and improved sleep.
- Tapping, also known as Emotional Freedom Techniques, or EFT: EFT involves tapping your fingertips on specific places of your body. Research has shown EFT lowers the stress hormone cortisol, lessening symptoms of anxiety.
- Havening techniques: Havening is a type of psychosensory therapy that uses touch to change thought, mood and behavior. Dr. Sauer says these techniques “stimulate delta waves in the brain and have been proven to calm anxiety.”
• Good nutrition
Nutrition is “a symphony” that should work together to optimize your health, says Dr. Sauer. Dietary supplements can be the “backup musicians,” plugging any holes in your diet and making sure you’re getting the nutrients you need. She loves green tea, which she says stimulates the prefrontal cortex. “It works nearly as well as stimulants. It tastes good, and you can drink as much as you want.”
Dr. Hallowell also encourages feeding your body with whole grains, fruits and vegetables, and avoiding processed foods. It’s especially important to stay away from sugar, which ADHD brains love — the dopamine rush you get from it causes you to want to eat more and more to keep the feeling going, he says.