By Mary Fetzer

Mental health concerns — such as feeling inadequate, anxious, depressed or distracted — can be difficult to define. Is it ADHD? Is it anxiety? Both? Neither? The answer isn’t always clear, thanks to symptoms that often overlap and co-occur.

Nearly 50% of adults with ADHD also suffer from an anxiety disorder, according to the Anxiety and Depression Association of America. And ADHD and anxiety have a lot in

common. A lack of motivation and the inability to focus are well-known symptoms of ADHD, and they can also be signs of anxiety disorder. Moreover, the result of ADHD symptoms — missing a deadline or forgetting an appointment — can lead to feelings of anxiety.

“I often explain to clients and families that ADHD and anxiety have a ping-pong effect,” says therapist Lee Wells, co-owner and clinical director of Mind Chicago, a family-focused therapy and testing practice in Chicago. “When ADHD symptoms interfere with functioning, anxiety symptoms increase — and as anxiety increases, it’s more difficult to manage the symptoms of ADHD.”

Understanding Anxiety

Anxiety often involves frequent or excessive worry or dread that is difficult to control, according to the American Psychological Association. The worries might be focused on specific facets of life, such as work or family, or they might just be an overarching, overwhelming feeling of general anxiety with no apparent trigger. The anxiety can manifest in restlessness, irritability, fatigue or any of an array of other negative responses.

Some people with anxiety find symptom relief from treatments like medication, therapy or mindfulness exercises. But treatment doesn’t seem to help others, which begs the question: Might it be something more than (or other than) anxiety? Like ADHD?

In two recent ADHD Online-sponsored Refocused podcasts — “Understanding ADHD and Anxiety,” part 1 and part 2 — clinical psychologist and ADHD advocate Marcy Caldwell discussed the often-missed connection between ADHD and anxiety.

Caldwell is the founder of Addept.org, a blog and digital resource that promotes approachable, science-backed strategies for adults with ADHD. She is also the director and owner of Rittenhouse Psychological Services in Philadelphia.

“Not only is the connection between ADHD and anxiety incredibly strong — right around 50% — but anxiety and all of its lovely symptoms tend to be more severe for the neurodiverse crowd,” Caldwell says.

Caldwell explains that anxiety is normal and a natural, adaptive and healthy response to a perceived threat. The worry, concern and physical sensations help people to respond to the threat to keep them safe.

“The problem comes in when that natural response is over-applied,” Caldwell says. “We don’t do this consciously; our brains hijack the system and cause us to over-respond to threats to misinterpret situations as threatening. It’s an over-reliance on this very natural system.”

The anxiety itself is not necessarily problematic, Caldwell say. But it can result in more concerning behaviors, such as panic and avoidance.

“The way our brains interpret the symptoms of panic is so incredibly uncomfortable,” she says. “Our brains say our life is ending, this is a life-ending threat and we have to respond. And that feels so terrible that people tend to try to make that stop and subsequently avoid anything that could cause that feeling again.”

Avoidance can happen without panic too, according to Caldwell. In either case, it can shrink people’s lives as they avoid more and more things.

When ADHD Is Also Involved

A certain level of anxiousness can be a normal, healthy thing. It can alert us to important dangers. But for someone with anxiety disorder, the emotions can be difficult to manage. And for people who are dealing with anxiety on top of ADHD, the difficulty can be even greater.

ADHD doesn’t cause anxiety, but anxiety can develop as a response to ADHD, thanks to the inconsistency that ADHD creates in a person’s life.

“I think it’s very easy for somebody with ADHD to feel like, ‘I’m wrong. I just need to stop doing this thing. I just need to stop going to extremes. I just need to chill out,'” Caldwell says. “ADHD brains tend to naturally fall in extremes, which can make attempts at self-regulating fall short.”

It’s this difference in the ability to regulate that can make dealing with anxiety “more extreme” for people who have ADHD, she says.

Making the Diagnosis

ADHD and anxiety can be confused for one another. They can coexist separately. Recognizing the connections, similarities and differences can help isolate the two disorders so that a proper diagnosis can be made.

Because ADHD and anxiety can manifest in similar ways, making a diagnosis must go beyond looking at just a list of symptoms, according to Caldwell. She says that experiencing big emotions or becoming easily distracted — symptoms that might be present for either disorder — have to be evaluated more closely.

Both disorders involve what Caldwell calls “big emotions.” But what the emotions react to can be different for those with ADHD versus those with anxiety.

“ADHD is known for flooding the brains with big feelings: good, bad and otherwise,” she says. “Anxiety can also flood the brain. But as a standalone disorder, it tends to only flood with worry, concern or fear. So the provider considering the diagnosis should ask: ‘Are the big emotions covering lots of topics or only anxiety-related feelings?'”

Another symptom found with both ADHD and anxiety is distraction. Examining distraction more closely is another possible way to distinguish the two disorders.

“Anxious brains are very prone to distraction and it can be really hard to focus when you have anxiety,” Caldwell says. “But that distraction — the thing that pulls the brain away — is usually worry or fear. With ADHD, however, distraction can be caused by anything.”

Caldwell says that a proper diagnosis will take time and involves the collection of a lot of information.

Treating Anxiety and ADHD

For the most part, there aren’t single treatments that can help both ADHD and a separate diagnosis of anxiety. Therefore, they should be treated separately but simultaneously.

Treatments for ADHD often include medications, such as stimulants, that increase levels of certain chemicals in the brain. The medication may be combined with therapy, such as behavior therapy or brain-training therapy, like neurofeedback.

Treating anxiety requires a different mix of medication and/or therapy. Antidepressants and anti-anxiety medications may be prescribed as a long-term treatment. And cognitive behavioral therapy is considered to be an effective treatment for anxiety disorders.

Because symptoms can overlap and because ADHD can exacerbate anxiety and vice versa, effectively treating one disorder often improves symptoms for the other. So it’s important to treat both.

“Anxiety is much more manageable when individuals have greater emotional regulation and can better meet personal and social expectations — which can be achieved with ADHD treatment,” Wells says.