Episode 89. Understanding ADHD and Anxiety with Dr. Marcy Caldwell Part I

Like Sully from the Pixar movie “Monsters, Inc”, anxiety can be the monster in the closet. What is anxiety? Maybe more importantly, how does it show up in a person’s life? Join us as clinical psychologist and ADHD advocate Dr. Marcy Caldwell talks all about anxiety and then helps explain why anxiety can be a bigger concern for a person with ADHD and the role our big feelings can play in that.

Marcy Caldwell, Psy.D., is the founder of ADDept.org, a blog and digital resource that promotes science-backed-but-still-approachable strategies for adults with ADHD. She is also the founder & supervising psychologist of Rittenhouse Psychological Services, a Philadelphia-based boutique practice focused on helping adults thrive while living with ADHD. Prior to that she served as the senior assessment supervisor at Tuttleman Counseling Services at Temple University and was a lecturing professor at the University of Pennsylvania. 

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Lindsay Guentzel (00:00):

Hello and welcome back to Refocused, a podcast all about ADHD. I’m your host, Lindsay Guentzel, and you are listening to part one of our conversation on understanding ADHD and anxiety with Dr. Marcy Caldwell.

Dr. Marcy Caldwell (00:18):

I sometimes like to think of anxiety as being like a monster and the monster will take up whatever size container you give it. So you see this monster, you’re scared of it, and you’re like, “Let’s throw it in the closet.” Right? We’re going to shut the door. And the monster takes up the size of the closet, right? But then you know that monster’s in the closet, so you avoid the closet. You avoid going anywhere near the closet because you’re kind of scared that the monster’s in there.

(00:50):

So by avoiding it, you give it more space and now it comes out of the closet and takes over the whole room. And now that room is scary and so you avoid that room. And so now it’s going to take up the whole house. And so this is how anxiety grows and it is how people’s lives shrink in response to anxiety.

Lindsay Guentzel (01:26):

Today’s show is a big one. Today we’re kicking off part one of our conversation on ADHD and anxiety with clinical psychologist and ADHD advocate, Dr. Marcy Caldwell. To get us started, Marcy offers up a primer on anxiety and shares the signs and symptoms we should be paying attention to, with examples on how it can show up in a person’s life. She also explains how a mental health disorder, like anxiety, can manifest physically for us. We’ll also dive into why anxiety can be a bigger concern for someone who has ADHD, more so than a person who is neurotypical and we’ll look at the massive overlap of symptoms that can cause problems when it comes to assessing and diagnosing ADHD.

(02:16):

Now, next week on part two, we’ll look at the role anxiety has played in masking ADHD symptoms, especially for women. We’ll also talk about treating ADHD and anxiety, including lots of practical coping strategies you can incorporate into your own routine. Now, we didn’t set out to have this be two episodes, but the conversation with Marcy is so good that we wanted to split it up into manageable bites so you get a chance to really listen to everything she’s sharing with us. So now that we all know what we’re talking about, let’s dive into the first half of my conversation with clinical psychologist and ADHD advocate, Dr. Marcy Caldwell.

(02:58):

In case you weren’t already super stoked about your ADHD diagnosis, wait until I tell you this. Not only is the connection between ADHD and anxiety, that pesky mental health disorder that brings on never ending feelings of worry and fear, restlessness, irritability, difficulty concentrating, 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. Cool, huh?

(03:41):

This is a topic licensed clinical psychologist Dr. Marcy Caldwell knows well. Marcy is the founder of Adept.org, a blog and digital resource that promotes science-backed, but still approachable strategies for adults with ADHD. She’s also the Director and Owner of Rittenhouse Psychological Services, a Philadelphia-based practice specializing in working with adults who have ADHD. And I’m so grateful to Marcy for joining us on Refocused to tackle this massive topic. Thank you for joining us, Marcy, welcome to the show.

Dr. Marcy Caldwell (04:13):

Thank you so much for having me. I’m thrilled to be here.

Lindsay Guentzel (04:16):

So to get started, let’s begin with the basics. What is anxiety and how do you explain it to your patients?

Dr. Marcy Caldwell (04:26):

So, I think that’s a really great question, even though it’s a basic one because I think it’s really easy to make anxiety be this big, bad, terrible thing, which of course it can be. But actually anxiety is a really normal thing. That is a very normal aspect of human life. Anxiety is a natural, adaptive, and healthy response to a threat. So this natural adaptive response creates worry and concern and physical sensations that help us respond to the threat to keep us safe and keep everything rolling as we want it to roll.

(05:07):

The problem comes in when that natural response is over applied. And we don’t do this consciously, this isn’t like, “Oh, I think this will be fun today. I’m going to over apply that threat strategy.” It’s our brains highjack the system, or sometimes our systems hijack our brain, either way, and they cause us to over respond to threats or misinterpret situations as threatening. And so it’s basically an over reliance on this very natural system.

(05:49):

And I point that out because, as we’re going to talk more about ADHD and anxiety, ADHD brains tend to go to extremes and the natural resting place or the healthy resting place for anxiety is really a middle ground. It’s like having enough anxiety that we’re responding to threat, but not so much that it takes over our life, but not so little that we’re also just letting the whole world happen and not be on top of things. And so it’s a very hard place to be.

Lindsay Guentzel (06:26):

Before we get into the different connections between ADHD and anxiety, let’s talk about how anxiety shows up in a person’s life. Are there signs and symptoms that tend to be more concerning? And are there ones that typically fly under the radar?

Dr. Marcy Caldwell (06:40):

Yeah. So the ones that tend to be more concerning and the reason why they concern me more are panic and avoidance. And the reason they concern me more is really the impact that they can have on people’s lives. Again, anxiety itself, not the end of the world. Okay, we all have it, we all want to have it, but the panic, it’s so incredibly uncomfortable, the way our brains interpret the symptoms of panic. Our brains say literally our life is ending, this is life-ending threat. We have to respond. And that feels so terrible that people tend to try to make that stop, obviously. That makes a lot of sense. And then therefore avoid anything that could cause that feeling again.

(07:38):

And the avoidance can happen even without panic. But the thing that happens with avoidance is that we start cutting out parts of our lives. I sometimes like to think of anxiety as being like a monster and the monster will take up whatever size container you give it. So you see this monster, you’re scared of it, and you’re like, “Let’s throw it in the closet. We’re going to shut the door.” And the monster takes up the size of the closet.But then you know that monster’s in the closet, so you avoid the closet, you avoid going anywhere near the closet because you’re scared that the monster’s in there.

(08:18):

So by avoiding it, you give it more space and now it comes out of the closet and takes over the whole room. And now that room is scary, and so you avoid that room. And so now it’s going to take up the whole house. And so this is how anxiety grows and it is how people’s lives shrink in response to anxiety. So that goal is kind of my biggest concern for folks is the shrinking of a life as a result of anxiety because of this avoidance, because the avoidance causes people to shy away from more and more things and the life constricts further and further.

Lindsay Guentzel (09:01):

I want to just ask really quick and take a step back. So, let’s pretend we have two people in a room, a neurotypical person and a neurodiverse person, and this is connecting back to the fact that you said people with ADHD, we tend to take things to the extremes. So let’s say, and I’m not using the word normal in the sense of I think that there is a difference between normal and a person with ADHD, but let’s say we have a neurotypical person who might experience anxiety on a daily basis. It’s less extreme, so it’s less noticeable, it becomes less of an issue in their life. Whereas a person with ADHD, those same feelings are exasperated, they’re over the top, they’re highlighted, they’re more focused. And then I imagine there’s also a part with the ADHD brain where they focus in on the anxiety so it even makes it more worse.

Dr. Marcy Caldwell (09:51):

So I want to provide one small little difference in what you said. You said that people tend to take things to an extreme or ADHD people tend to take things to extreme. I would say ADHD brains tend to naturally fall in extremes, right? And I know that’s probably what you meant, but-

Lindsay Guentzel (10:10):

No, language is super important. I’m new to this, I’ve only been diagnosed for two years, and I say every interview, I learn something new. And we’re learning now more than ever language is so important. So I appreciate you clarifying.

Dr. Marcy Caldwell (10:23):

I bring up that clarification because I think it’s very easy, as 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.” And the reason why people with ADHD tend to go to extremes is because their brains naturally fall in the extremes. The very basic difference with ADHD brains is a difference of regulation.

(10:54):

So that difference of regulation means that rather than having a brain full of lots of little dimmer switches that can find the right level of any given brain function, it has a whole bunch of on/off switches. So it goes all in or all out. And that is true of emotions too. It’s a slightly more nuanced and complex thing than just all in or all out on emotions, but for basis of simplicity, we’ll go with all in and all out. And so it’s going to go all in on anxiety and it’s going to go all out on anxiety, and we do see both extremes. Of course, in my practice I tend to see more of the all inners than the all outers, but we definitely see both extremes for folks with ADHD.

Lindsay Guentzel (11:39):

When we talk about mental health stuff, and I say stuff because it’s just, there’s so much that it all encompasses, we tend to isolate it to the mind. And I say we meaning just the general population. We tend to sometimes forget that mental health disorders can present in very physical ways within the body. And you were starting to get there a little bit when you were talking about panic and how it can show up. And so I’m wondering if you can just spend a little time talking about the physical manifestations that can come out of anxiety.

Dr. Marcy Caldwell (12:08):

I’m a bit of a psychology geek, so I find this kind of cool, but one of the cool things about anxiety, when we’re talking about anxiety is the very physical nature of it, that there are physical symptoms for most mental health issues, but anxiety is one of the most physically based ones or physically experienced ones. So there are a lot of physical symptoms that come up and they’re all kind of related to the same system, the same threat system, that our bodies are basically preparing for a fight or flight situation. And so all of the symptoms are kind of related to that. So our muscles tense, our hearts race, our breathing constricts, all to get the most oxygen possible to our muscles, all to get us ready and prepared.

(13:06):

The other thing that happens is that our GI system kind of shuts down. So that GI system, if you were facing a bear, it would be really important that you focus all of your body’s energy on facing that bear. So our bodies say, “Okay, let’s not focus on all this other stuff, this digestion stuff. That’s going to take up a whole lot of energy. We don’t need to do that. We’re also going to shut down our frontal lobe. That takes a lot of energy. We don’t need to do that. Let’s just focus on getting out of here.” So it’ll shut down our digestive system, which will make us nauseous, sometimes it’ll even clear it out, which will cause diarrhea and cause some heartburn because digestive juices will kind of float up. And our thinking gets very narrow, right on the threat.

(14:01):

So all of these symptoms that we experience are in order to save us, they’re here for a good reason, but because most of our lives don’t involve lions, tigers, and bears, they feel inappropriate. So we get that very extreme response to what does not need a fight or flight kind of response. And so that becomes very difficult. And so we can get gradations of this experience.

Lindsay Guentzel (14:30):

I just mentioned that on every podcast I learn something new, and I’m sitting here as you’re explaining how the body, because it is so smart, starts to shut things down to preserve energy so that it can focus in on the task at hand, which is this very anxiety-filled moment. And I’m going, “Yes, of course.” And if you’ve ever experienced a moment of anxiety, of high anxiety, you can go back and listen to exactly what you just said and go, “Yep, that was when this started to shut down. Okay.” It is incredible.

Dr. Marcy Caldwell (15:00):

Yeah. Our brains and bodies are amazing, absolutely amazing. And of course they frustrate us because there are ways in which our bodies haven’t evolved as quickly as our surroundings, and this is one of those, the biggest scenarios in which this is the case, that this system was created to keep us alive and keep us safe in environments where keeping us alive was a daily issue. That usually, for a lot of people thankfully, is not a daily issue anymore. So we don’t need that kind of strong response, but our bodies haven’t evolved to get to a place where we have a more nuanced response to the threats that show up.

Lindsay Guentzel (15:45):

You mentioned a little bit about the GI tract. I’m wondering if we can talk about the gut-brain connection and how that plays a role in anxiety and how it manifests in the body.

Dr. Marcy Caldwell (15:53):

Yeah. So it’s really interesting because there has been a lot of recent research about this. So we used to think that anxiety and tension in general showed up in the GI system, we’ve known that for a long time, in this kind of, “I’m anxious my digestive system is going to respond because of my anxiety,” in the way that I just talked about. And that is true, but what we’re finding out is that it actually goes the other way too. So our GI tracts have 100 million nerve cells in them that are responsible for timing digestion, responsible for making the digestive system process work. And they’re also responsible for communicating to our brain. So some researchers actually call that whole system, that 100 million nerve cells, our second brain, and we don’t have kind of conscious thought obviously in our esophagus, but there is a communication that happens between them.

(17:01):

And so what we’ve learned is that signals from the gut can actually change mood and that this is a dual road, and this is kind of true for anxiety symptoms in general. If you are somebody who is prone to a lot of anxiety, or particularly prone to panic attacks, let’s say, and panic attacks tend to manifest very physically, you have difficulty breathing, heart racing, all this stuff. If you are put in a situation, let’s say you’re on a run and your heart is racing and your breath is shallow, it doesn’t take much for your brain to trigger that physiological symptom as anxiety and quickly flip over into a panic attack, right? Because you’re already stimulated.

(17:55):

And the same thing can happen with our gut. So changes in our digestive system can then create changes in our mood. And this is particularly troublesome for folks with IBS or chronic constipation or diarrhea. And, oh, by the way, those are more common in folks with ADHD. So this becomes a very interconnected and complicated issue.

Lindsay Guentzel (18:25):

So I feel like now is a great time to dive into this gray area; the different connections between ADHD and anxiety. ADHD doesn’t cause anxiety, but anxiety can develop as a response to ADHD, and this is related to the inconsistency that ADHD creates in a person’s life. And it’s also important to note that ADHD and anxiety can be confused for one another. It’s another one of those lovely overlapping symptom scenarios that we deal with. And at the same time, these two disorders can also coexist separately. So taking all of that into account, where do we start when explaining the connections and the differences and how do you isolate a proper diagnosis when so many of the symptoms overlap between the two disorders?

Dr. Marcy Caldwell (19:09):

Yeah, it is a very messy, muddly picture for sure. So when it comes to diagnosis, I always say, a slow diagnosis is best. A slow diagnosis with a lot of information gathered from a lot of different sources in a lot of different ways is always going to be best. So one of the key things to look at is, were any of these symptoms present in childhood? Anxiety can obviously occur in childhood for sure. It tends to show up in slightly different ways in childhood than adulthood and slightly less ADHD-like ways. So I’m always looking, if we’re trying to figure out are these symptoms anxiety or ADHD or both? I often will start with, what was going on in childhood? What was showing up there? Because ADHD, by definition, needs to show up before age 12, so that’s going to give me some things to look at.

(20:13):

ADHD also is known for big feelings, right? Very big feelings, known to feel really flooded. Anxiety can also feel flooded. However, anxiety alone tends to only flood with worry and concern and fear, right? ADHD brains tend to flood with all the feelings, good, bad, and otherwise. That’s another thing that I’m going to look at is, are the big emotions, are they covering lots of different topics or really only in relationship to fear, worry, concern, that sort of thing? Same with distraction. So anxious brains are very prone to distraction, can be really hard to focus when you have anxiety. However, that distraction, the thing that pulls the brain away is usually worry, is usually concern, is usually fear. For ADHD, it can be anything, right? Anything can pull the ADHD brain away.

(21:17):

So we’re looking at those differentiators, right? It’s more than just the listing of symptoms. If you look at just the listing of symptoms, there’s so much overlap, it’s almost hard to tell, which is why you can’t do it with just one screening measure. You can’t do it with just one checklist that a doctor hands you. You really have to be teasing out what those symptoms are and how much is involved in them and is this particular symptom leaning more ADHD? Is it leaning more anxiety? Is it both? Is it holding both? Because as you said, about 50% of folks with ADHD also have clinical levels of anxiety. And I would say that the other 50%, even if it’s not clinical levels, are experiencing some anxiety for the most part. Maybe that’s probably a little unfair, maybe not 50, but certainly within my practice, it’s very rare that you find somebody who doesn’t have anxiety of some sort.

Lindsay Guentzel (22:18):

You mentioned kids and anxiety. What are some ways that anxiety shows up for children? And the one that comes to mind for me that I can look back and know that was very apparent to everyone was I had severe separation anxiety. I was very much a mama’s girl, I did not like when she left, even for an hour. And that panic that would set in and the big emotions that you’re mentioning, oh, my poor sisters. I feel like I’m owing them five years of just pure chaos because I would completely lose it the second she would walk out the door. So I’m wondering if just for some of the parents out there who are listening who maybe are sensing some of these things happening in their own homes, what are things that they should be paying attention to when it comes to anxiety at a young age?

Dr. Marcy Caldwell (23:08):

So I will first say that I am not a child expert, but I have kids myself. I have a anxious ADHD kid myself. So I can tell you that separation anxiety is big. Nightmares are also very common with kids with anxiety, school refusal and social fears, slowness to warm up in general, and a uncertainty around novel situations, which is always an interesting thing when it’s a kid with anxiety and ADHD, right? Because A D H D brains tend to seek out novelty, but the anxiety will often kind of hold them back. So it’s a way in which they interplay.

(23:54):

And the anxiety can help, I mean the ADHD actually can help an anxious child go into those novel situations a little bit more, but the anxiety is going to make them more nervous as they approach it. And you’ll also see irritability. I think that’s a thing that sometimes people mistake about anxiety is that, yes, it can obviously show up in this kind of classic, worried, fearful way, but it can also show up in a slightly more angry, irritable way. That is something that we often will see for kids is this irritability can come up and the people, particularly anticipating something scary or big, can become a lot more irritable.

Lindsay Guentzel (24:43):

That’s a perfect segue because I imagine where we are in 2023, with 24 hour news cycle and social media that feeds us good stories sometimes, nice heartfelt warm stories that make us feel good about ourselves, but I would say the majority of the stuff that’s being pushed towards us is anxiety ridden. It’s stuff that’s going to make this worse. So how does that play a role in what you’re seeing right now with how anxiety is showing up for people?

Dr. Marcy Caldwell (25:16):

I saw a lot of this around COVID in particular, the kind of doom scrolling news media vortex. And ADHD brains are particularly prone to doom scrolling. They’re particularly prone to that negative cyclone that happens because what happens is, so ADHD brains, at their base, they have a dopamine diffusion deficiency, which is just a fancy word for not enough good stuff going on, not enough of that reward and that kind of like, “Oh, yay,” feeling. So they’re seeking it out all the time is part of why novelty is so appealing, because novelty offers a little bit of that.

(26:04):

So social media, TikTok, all these things, there is an algorithm designed to keep it moving, right? Keep it novel, keep it interesting to you specifically, things that you’re likely to be interested in, and very quick. So it works perfectly for our brands to keep us going. It’s one of the reasons why long-form articles are not the type that an ADHD brain tends to gravitate to. This quick media, it’s much easier for an ADHD brain. And it fuels an ADHD brain. It gives the ADHD brain what it’s looking for. It’s giving it tiny little hits of dopamine basically, again simplification, and those tiny little hits keep it coming back for more.

(27:03):

So imagine if you had a dog who you were trying to train, right? You give it little treats, lots of little treats, and the dog keeps at it, right? If you gave a dog a full bowl of treats, the dog would just eat the bowl of treats and then wander away and take a nap. Social media kind of does the same thing for our brains. It gives us just tiny little hits that just keeps us coming back for more, not enough to actually satiate us, but enough to keep us coming back for more. And so that negativity, we kind of stay with it longer and it filters in more and we feel it longer and we kind of interact with it more because, or at least in part because the system is created to make us stay there.

Lindsay Guentzel (28:00):

You are listening to part one of our conversation on understanding ADHD and anxiety with Dr. Marcy Caldwell. Marcy is the founder of Adept.org, a blog and digital resource that promotes science-backed, but still approachable strategies for adults with ADHD. She’s also the Director and Owner of Rittenhouse Psychological Services, a Philadelphia-based practice specializing in working with adults who have ADHD. To learn more about the work Marcy is doing, you can find all of the links in our show notes.

(28:34):

Be sure to join us for part two of our conversation next week where we’ll talk with Marcy about how gender can affect diagnosis and treatment, especially for women. Plus, we’ll learn more about treating ADHD and anxiety, including how stimulant medication fits into the equation. We’ll also talk through practical coping strategies and how they can help a person manage the body’s stress response cycle to keep anxiety at a healthy level.

(29:02):

If you take anything away from today’s episode, I hope it’s this; anxiety is actually a really normal, healthy thing. When Marcy said that, it was truly the first time I had ever heard it, and it makes sense. Evolution is a crazy thing, and if you happen to regularly run into bears while you are out and about in life, please email me immediately because I need to hear more about this. The thing is, we can all find a healthy resting place or even some middle ground for our anxiety when we have the right tools. Sure, it’s a little harder for us ADHDers, but we can get back there with some extra breadcrumbs and a really good map. Those things can help us find that consistency and balance that is so crucial in our lives to help us find relief and peace, and we’ll learn more about some of those things next week.

(29:58):

So take a big week-long stretch, move your legs a little bit, have a snack, get some rest, and join us back here next Monday for part two of our conversation with Dr. Marcy Caldwell. And if you’re a person with ADHD who also struggles with anxiety and you’d like to share your story with us, I’d love it if you’d get in touch. The easiest way to do that is email [email protected], or send us a message on social media @RefocusedPod.

(30:28):

Before we wrap this up, a quick reminder just in case it’s been on your to-do list but you need that extra push, it would mean so much to the entire Refocused team if you would take some time and leave us some love online, whether that means giving us the good old rate, review, subscribe, or by sharing us with your social networks. Maybe it’s a favorite episode or a story you really connected with from our first Refocused together. And we’ve made it easier for you to show us some love. You can head to the show notes to find a direct link to share a review on your favorite streaming platform right now.

(31:04):

Thank you so much for listening. If you’re new here, my name is Lindsay Guentzel, I’m the host and executive producer of Refocused, a podcast all about ADHD. That would not be possible without the incredible talents of the team I get to work with, including Phil Rodamen, our coordinating producer who leads our live production, scheduling, and audio editing. Sarah Platenitus, our managing editor responsible for leading our research as well as guest and show development. Al Chaplin, our go-to for planning, creating, and organizing content strategy for social media. Support for this podcast comes from our partner, ADHD Online and the incredible team of people I’m honored to work with every day, including Keith Boswell, Suzanne Spruette, Melanie Mile, Claudia Gotti, and Tricia [inaudible 00:31:54]. Our show art was created by Sissy Yee of Berlin Gray and our music was created by Louis Inglis, a singer-songwriter from Perth, Australia, who was diagnosed with ADHD in 2020 at the age of 39. Finally, a big thanks to Mason Nelle over at Deksia in Grand Rapids, Michigan for all of his help in getting our videos ready to share with you guys.

(32:15):

Links to all of the partners we work with are available in the show notes. To connect with the show or with me, you can find us online @RefocusedPod, as well as @LindsayGuentzel, and you can email the show directly, [email protected]. That’s [email protected]. I’m so excited for you guys to listen to part two of our conversation with Dr. Marcy Caldwell next week. In the meantime, take care of yourselves and please, in an effort to reduce the unbelievable amount of stress we all carry around with us unnecessarily, be a little kinder to yourself this week.

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