Episode 90. Understanding ADHD and Anxiety with Dr. Marcy Caldwell Part II

Today we continue our conversation with Dr. Marcy Caldwell about ADHD and its lovely comorbidity buddy, anxiety. You will learn about what mental health providers like Marcy take into account when they’re working with a patient who has ADHD and anxiety. We’ll hear how stimulant medications fit into the equation, plus Marcy offers up a long list of coping strategies we can all add into our own lives.

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 (00:03):

Welcome back to Refocused. I’m your host, Lindsay Guentzel. On today’s show, we are continuing our conversation with clinical psychologist Dr. Marcy Caldwell, talking all about ADHD and its lovely comorbidity buddy, anxiety.

Dr. Marcy Caldwell (00:20):

A lot of folks have anxiety and they fight against this, and they don’t allow it to shrink their life. That’s amazing because the tendency of anxiety is to start to shrink away from the things that make us anxious. It’s really uncomfortable to be anxious. It really feels terrible, and so it makes a whole lot of sense that you would want to avoid that.

Lindsay Guentzel (01:10):

This part of the conversation with Dr. Marcy Caldwell is where I got that big old lump in my throat. At that moment, I felt all of the feelings that come with realizing how years of anxiety have caused so many of us to shrink our lives. It’s a really powerful message, one we’re going to explore more today. As I’ve mentioned, this is part two of understanding ADHD and anxiety with Dr. Marcy Caldwell. If this is the first time you’ve listened to Refocused, welcome. I highly recommend pressing pause and going back one episode to part one or feel free to check out any one of our 80 plus episodes all about ADHD.


But back to today’s show, I do want to note that anxiety is something I’ve dealt with for as long as I can remember. After my diagnosis, I realized it’s one of the comorbidities that has latched onto my ADHD. Sometimes I use the word lovely and anxiety in the same sentence. And in those moments, please know I’m being very tongue in cheek. Anxiety is no joke, but lots of really sad or scary or overwhelming things in life, sometimes taking a lighthearted approach can make it easier to process and talk about. I don’t really think anxiety is lovely. In fact, it’s been pretty damaging in my life. We know from last week’s episode that anxiety is a good healthy part of life.


Of course, that’s when it’s managed properly and when we’re utilizing the tools in our mental health toolboxes so it doesn’t jump up to a level nine or 10. Raise your hand if you’ve been up there around level nine or 10. Yep, me too. And it’s awful. How do we do that? How do we start managing all of the stuff that comes with anxiety? Well, that’s where we’re headed on today’s show. We’ll talk about the role anxiety plays in masking ADHD symptoms and ultimately how it and bias negatively impact diagnoses for women and LGBTQ+ folks. We’ll dive into what treatment looks like for someone who has ADHD.


We’ll hear how stimulant medications fit into the equation, how the body’s stress response cycle works, and how burnout on top of ADHD just adds fuel to the fire. Marcy also offers up a short list of coping strategies we can all add into our lives in our own ways to help us get our anxiety to a place where it’s manageable, like not causing an upset stomach every time you open your inbox and see a new message from your boss. Emails, you guys, not supposed to be that scary or evoke such powerful feelings that our anxiety kicks in, dread settles over us, our defenses go up, and all of a sudden, our attempt at cleaning out our inboxes suddenly becomes a meme that everyone knowingly gets.


I get it. I do. It happens to me on the daily, and I know I am the woman who ends every show by encouraging listeners to email us. I like those emails. Those emails are great. Keep sending them in. I mean, no one said anxiety always makes sense, right? There is a lot to get to on today’s show, and I am so glad you’re here with us. Let’s get started with part two of understanding ADHD and anxiety with Dr. Marcy Caldwell. We’re at this point right now where we’re finally acknowledging women have been left behind when it comes to diagnosing ADHD, and some of that comes from the fact that the diagnostic criteria has changed so much over the years.


We do now have a better understanding that ADHD affects every person differently. But I know from my own experience, I was diagnosed and treated for anxiety when I was in my early 20s, and not once in any of those appointments that I sat through was ADHD ever brought up. I’m curious how you view anxiety and its potential to overshadow a proper ADHD diagnosis for a woman.

Dr. Marcy Caldwell (05:50):

I think anxiety is the number one overshadower. There are certainly others too, depression, mood disorders, borderline personality disorder. I’m hopeful that this is slowly changing, but I think for so long we never talked about the emotional experience of ADHD. It was always thought that any emotional experience was something that came on the heels of ADHD. That you had ADHD and then the emotional stuff just happened because ADHD was hard or whatever. We’re now starting to understand, no, this regulation difference in an ADHD brain impacts how ADHD brains experience emotion.


We’re starting to understand that a lot of the emotional implications are maybe not even a different disorder, but sometimes just ADHD being expressed as ADHD is. As we’re starting to understand that more, we’re starting to see ADHD as primary and see that first. Because particularly for women, because women tend to be more likely to have inattentive type ADHD and inattentive type tends to be felt more internally rather than seen externally. Women tend to be internalizers in general.


We tend to take any experience that we’re having and view it as something that’s wrong with who I am and transform that experience into something like depression or anxiety. And then we report it that way as, this is what’s going on for me. And then doctors are prone to the same biases that everybody else are. We think of ADHD as being a disorder of hyperactive little boys, and we think of anxiety and depression as being disorders of women. A woman walks in and the first thing that you think is depression, anxiety, and that sort of thing.


You see a little boy walk in, the first thing you think is ADHD. We have to be very real about that intrinsic bias. Of course, all mental health professionals are supposed to fight against that, but we’re human too. I think it’s a really important point. I also think that there’s a way in which that misdiagnosis or overshadowing, because it’s not always a misdiagnosis, it’s just we’re only going to see one part of what’s happening with a person, is it really keeps it going longer.


Because not only are we not getting at the other part of what’s going on for the person, but without the ADHD diagnosis, we know that when people are diagnosed later, they tend to show much more shame, much more depression, much more anxiety, because we don’t have a reason, we don’t have a way of explaining what’s going on. We don’t have a way of understanding what’s going on and has made us different. What do we do?


Of course, we say, “Oh, there must be something wrong with me. I’m obviously doing things differently than everybody else. This isn’t working the same way for me that it’s working for everyone else. There’s something wrong with me.” That doubles down on the depression, the anxiety, or what other mental health issues you’re having at the same time.

Lindsay Guentzel (09:33):

I’m glad that you brought up the bias that you deal with every day. I’m wondering if you can touch a little bit on gender and bias and how anxiety might show up for a person who is non-binary or is trans. You’re obviously working against research that falls into very strict categories of man and woman. How has that changed over the years for you from a provider standpoint?

Dr. Marcy Caldwell (09:56):

That’s a great question because… When we talk about research, the research isn’t there yet. The research hasn’t caught up. We don’t have a huge amount of research on how this shows up for gender-nonconforming, non-binary, LGBTQ folks. However, what we do know is that there is a way in which different intersecting identities and different intersecting biases compound each other. That it’s not an additive effect, it’s a multiplication effect or even an exponential effect.


The way in which being neurodiverse plus gender queer and any other intersecting identities and the weight of the bias against all of those can have an exponential impact on the mental health of a given person. And because we don’t have the research and because the truth is that we’re pretty new at thinking and talking about all of these issues, I think mental health professionals are also still new, and they’re also still trying to figure it out, and they’re also still trying to listen and hear.


Thankfully, the profession is hearing more and listening more rather than just dictating from on high as we have traditionally done. My hope is that we continue to do that. We continue to listen. We continue to hear. We continue to allow people to speak and really honor their experience rather than this top-down medical model that we’ve been in for so long.

Lindsay Guentzel (11:52):

Let’s move into the treatment side of things when it comes to anxiety and ADHD. I’m wondering how you adjust your treatment methods for patients who have ADHD, but are also dealing with anxiety as a comorbidity.

Dr. Marcy Caldwell (12:07):

The truth is I don’t know that we do adjust it. Because at least for us, the way we work is very individual. We’re getting a sense of what’s going on for a person as a person. And sure, does a diagnosis help inform various strategies, various techniques, various treatments? Yes. But once we’ve gotten the diagnosis, once we’ve gotten the understanding of how things are interplaying for folks, we’re really going down to symptoms and addressing symptoms. At our practice, we really think about the ADHD experience as being kind of like a triad.


There are three main things happening in the ADHD brain, and they are the regulatory experience of an ADHD brain. That’s those on-off switches that I was talking about. That basic neurobiology of ADHD brains that make it go all in or all out. There is the practical experience, which is basically that regulatory experience where the bottom of the iceberg, the practical would be the top of the iceberg and how all of that regulation shows up. It’s the procrastination. It’s the disorganization. And then there’s the emotional.


The emotional is both the big feelings, this very natural neurobiologically informed tendency to have very big feelings, but it’s also the experience of living and working and walking around in a world that is not really well-suited for your brain and the way your brain works naturally. These three things all interplay, and anxiety exists within those three planes too for an ADHD brain. For example, the regulatory aspects, we think of six things that fuel our regulatory capacity. Those six things are sleep, exercise, nutrition, medication, meditation, and connection.


All six of those we can think about how they are related to anxiety. When somebody comes in and they have both ADHD and anxiety, I’m going to be looking at how is their ADHD playing in on all these three aspects? How is their anxiety playing in on all these three aspects? Are they getting enough sleep? Is anxiety making it hard for them to sleep? Is ADHD making it hard for them to sleep? Are they feeling more anxious on days where they don’t sleep well? Because guess what? That’s pretty common. Are they exercising?


Exercise is a huge natural stimulant and can be really, really useful for ADHD, but oh by the way, also really useful for anxiety and so much is exercise playing in. Is that something that we can add in? And then on the practical side, anxiety plays there too. Very obvious how ADHD and practicality play together, but anxiety is there too. Part of the role that anxiety plays for ADHD brains is trying to keep it all together. It knows, hey, you’re prone to forgetting things. You’re prone to missing things. I’m going to be here to try to make sure that you don’t do that.


I’m going to stick around and try to make sure that we’re aware of all the things. Anxiety tends to get bigger when there’s more disorganization for a variety of reasons. Can we bring some more organization? Can we bring some more planning? Can we get some of those things out of your brain, like circling around in your brain, and more onto paper? This is the way in which helping to work with ADHD can also help to work with anxiety. And then of course, the emotional aspect is probably a little bit more intuitive when it comes to anxiety.


We’ll do all of the more standard anxiety-based emotional treatments there. We’re really looking at the whole triad and how both things are going to be impacting all sides of that triad.

Lindsay Guentzel (16:23):

I’m wondering how medication fits into this conversation. Stimulant medications help balance out the dopamine that our brains tend to be missing. I know from my experience, managing all of that and balancing that out really did help with a lot of the anxiety that I was feeling. I’m curious how that plays a role in figuring out what a treatment plan might be.

Dr. Marcy Caldwell (16:44):

Medication can be an absolutely wonderful support additive treatment. It depends on where you want to put it in your personal bucket. But simulant medication is the most effective psychotropic medication that we have of all the medications that we have for all the mental health disorders, and yet it is certainly not perfect. Medication can help anxiety be better. I mean, it can make people feel better, in part because it fills up that regulatory store. It makes it easier to keep emotions more right-sized. It makes it easier to do those practical strategies that keep anxiety more right-sized.


It’s going to help ease some of the ADHD symptoms, which will also help ease some of the anxiety symptoms. It can also make anxiety worse. It’s a stimulant, so it’s going to stimulate a whole bunch of systems in our bodies, including that threat system, and it’s going to stimulate that too. For some folks, they can find that their anxiety gets worse on stimulants, and for those we have other medications. If that’s the case for you, that’s okay. We can try other things.


Medication is both friend and foe when it comes to anxiety and is super, super useful, but also doesn’t work for everybody. It’s a very individualized experience. The truth is we are really, really new at mental health in general, at the brain in general, at medications specifically. There’s a lot we don’t know, and that’s a lot of trial and error, and that can be really frustrating. I encourage people to keep at it and keep trying and keep trying to figure out what’s working and really talking with their doctors and really communicating very clearly and effectively as possible.

Lindsay Guentzel (18:50):

You said practical strategies. I’m wondering if you can talk a little bit about the coping skills or just new habits that you help introduce to your patients to help them deal with some of the symptoms that can come up from anxiety, but also to address the bigger issue to make the anxiety stop happening as frequently.

Dr. Marcy Caldwell (19:08):

Amelia Nagoski wrote a wonderful book called Burnout, and in that book, she talks about the stress response cycle. The stress response cycle is basically that threat system that we talked about. When it was originally derived, when we actually had to respond to threats and our system got activated to respond to threats, the response to that threat would then end the cycle and the cortisol that’s secreted in our brains when we’re in that threat would go away. It would settle down, and that would then make everything okay. We would feel okay. We wouldn’t continue to feel anxious.


It wouldn’t have this negative impact on our long-term health that anxiety can have. But because we are no longer responding to threats in the same way, we are no longer fighting the lions, tigers, and bears, we’re no longer running away, we’re no longer freezing as still as possible and using all of our musculatory energy to be as still as possible, we no longer get the completion of that cycle. We no longer get that relief and the cortisol levels stay high. We may not still be in that really intense stress moment, that kind of like panicky moment, but our brain hasn’t decided everything’s totally fine.


I work with folks on how do we complete that stress response cycle. There are a lot of very practical behavioral things that we can do. A big one is exercise and particularly intense exercise. That’s going to be the easiest way to complete the stress response cycle because it’s the closest to what it was designed to do. Go for a run is as close to running from the bear as we could get. For folks that that is accessible, that is huge. But that’s not accessible for everybody for any number of reasons. There are lots of other ways to do that, including things like long grounded hugs or sex or meditation.


There are a bunch of other ways to complete that cycle. Working with folks on developing routines and habits where we can be completing that cycle at least daily because that stress is going to build up and we need to do something that then lowers it back down. What are we doing on a daily basis, not just when we’re like, oh, I really freaked out. I need to make sure I do that thing, but on a daily basis because the anxiety’s going to bring it up, what are we going to do to bring it back down? And that’s really going to have long-term health implications.


That’s going to make sleep better, and it’s going to start to create this upward spiral. We do a lot of that behavioral… I mean, you can put it in the self-care camp if you want. Sometimes people are like, “Ugh, self-care.” We get a lot of pressure to do a lot of self-care, so we can spin it however you want to spin it. But really part of it is fueling that regulatory capacity. Then there are other things about evaluating our thought processes because we often over interpret threats. We see more threats than are there because our brain is kind of like, I want to make sure I don’t miss anything. I want to make sure.


There’s a way in which society can say, oh, you’re being too sensitive. Again, put it back on the person. It’s not that. It’s not that you as a person are doing something wrong, it’s that your brain has said, “This is scary.” There’s a lot of stuff out here to be scared of. If there’s a lot of stuff to be scared of, then we need to be very careful that we notice all the things. It’s going to be better to notice more things than fewer things, because one of those things could kill us. If we notice all the things and a few more, that’s okay. There are ways in which we can start to examine that and start to see is that thing, is that actually a threat, or is that something else?


Oftentimes our brains will attribute a emotion or feeling or intention on something that’s quite ambiguous, right? Somebody’s giving you a funny look. We tend do, particularly if you’re anxious, particularly if you have some social anxiety, “Oh, they don’t like me. What’s wrong with me? Do I look funny? Do I have something in my teeth?” It becomes about me. That funny look maybe is about you. It’s true. Maybe you do have something in your teeth, but it’s also true that it could be that their stomach is off and they’re trying to brace against some discomfort.


I mean, any number of things. They had an itch and they were trying not to itch it. There are all kinds of things that can cause a funny look, and you are only one of them. Starting to examine that, starting to take off I like to think of them as thinking goggles. They’re like goggles that start to color the way we interpret the world, and starting to take those off can be really useful for seeing fewer threats out in the world and responding to the threats that we do see in a more moderate way.

Lindsay Guentzel (25:00):

I love the idea of thinking goggles and having your thinking goggles on. It’s a great visual. I want to wrap up by asking you what you view as the biggest concern regarding the effect anxiety can have on a person with ADHD.

Dr. Marcy Caldwell (25:14):

I think I’m going to circle back to the beginning, which is this shrinking of a life. A lot of folks have anxiety and they fight against this and they don’t allow it to shrink their life. That’s amazing because the tendency of anxiety is to start to shrink away from the things that make us anxious. It’s really uncomfortable to be anxious. It really feels terrible, and so it makes a whole lot of sense that you would want to avoid that. When we do that, we tend to shrink our lives. We tend to shrink our impact on our lives.


We tend to shrink the people, the number of people, the experiences that we have. And not only is that painful and sad and lonely for that person, but I’m a huge proponent of the beauty of an ADHD brain and what ADHD brains bring to this world. When ADHD brain who feel anxiety shrink away, they’re also not able to bring all that beauty out into the world. I think the world suffers as a result as well.


That’s the thing that breaks my heart the most around the anxiety and ADHD connection is that it tends to cause people to pull away, and that pulling away becomes a downward spiral and also keeps the rest of us from experiencing your light. That’s what makes me sad.

Lindsay Guentzel (26:49):

Marcy, that was a beautiful place to end it, just the line shrinking of a life is going to be something that I’m going to take away from this and hold on to for a very, very long time. Thank you so much for coming on and sharing so much about anxiety and ADHD, and thank you so much for everything that you’re doing for the ADHD community.

Dr. Marcy Caldwell (27:08):

Thank you. It’s been such a pleasure.

Lindsay Guentzel (27:17):

Marcy Caldwell is the founder of ADDept.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. We’ve shared all of the links for you to connect with Marcy and to find the incredible arsenal of resources she shares with the ADHD community in the show notes.


One thing that really stuck out for me from my time chatting with Marcy is how much power something like anxiety can have in our lives. And for a lot of us, especially us women, we tend to internalize it and ruminate on it. It’s something I struggled with for so many years without knowing what I was dealing with. But once you identify it and you acknowledge it, you can start to notice patterns when it comes up.


For example, while I love my morning cup of coffee, when I have just a bit too much caffeine, keeping in mind I do take Vyvanse, a stimulant medication every morning for my ADHD, sometimes that caffeine is just a little too much and the anxiety starts to come out physically. For me, it’s this spot right below my chest. There’s a little bit of tightening, a little bit of a flip-flop tummy. I’m working on being vocal about what I’m feeling, especially if it’s intrusive thoughts that have no place in my head.


I know it can be overwhelming to open up about our feelings, especially when they don’t quite make sense or you don’t think they make sense. I have found that getting it out of my head actually helps in stopping it from popping up over and over again, like my hyper fixation loosens up the more I’m honest about it. These back-to-back episodes with Marcy left so much more for us to unpack, which is why we’re leaving some time to do just that, unpack it.


On next week’s episode of Refocused, I’ll be joined by our coordinating producer and fellow ADHDer Phil Rodemann, as well as Jaye Lin, an ADHD coach, educator, speaker, and podcaster to talk about the incredible amount of information Marcy shared with us regarding anxiety and how it can show up in the life of a person with ADHD. I met Jaye Lin at the International Conference on ADHD in Dallas this past November, and I’m so excited to have her join us because of her experience as an ADHD coach and because anxiety has also been a prominent comorbidity in her life as well.


Our plan is to roll with the same layout for our upcoming episodes on ADHD and depression, as well as ADHD and obsessive compulsive disorder. We’ll have plenty of opportunities coming up for listeners to share with the show. You can email us, [email protected], or send us a message on social media @refocusedpod. We would love to hear your thoughts on how anxiety shows up in your life and what you’re taking away from these latest mental health focused episodes.


We would love to hear from you. In the meantime, 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 a favorite episode or a story you really connected with from our first Refocused, Together. We’ve made it easier for you to show us that love. Head to the show notes to find a direct link to share a review on your favorite streaming platform right now.


Thank you so much for listening. If you’re new here, my name is Lindsay Guentzel. I am 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 Rodemann, our coordinating producer who leads our live production, scheduling, and audio editing, Sarah Platanitis, 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, Lauren Terry, our associate producer and jack of all trades who, if I can add, just graduated from high school a few weeks ago.


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, Susanne Spruit, Melanie Mile, Claudia Gotti, and Tricia Merchant Dunny. Our show Art was created by Sissy Yi of Berlin Grey, and our music was created by Luis Ingles, a singer/songwriter from Perth, Australia, who was diagnosed with ADHD in 2020 at the age of 39.


Finally, a big thanks to Mason Nelly over at Dexia in Grand Rapids, Michigan for all of his help in getting our videos ready to share with you guys. 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 say it every week, and I mean it, 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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