You are unable to concentrate at work. You’re unable to shut off your mind at night. You are unable to remember key dates, fail to complete tasks on time, feel like you are behind on things, and you have this feeling that something is not right – but you can’t quite put your finger on it.
You do a Google search for your symptoms. ADHD comes up. So does anxiety. Both seem to fit. So which one is it?
One of the questions that adults frequently ask me when they come to my practice is this one. And the truth is, it’s complicated – ADHD and anxiety disorders do, in fact, intersect in ways that can be puzzling to even seasoned clinicians. But knowledge of the difference is not only an academic pursuit. It is a determining factor for the actual treatment that will benefit you.
As an adult ADHD psychiatrist serving patients throughout NYC and NJ, I have tested hundreds of adults who presented with symptoms of anxiety who were subsequently diagnosed with ADHD. And others who felt they knew they had ADHD – but they needed anxiety treatment first. It’s important to get this right. Here is how this article is going to describe.
Why ADHD and Anxiety Are So Easy to Confuse
There are many similarities on the surface between ADHD and anxiety in adults. Both can cause:
- Struggle to focus and keep attention
- Unable to sit still (mentally and physically)
- Difficulty sleeping or having a busy mind at night
- Roughness, short-tempered and loss of tolerance for frustration
- Not finishing tasks when they seem too difficult
- Forgetfulness and disorganization
- A feeling of being behind, overwhelmed, or not keeping up with others
If you read that list you can imagine that it is easy to see how adults – and sometimes their doctors – get them confused. Though symptoms may appear alike at the surface, the cause of the symptoms is actually quite different. It is that difference that is crucial to the correct diagnosis.
The Core Difference: Why It Happens
In ADHD, the problem with focus, organization and follow through is neurological. Structurally and functionally, the executive function system in the brain, which is responsible for control over attention, impulse control, working memory, and time management, is distinct. Not being stressed or about what is happening in your life isn’t the problem. Is consistent across situations, present since childhood (even if not recognized), does not go away when stressors are removed.
People with ADHD often say they have fifty tabs open in their mind and can’t even close them all. They may be able to focus on something that is really interesting to them for extended periods of time, but find it difficult to focus on something that requires effort and perseverance without any instant reward.
With anxiety, the difficulty with focus and concentration is driven by worry. An anxious brain is not trying to regulate attention neurologically, it’s preoccupied. Mental bandwidth is used up by racing thoughts, catastrophic thinking, physical tension and hypervigilance which make it difficult to concentrate, sleep or relax. Emotional alarm system is turned on and the focus problem comes second.
The key difference: ADHD is an attention regulation disorder. Anxiety is a predominant fear and worry issue, which secondarily impacts attention.
How to Tell Them Apart: Key Clinical Differences
These differences cannot take the place of a careful examination but are useful clues as to which condition is more likely to be responsible for your symptoms.
What drives the distraction?
When you have ADHD, interesting things work just as well as unpleasant things to distract you. A passing thought, noise, something more stimulating distracts you. The distraction is not directly associated with concern.
When anxious, distraction tends to be content-specific. You find yourself thinking about it and it won’t go away: a failure to communicate, a health problem, uncertainty about the future. But it’s not random, it’s rumination.
What happens when the stressor is removed?
If you have ADHD, taking away stress or pressure will not have a huge impact on your attention span. This executive function deficit is always present. Taking a vacation will not cure ADHD.
Anxiety can cause people to concentrate much more effectively when the tension subsides. If this is evident in times when your attention is at its best and worse when you are more stressed, the drive is more likely to be from anxiety.
How do you feel about starting tasks?
Often adults with ADHD have trouble initiating tasks and this is not due to fear of the results or their perceived lack of enthusiasm for the activity, but a lack of mental energy to get going. There is no fear, there is just an inability to start, which is very strange, but actually wanting to.
Anxiety in adults keeps them from doing things mostly because they are afraid of their performance, being judged, failure, or consequences. The avoidance is not an activation avoidance but a fear avoidance.
Does your mind race at night – and about what?
ADHD and Anxiety can interfere with sleep. But the content is saying. People who have ADHD often report that their mind just spins off into many directions, ideas, random memories, unrelated thoughts – with no one thread of concern. Often, adults with anxiety report that they have thoughts or worries that repeatedly and endlessly come back to a specific worry or fear.
Were there signs in childhood?
ADHD is a neuro developmental condition, meaning that it has existed since childhood, without diagnosis or without a label. If you can find a consistent history of these issues in your school experience, such as: trouble concentrating in class, forgetfulness for homework, being told that you were not working at your potential despite your efforts, then there’s a possibility that you have ADHD.
Anxiety can happen at any age. Does not need a history of childhood, although childhood anxiety is certainly possible.
When It Is Both: ADHD and Anxiety Together
The catch? About half of all adults with ADHD are also suffering from a co-occurring anxiety disorder. Both conditions coexist in a large part of the population, and for these people, self-diagnosis is not a valid way to distinguish one from the other, so a proper evaluation is so important.
Anxiety can be a symptom of ADHD. Putting in place the years of forgetting, underachieving, disappointing others, and not coping with the fundamentals of life, is a rather reasonable amount of ongoing stress and anxiety. Not many adults get anxiety directly as a result of their ADHD, but because for years they have been living in a nervous system that’s been stressed.
On the flip side, an untreated anxiety disorder can also be so similar to ADHD that the clinician overlooks the anxiety disorder entirely and treats what appears to be ADHD with stimulants which can exacerbate anxiety.
That’s where the order of the evaluation comes into play. A comprehensive clinical evaluation is used to differentiate:
- ADHD alone – where anxiety-like symptoms go away when ADHD is treated
- Anxiety only – where attention problems go away after anxiety issues are resolved
- ADHD in combination with anxiety – when ADHD and anxiety occur on their own and need to be addressed in different ways
This can have truly serious consequences if done wrong. A stimulant that is used to treat someone who is anxious and has focus problems can add a lot to their anxiety. A medication taken by a person with ADHD to minimize anxiety can help soothe the person, but it will not correct the neurological attention deficit at all.
What Accurate Diagnosis Requires
When diagnosing ADHD versus anxiety – or when it appears both are present – an accurate differential diagnosis takes more than a symptom checklist and a ten-minute appointment.
The adult ADHD psychiatrist will conduct a detailed clinical interview, review your history, including as a child, the use of validated rating scales for both ADHD and anxiety, consideration of any other co-occurring disorders, and a frank discussion of the implications of your evaluation and treatment options.
In my experience, I have seen adults in New York and New Jersey who have been to a lot of doctors and specialists for years with a misdiagnosis or not a full diagnosis. Some were receiving treatment for anxiety for 10 years before anyone thought of ADHD. Others were diagnosed with ADHD, but their anxiety was not treated and they did not stabilize on medication.
The first time it can be frustrating, if you don’t get the whole picture.
Treatment When ADHD and Anxiety Co-Occur
Sequencing and co-ordinating treatment is necessary when both conditions are confirmed.
Medication choices matter significantly. While stimulants can be highly beneficial for people with ADHD, they can also increase anxiety in some adults, especially used at higher doses. For those who have a significant comorbid anxiety diagnosis, non-stimulant ADHD medications, especially atomoxetine (Strattera), may be the initial treatment of choice as they do not activate the nervous system like stimulant ADHD medications do, but treat ADHD-related norepinephrine dysregulation.
Some adults respond well to a low dose of a stimulant in combination with an SSRI or SNRI that treats the anxiety component. This will need careful clinical supervision.
Therapy plays a meaningful role. There is solid evidence supporting CBT for anxiety and ADHD. CBT directly focuses on worry patterns and avoidance behaviors for anxiety. CBT for ADHD emphasizes skills that are essential for managing executive functioning, such as time management, organization, and emotional regulation, which are trained by medication, but not enough on their own.
Lifestyle factors. There is strong evidence for the effectiveness of exercise in decreasing symptoms of ADHD and anxiety. Both conditions have a tremendous importance with regard to sleep hygiene. Treatment of these foundations in addition to medicine and therapy yields better results than medicine alone.
Ready for a Clear Answer?
If you’ve been asking yourself and your doctor, ‘Do I have ADHD or anxiety – or both?’, the best thing you can do is get a comprehensive evaluation with a psychiatrist who specializes in the evaluation and treatment of adults with ADHD.
Dr. John C. Shershow, M.D. offers a comprehensive adult ADHD evaluation and treatment using telehealth in NYC and NJ. Accepting new patients.
Call (212) 265-4310 or visit drjohnshershow.com/contact-us/ to schedule your evaluation.
Frequently Asked Questions
Q: Can ADHD be misdiagnosed as an anxiety disorder in adults?
Yes, and it does occur often – particularly in women and high-functioning adults who have learned good strategies to compensate. After fighting with ADHD symptoms for years, the constant stress of trying to fight them can become generalized anxiety disorder. A psychiatrist with experience in adult ADHD will assess for either, and conduct a thorough developmental history, looking for patterns that indicate that ADHD may have been present long before the onset of anxiety.
Q: If I treat my ADHD, will my anxiety go away on its own?
Yes – especially for adults, where anxiety is a downstream effect from years of poorly managed ADHD. After medication for ADHD and when the chaos abates, anxiety can go down a lot and not be treated as an anxiety disorder. Others, particularly persons with independent anxiety disorder, need individualized treatment for the anxiety. This is why an extensive evaluation is important, and not assuming that one diagnosis fits all.
Q: Can stimulant medications make anxiety worse?
They can, in some patients (especially if there is a strong anxious component to the clinical picture) Stimulants activate the dopamine and norepinephrine systems, enhancing focus and motivation but also exacerbating physical symptoms of anxiety, like speed or tension, racing ideas, etc., in susceptible individuals. One is a possible explanation, therefore, why non-stimulant medication is sometimes used to treat ADHD if anxiety is also confirmed, or why stimulants are initiated at a low dose and gradually increased.
Q: How do I know if I need to see a psychiatrist or a therapist for this?
A psychiatrist should be your first choice if you think you might have either ADHD or anxiety or both. Psychiatrists are qualified to diagnose both of these and have the ability to prescribe medication if necessary, and to refer you to a therapist for the behavioral skills aspect. The treatment of a condition without a diagnosis of one can result in years of therapy for the wrong condition. After a correct diagnosis and a medication plan, a therapist can be a very valuable component to the ongoing care plan.
Q: Does ADHD cause anxiety, or does anxiety cause ADHD?
Neither causes the other directly in a biological fashion. ADHD is a condition that affects the developing brain that is present at birth. Anxiety disorders are polygenetic, meaning they are created by a mix of genetic, temperamental and life experiences. But it is almost certain that living with poorly diagnosed ADHD for several years or more causes cumulative anxiety – the constant underachievement, forgetfulness and difficulty causing a real and understandable level of stress. Anxiety consumes a lot of mental space, and can create attention problems similar to ADHD. This is a two-way and clinically important interaction between the two.
Q: Can I get evaluated for ADHD and anxiety in New Jersey or New York via telehealth?
Yes. Dr. Shershow is board certified in New York and New Jersey, and provides comprehensive adult ADHD and anxiety evaluations via fully secure telehealth visits. Clinically, a virtual evaluation is the same as an in-person evaluation for diagnosis. Telemedicine psychiatric evaluation and, if applicable, medication management (including for ADHD and anxiety disorders) is allowed in both New York and New Jersey.