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Treatment of Anxiety and Coexisting Conditions with ADHD in Young Adults

by Terri Bacow, PhD

Treatment for ADHD with therapy may take a variety of forms.  But what if you have ADHD and you also have anxiety? First of all, know that this is incredibly common. The norm is for ADHD to be accompanied by at least one other psychiatric condition (but do not worry if you do not have one!) Approximately 25% of children with ADHD will meet criteria for an anxiety disorder. The rate of overlap between ADHD and anxiety for people of all ages is about 28%. So what to do? First, it may help to clarify that we all experience a normal amount of anxiety in our daily lives because life can be inherently stressful.  Anxiety only becomes a “problem” if it begins interfering with things that you would like to do or creates considerable distress.  For example, you could be less than thrilled to use airplanes as a form of travel, but it is not until you begin to avoid flying altogether or panic every time that you have to get on a plane, that it is time to seek treatment.

Anxiety is by nature, actually very adaptive.  If a wild boar is running towards you (or a fast city bus) it is best to get out of the way! Some of us have alarm systems that are more sensitive than others such that things that do not give other people pause, make us highly anxious or worried.  The goal of therapy is to help reduce these alarm systems to a place where we react to things that most people would react to under the same circumstances and the anxiety is no longer interfering with our ability to function.

What if ADHD is present or added to the mix? For some people, the experience of ADHD is inherently one of chronic anxiety.  It is stressful, arguably extremely so, to have difficulties attending, focusing, organizing time, completing one’s work, planning ahead, curtailing impulses, sitting still, when these “executive functions” are part of our daily lives and present in almost every task. Many of the patients I see report this type of stress and have difficulty managing it, which makes it very common in clinical practice. Some questions that folks with ADHD commonly report include:

  • What have I forgotten?
  • What will go wrong next?
  • How can I keep track of the balls I have in the air?

Not surprisingly, individuals with ADHD are also highly resilient and have developed a variety of excellent strategies to cope with these challenges.  Dr. Hallowell, in his book, “Worry” describes the very natural anxiety that people with ADHD experience as a “startle response.”  Dr. Hallowell describes the following sequence:

  1. Something “startles” the brain (i.e. a transition)
  2. A “mini-panic” ensues; the mind does not know where to focus
  3. Anxious rumination replaces panic; the focus is on worry (“Will I get my taxes paid on time?”)

In this sequence, the ADD mind uses worry to get organized (or stuck) and avoid chaos. The worry serves as something concrete to focus on. This very normal process is what I would consider “secondary” anxiety in that the anxiety is secondary to ADHD.  In other cases, anxiety is the primary problem.  The anxiety difficulty is a disorder that is truly separate from the ADHD and co-occurs with it. Some examples include OCD (obsessive-compulsive disorder), panic disorder, post-traumatic stress disorder, generalized anxiety disorder and social phobia.

Whether you have ADHD and also feel a little bit anxious, or you have ADHD and feel VERY anxious, do not fear – help is available! The most effective type of therapy for both ADHD and anxiety disorders is cognitive-behavioral therapy, or CBT.

CBT is similar to all other types of therapy in that it involves a one-on-one conversation with your therapist, and in this way it is extremely similar to traditional talk therapies.  The CBT therapist, however, is more active and directive, and the goal of CBT is to teach patients specific coping skills to manage his or her symptoms.  In this manner, CBT tends to be a more structured and didactic.  It is also quite effective, with the aim to reduce symptoms within six months. CBT is based on a specific model that emphasizes the way we think and how we react, and teaches that any given emotion, whether it be anxiety, frustration, anger or sadness, can be broken down into three components: a thought, a feeling and a behavior.  This core CBT model theorizes that if you change the way you think or the way you behave, you can improve the way that you feel.  CBT is comprised of a wide variety of short-term interventions aimed at teaching the patient skills to change thinking and behaviors and improve emotion regulation.  These may include simple skills such as problem solving and more complex ones such as identifying and reframing our beliefs in a variety of situations that trigger negative emotions.

Having ADHD can be a confusing experience, as strengths are often mixed with real challenges. There is an enormous benefit of receiving therapy and/or coaching and sometimes combining the two interventions can achieve ideal results.  This is good news for all of us who feel anxious and are seeking a bit of calmness and relief in our lives!

 

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