We live in anxious times.
We worry about many things from the moment the alarm goes off in the morning — from contracting Ebola to finding a job in a tight economy to hoping the car doesn't break down in six months. Anxiety becomes a diagnosable illness, though, only when its causes are not tied to the events of our lives but have a life of their own. When free-floating anxiety gets so bad that it impairs our ability to function, it needs to be formally diagnosed and treated.
Anxiety Disorders (AD) occur much more frequently in people with ADHD than they do in the general population. Childhood anxiety disorders are the second most common condition coexisting with ADHD. The National Comorbidity Survey Replication reported that 47 percent of ADHD adults had an anxiety disorder of some kind.
The correlation between ADHD and anxiety challenges the wishful thinking that a child will grow out of his fearfulness if the family waits long enough. The fact is that anxiety disorders get more frequent, more impairing, and become more ingrained as the child moves into adolescence and adult life. Research and clinical experience support intervention as early as possible.
ADHD and anxiety disorder symptoms overlap. Both cause restlessness. An anxious child can be highly distracted because he is thinking about his anxiety or his obsessions. Both can lead to excessive worry and trouble settling down enough to fall asleep. It takes time to do a comprehensive history to determine whether a patient is struggling with one or both conditions. Expect your clinician to ask you to fill out checklists and scales to add your insights to the process.
Is Anxiety Under-Diagnosed?
Thomas Spencer, M.D., of Harvard Medical School, warns against doctors missing anxiety because the number of symptoms does not meet the largely arbitrary diagnostic cutoffs of the DSM-V. Spencer has introduced the informal concept of MAD (Multiple Anxiety Disorders), so that severely impairing levels of anxiety are not missed because they fall short of a full syndrome. He has shown that anxiety complaints are common in people with ADHD (the average patient will have nine or more symptoms of anxiety), but they usually don't have enough in one category to reach a formal diagnosis. So many people are not diagnosed with anxiety and don't receive appropriate treatment.
Other clinicians are concerned that manifestations of anxiety might be due to the hyperarousal of ADHD. The difficulty that most people with ADHD have in accurately naming their emotions is well documented. They do not use emotional labels in the same way that non-ADHDers do, and this leads to misunderstanding and misdiagnosis.
When a person with ADHD complains of severe anxiety, I recommend that the clinician not immediately accept the patient's label for her emotional experience. A clinician should say, "Tell me more about your baseless, apprehensive fear," which is the definition of anxiety. More times than not, a person with ADHD hyperarousal will give a quizzical look and respond, "I never said I was afraid." If the patient can drop the label long enough to describe what the feeling is like, a clinician will likely hear, "I am always tense; I can't relax enough to sit and watch a movie or TV program. I always feel like I have to go do something." The patients are describing the inner experience of hyperactivity when it is not being expressed physically.
At the same time, people with ADHD also have fears that are based on real events in their lives. People with ADHD nervous systems are consistently inconsistent. The person is never sure that her abilities and intellect will show up when they are needed. Not being able to measure up at the job or at school, or in social circles is humiliating. It is understandable that people with ADHD live with persistent fear. These fears are real, so they do not indicate an anxiety disorder.
A correct diagnosis is the key to good treatment outcomes. The distinction between anxiety and hyperarousal makes a big difference in which treatments will work.