It is believed that around 80% of people with attention deficit hyperactivity disorder (ADHD) are diagnosed with at least one other mental health condition throughout their lives.
These conditions can include anxiety and depressive disorders.
In This Article
Can ADHD and social anxiety disorder occur together?
Although any anxiety disorder can coexist with ADHD, social anxiety disorder (SAD) is one of the most common. SAD is associated with an intense and debilitating fear of some or most social situations.
People with SAD often fear being negatively judged by others and becoming embarrassed in specific social settings.
People with ADHD, who already struggle with understanding social cues and with tackling big emotions, make them particularly vulnerable to social anxiety.
While ADHD and SAD appear to be very different disorders, research continues to find that they often occur together.
What does the research show?
According to the National Comorbidity Survey Replication, approximately 30% of adults with ADHD also have comorbid SAD.
A study looked at comorbidity in those with SAD and found a high rate of ADHD in these individuals and that the presence of ADHD was associated with symptom severity (Koyuncu et al., 2015).
Specifically, the inattentive subtype of ADHD may be more linked to SAD than the combined ADHD type (Koyuncu et al., 2019).
It is thought that anxiety disorders occur much more frequently in those with ADHD compared to those who do not have ADHD.
Sometimes symptoms of other conditions, such as SAD, can be masked by the symptoms of ADHD, which can make it hard to realize there is a comorbidity.
Consequently, SAD can often go undiagnosed in those with ADHD.
Just as untreated ADHD can contribute to problems in everyday life, comorbid SAD can cause problems if they are left undiagnosed and untreated
ADHD and SAD similarities
Although ADHD and SAD are two distinct disorders, there are many ways in which their symptoms can overlap:
Difficulties socializing
SAD symptoms specific to socializing include struggling with the fear of rejection and being negatively judged by people, while ADHD can make someone impulsive, interrupt others, and have problems picking up on social cues.
Someone with ADHD and SAD may therefore find it incredibly difficult to make and maintain friendships and may be uncomfortable talking to anyone outside of their comfort zone, who likely understands their symptoms.
Difficulty sustaining attention
Someone with SAD symptoms may become so preoccupied with their worries that they can appear to zone out, specifically in social situations.
Those with ADHD are usually inattentive and find it difficult to sustain focus for extended periods of time.
This means that those with comorbid SAD and ADHD can find it very difficult to concentrate or pay attention.
Difficulty completing tasks
Since those with SAD may find it hard to ask for help, they can become stuck on a task. Likewise, they may find they become extremely anxious during a task, which prevents them from completing it.
Those with ADHD often have difficulty sticking to deadlines due to poor planning skills and forgetfulness.
A combination of SAD and ADHD can make it increasingly harder for someone to complete tasks on time.
Low self-esteem
Those who have both ADHD and SAD may have low self-esteem. In fact, research has found that children and adolescents with ADHD and SAD had lower self-esteem than those with ADHD only (Çelebi & Ünal, 2021).
Because of the combined social anxiety with SAD and the impulsive social behavior of ADHD, people with both disorders may feel very self-conscious around others and tend to be intensely self-critical.
Avoidance
Due to the difficulties in social interaction and feeling anxious around others, those with comorbid SAD and ADHD may avoid experiences or places where social interaction will occur.
If they have to attend a social event, they may worry for days or even weeks beforehand, and they may be more likely to cancel at the last minute to avoid the distress altogether.
Can ADHD be misdiagnosed as SAD?
It is not uncommon for people with ADHD, especially girls and women, to be diagnosed with SAD in the first instance.
Since some of the symptoms of ADHD and anxiety can be similar, if females present as having less severe ADHD symptoms or they have learned to mask their symptoms, their ADHD could be misdiagnosed as SAD.
Why do ADHD and SAD occur together?
It is not known for sure why ADHD and SAD occur together, but some believe genetics, environmental toxins, or premature birth may be an influence.
Others believe that ADHD symptoms themselves can contribute to social anxiety.
Symptoms of ADHD, such as inattention, hyperactivity, and impulsivity, can put a person at a greater risk of being bullied or socially rejected.
For fear of being bullied, those with ADHD may withdraw into themselves and avoid social settings they believe to be threatening, which can, in turn, cause SAD to develop.
A study found that those who had SAD with ADHD had higher rates of emotionally traumatic experiences compared to those with SAD only.
This implies that experiencing more traumatic experiences could contribute to ADHD and SAD occurring together.
Differences between ADHD and SAD
It can be difficult for those diagnosing these disorders to differentiate between ADHD and SAD. The symptoms of ADHD are different from those of SAD or any other type of anxiety.
ADHD symptoms primarily involve issues with focus and concentration. Anxiety symptoms, on the other hand, involve issues with nervousness and fear.
Those with anxiety are likely to experience physical symptoms such as sweating, trembling, blushing, and muscle tension, while those with ADHD will likely have poorer time management, forgetfulness, and difficulty regulating their emotions.
SAD can cause someone to be unable to concentrate in situations that cause them to feel anxious, whereas those with ADHD will find it difficult to concentrate most of the time in any situation.
A key to understanding the difference between the two is to look at the type of thoughts that occur for the individual.
Those who have SAD are likely to have thoughts about being judged, worrying that they will make a mistake, or being anxious about an upcoming social interaction.
Those with ADHD, however, are likely to have thoughts about many different subjects and find they cannot concentrate on one thought for too long before moving on to something else.
Can untreated ADHD lead to SAD?
Any type of mental health disorder that goes undiagnosed and untreated is likely to worsen over time, causing a worsening in symptoms and possibly triggering other issues. Untreated ADHD can lead to problems in everyday life and comorbid conditions such as SAD.
People with ADHD are typically more impulsive than others. Since they may act without fully understanding the consequences of their actions, it can cause problems that can eventually overwhelm the person, resulting in anxiety.
If people around the person with ADHD do not fully understand the condition, they could socially reject the person. This can cause more social isolation for the person with ADHD and make them more nervous in social situations, which could eventually lead to social anxiety.
ADHD has also been linked to substance abuse, especially alcoholism. Alcoholism increases a person’s risk of developing depression and anxiety.
Treating ADHD and SAD together
If you suspect you have ADHD, it’s important to tell your doctor about all your symptoms, even if you think they are unrelated.
It is possible you could have additional disorders, such as SAD, which must be considered when deciding on treatment options. It is also important to inform your doctor about any new symptoms since you could develop SAD or another condition over time.
If SAD and ADHD are functioning independently of each other, the doctor may decide to treat both conditions simultaneously.
Or they may choose to treat whichever condition is causing the most problems first before moving on to the other condition.
If the doctor believes that the anxiety is being caused by or is heavily influenced by your ADHD, the doctor may take a different approach to treatment. If the anxiety is the result of ADHD, the doctor may decide to treat
ADHD first with medications as this may reduce the anxiety symptoms. Treating ADHD and SAD simultaneously can be challenging because some medications for ADHD can worsen anxiety symptoms.
The doctor will not want to prescribe ADHD medication if it can worsen anxiety.
Medications
Medication options for ADHD with SAD include stimulants and non-stimulants. Stimulants are primarily used for ADHD. Some types of stimulants may also bring some relief from anxiety symptoms.
Ritalin, for instance, has been shown to be associated with improvements in both ADHD and SAD symptoms in children, adolescents, and adults.
Non-stimulants are often the medication of choice for many people with anxiety disorders. Some selective norepinephrine reuptake inhibitors (SNRIs) may target both ADHD and anxiety symptoms.
A study in 2009 found that a type of SNRI called Strattera improved both ADHD and SAD in adults (Adler et al., 2009).
Talk therapy
While medication is usually the first line of treatment for people with ADHD, many people can also benefit from talking therapies, especially if they live with anxiety.
Cognitive behavioral therapy (CBT) is useful in addressing many of the underlying challenges of both ADH and SAD, as well as the symptoms that can overlap. CBT involves identifying negative thought patterns and behaviors and restructuring them into healthier ones.
CBT has proved to be very effective at treating SAD, especially the use of exposure therapy. Exposure therapy is a technique of CBT that can be used with SAD to gradually expose people to fearful social situations so that the situation elicits less fear over time.
In other types of CBT, social skills can be learned and practiced, which can be useful for those with both SAD and ADHD.
Managing ADHD and SAD
Be kind to yourself
Those with ADHD and comorbid SAD are likely to be very self-critical. Try to limit negative self-talk as much as possible.
You could come up with phrases you can say to reassure yourself, even writing these down and placing them in a spot that is within sight every day to remind yourself.
If you are finding your negative self-talk is getting hard to control, this can be something to talk to a doctor or therapist about.
One thing at a time
Try to think about what one thing you want to change that is the biggest struggle right now.
Focus on this one goal to fully work on until you feel you have improved in this area. It can be helpful to look for easy wins that can build self-esteem and a sense of security.
Journaling
Keeping a journal can be a good way of keeping track of feelings and emotions and any progress you have made.
As people with ADHD and SAD can have a lot of negative and various thoughts, it can be good to get everything written down in a journal to help manage these thoughts and clear the mind.
A journal is only for the purpose of the individual, so there is no wrong way to do it. It can also be useful to help you pinpoint things you may want to discuss with the doctor or therapist.
Relaxation exercises
Those who have comorbid ADHD and SAD may find they get into spirals of anxiety or have racing thoughts. When anxious, breathing becomes shallow, among other physical sensations being triggered.
Completing some relaxation exercises such as meditation, mindfulness, or deep breathing can help to bring down the anxious symptoms.
Using these relaxation techniques can help you to slow down and keep you in the present moment instead of worrying about what needs to be done or focusing on future events.
Socialize
While it may seem difficult to socialize, it is important to try to socialize at least once daily to keep building social skills up.
It is important to challenge yourself to get out of the cycle of anxiety and overcome your fear of socialization.
Suppose you find it too challenging to socialize with people in person. In that case, you could start off small by communicating via text messages until you feel more comfortable building up to face-to-face conversations.
Confide in others
People with ADHD can have difficulty making and maintaining friendships, sometimes due to their social behavior, such as being impulsive in conversations which can be frustrating for others.
With comorbid SAD, they can become overwhelmed and fearful in social situations. Confiding in those around you about your struggles can help others understand your condition and support you in overcoming some of your obstacles.
Exercise regularly
Exercise has shown to be effective at helping to reduce anxiety, with people reporting feeling a lot calmer, specifically after completing an aerobic exercise.
Exercise can also help those with ADHD to focus on one task at a time and put a lot of their restless energy into doing something which is also good for their health.
Learn your triggers
Anxiety can be triggered by specific events, such as public speaking or engaging in one-on-one conversations. Once you have identified your triggers, you can come up with ways to manage your anxiety in these situations.
For instance, someone who fears public speaking could prepare notes and practice their presentation to help them feel less anxious speaking in front of others.
Create a schedule
With ADHD, individuals may find it very difficult to complete tasks, especially on time. Tasks with a deadline can make anxiety worse for some people.
A way to help avoid anxiety is to create a schedule and stick to it. You could allocate a task or goal to complete in each hour of the day, allowing extra time for each task if you think it will realistically take you longer than you think.
It is important not to set unattainable goals for yourself as this can have the opposite effect and cause more anxiety.
Another method can be to schedule segments of time where you focus on the task at hand and nothing else. You could set a timer for 30 minutes- during this time you put away any distractions and focus solely on your task.
This can take some practice to get used to, but it can be a good way to ensure you get all your tasks done without losing focus.
References
Adler, L. A., Liebowitz, M., Kronenberger, W., Qiao, M., Rubin, R., Hollandbeck, M., Deldar, A., Schuh, K. & Durell, T. (2009). Atomoxetine treatment in adults with attention‐deficit/hyperactivity disorder and comorbid social anxiety disorder. Depression and Anxiety, 26(3), 212-221.
Çelebi, F., & Ünal, D. (2021). Self esteem and clinical features in a clinical sample of children with ADHD and social anxiety disorder. Nordic Journal of Psychiatry, 75(4), 286-291.
Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., Farone, S. V., Greenhill, L. L., Howes, M. J., Secnik, K., Spencer, T., Ustun, B., Walters, E. E. & Zaslavsky, A. M. (2006). The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. American Journal of psychiatry, 163(4), 716-723.
Koyuncu, A., Ertekin, E., Yüksel, Ç., Aslantaş Ertekin, B., Çelebi, F., Binbay, Z., & Tükel, R. (2015). Predominantly inattentive type of ADHD is associated with social anxiety disorder. Journal of attention disorders, 19(10), 856-864.
Koyuncu, A., Çelebi, F., Ertekin, E., Kök, B. E., & Tükel, R. (2019). Clinical effects of ADHD subtypes in patients with social anxiety disorder. Journal of Attention Disorders, 23(12), 1464-1469.
Next Step for ADHD. (2021, June 23). ADHD and Social Anxiety: Can They Occur Together? https://www.nextstep4adhd.com/adhd-and-social-anxiety-can-they-occur-together/
