ADHD and anxiety: Why they go together and how to treat them
Your psychiatrist says you have ADHD. But the constant anxiety doesn't go away with medication. In fact, some days it seems worse.
Is the stimulant causing anxiety? Or was it anxiety you had all along?
The answer is usually: both are neurobiologically connected. And treating them requires understanding why they appear together.
The numbers don't lie
ADHD-anxiety comorbidity is one of the highest in psychiatry:
- 50-60% of adults with ADHD have a comorbid anxiety disorder
- 30-40% in child population with ADHD
- More than 60% of individuals with ADHD present at least one comorbid psychiatric disorder, with anxiety being one of the most frequent
This isn't coincidence. It's not "bad luck having two independent diagnoses".
There are deep neurobiological reasons.
Norepinephrine: the key player nobody mentions
Everyone talks about dopamine in ADHD. But anxiety in ADHD has more to do with norepinephrine (NE).
Norepinephrine dysregulation is the critical nexus between ADHD and anxiety.
Here's how it works:
- ADHD: Norepinephrine deficit in prefrontal cortex → problems with attention, organization, emotional regulation
- Anxiety: Norepinephrine hyperactivity in amygdala → exaggerated stress response, hypervigilance
- Comorbidity: Norepinephrine system dysregulated in both directions simultaneously
2024-2025 research finds that dopamine (DA) and norepinephrine deficiencies, particularly in the striatum, are strongly linked to the pathogenesis of ADHD with comorbid depression. But the connection with anxiety is equally strong.
Reduced dopamine transporter (DAT) availability in the striatum is a key neurobiological link observed in both conditions.
ADHD creates anxiety: the vicious circle
Even without genetic predisposition to anxiety, ADHD itself creates ideal conditions to develop it:
Chronic ADHD stress:
- You forget deadlines → anticipatory anxiety
- You're repeatedly late → social shame
- You constantly lose things → recurring panic
- You don't finish what you start → chronic guilt
- Emotional dysregulation → intense and unpredictable emotional reactions
Each failure generates stress. Each stress generates cortisol. Chronic cortisol sensitizes the brain's alarm system.
Result: Your brain learns to be in constant alert state because "something always goes wrong".
Anxiety then is not a separate disorder. It's an adaptive (though dysfunctional) response to the chaos of untreated ADHD.
Why diagnosis usually fails
Here's the clinical problem:
Anxiety masks ADHD:
- Anxiety symptoms (constant worry, distraction by anxious thoughts) overlap with ADHD
- Doctors more familiar with anxiety/depression than with ADHD
- 28% of individuals referred to tertiary clinic for anxiety/depression evaluation had undetected ADHD
- Significant predictors of undetected ADHD included the number of SSRIs previously received
Consequences:
- Years of anxiety treatment without results
- SSRIs that help partially but don't resolve the problem
- Patient frustration: "Why doesn't anything work?"
The answer: because they're treating the consequence (anxiety) without touching the cause (ADHD).
Women: especially difficult diagnosis
The problem is worse in women:
- Women predominantly present with inattentive ADHD + higher rates of comorbid anxiety/depression
- Improved clinical recognition of inattentive presentations is critical to avoid misdiagnosis
- Masking (consciously compensating symptoms) leads to late diagnosis
Result: decades with "generalized anxiety" diagnosis when the primary problem was ADHD.
Stimulants and the anxiety paradox
Most frequent question: "Won't stimulants make my anxiety worse?"
The answer, backed by recent research, is surprising: generally no, and often they reduce it.
Here's why:
Paradoxical mechanism:
- Stimulants increase norepinephrine AND dopamine in prefrontal cortex
- Prefrontal cortex with more resources → better amygdala regulation
- Improved amygdala regulation → less anxiety response
What research says:
- Norepinephrine reuptake inhibitors with serotonin receptor modulation address emotional dysregulation alongside core ADHD symptoms
- Medications that inhibit norepinephrine and serotonin reuptake increase availability of these substances in synaptic clefts
- Higher norepinephrine levels useful for attention/focus through adrenergic receptor activation
In practice:
- For many, treating ADHD reduces anxiety indirectly (less chaos → less stress)
- If anxiety persists, then consider specific anxiety treatment
- Some need both: stimulant + SSRI/therapy
Exceptions:
- ~20-30% do experience increased anxiety with stimulants
- More common with high doses or fast titration
- Solution: lower doses, extended release, or non-stimulant medication (atomoxetine, guanfacine)
Treat ADHD first: the golden rule
2024-2025 clinical consensus is clear:
Recommended treatment sequence:
Evaluate if ADHD is primary: Did ADHD symptoms precede anxiety? Does anxiety worsen with chaos/disorganization?
Treat ADHD first: Medication + ADHD-focused therapy (adapted CBT, organization skills, emotional regulation)
Reassess anxiety after 2-3 months: If anxiety improves significantly → ADHD was the main driver. If it persists → real comorbidity requiring additional treatment.
Add anxiety treatment if necessary: SSRIs, cognitive-behavioral therapy for anxiety, mindfulness, DBT for emotional regulation
Why this order:
- Treating anxiety first without addressing ADHD → partial improvement, frustration
- Treating ADHD first → frequently resolves or reduces anxiety as positive side effect
- More efficient: one treatment can resolve both problems
Differentiating: ADHD causing anxiety or real anxiety?
Clinical clues:
ADHD as primary cause:
- Anxiety mainly situational (deadlines, organization, social due to impulsivity)
- Anxiety improves dramatically with structure/ADHD medication
- History of "functioned well in structured school/work, collapsed when autonomy increased"
- Worries centered on consequences of ADHD symptoms
Primary anxiety disorder:
- Generalized anxiety, not just situational
- Worries about topics unrelated to ADHD
- Anxiety present even in periods of good organization
- Limited response to ADHD treatment
Both (real comorbidity):
- Anxiety improves partially with ADHD treatment but doesn't disappear
- Biological anxiety component independent of ADHD stress
- Strong family history of anxiety disorders
CBT, DBT and emotional regulation
Beyond medication:
CBT adapted for ADHD + anxiety:
- Focus on organization and structure (reduces anticipatory anxiety)
- Exposure techniques for social anxiety (common in ADHD due to past impulsivity)
- Cognitive restructuring for negative beliefs ("I always screw up")
DBT (Dialectical Behavior Therapy):
- Originally for borderline disorder, but incredibly effective for ADHD + anxiety
- Distress tolerance skills (when anxiety appears, what to do)
- Emotional regulation (the key deficit in ADHD)
- Adapted mindfulness (short versions, not long meditations)
2024-2025 evidence: CBT and DBT work for both, but require ADHD-specific adaptations (shorter sessions, more structure, reminders).
What now?
If you have ADHD and anxiety:
First:
- Confirm that ADHD is well diagnosed
- Evaluate if anxiety preceded or followed ADHD
- Consider if ADHD stress is generating anxiety
Treatment:
- Prioritize ADHD treatment (medication + therapy)
- Don't assume stimulants will worsen anxiety (they often help)
- Give it time (2-3 months) to see if anxiety improves with ADHD treatment
- If it persists, add specific anxiety treatment
Look for professionals who understand:
- The neurobiological ADHD-anxiety connection
- That anxiety can be secondary to ADHD
- That treating ADHD first is usually right
2024-2025 research is clear: ADHD and anxiety are neurobiologically connected through norepinephrine and dopamine systems. More than half of people with ADHD experience anxiety. And treating ADHD first, even with stimulants, frequently reduces anxiety.
It's not anxiety OR ADHD. It's ADHD causing/exacerbating anxiety. And treating them in the right order matters.