Untangling the Relationship between ADHD and Social Anxiety
With the growing acceptance and interest in Attention Deficit Hyperactivity Disorder (ADHD) in mainstream society, more individuals are starting to examine their own experiences and search for explanations that could shed light on why they face difficulties in certain aspects of their lives. Many individuals who seek ADHD assessments often express concerns about their socialisation skills, including difficulties in maintaining connections with peers and friends, missing or misinterpreting social cues, or a general sense of discomfort in social situations. These experiences are often accompanied by strong emotional distress which can lead people to engage in safety behaviours or actively avoid social situations altogether. Not surprisingly, ADHD and Anxiety disorders share many common features and often occur together. Of all anxiety disorders, Social Anxiety Disorder (SAD) is thought to share the most comorbidity with ADHD with some studies estimating the rate of comorbidity to be approximately 60-70%. (1).
What is Social Anxiety Disorder
Social Anxiety Disorder (SAD) is characterised by a fear of social situations or events where a person may be negatively evaluated or judged. The type of things a person fears can be wide ranging, from being observed eating, or engaging in conversations with others, through to showing visible signs of anxiety such as blushing, sweating or trembling. These symptoms are usually so uncomfortable that people go to great lengths to avoid social situations. They may also become ritualistic or controlling about the social events that they do attend in an attempt to limit their arousal and increase their sense of safety.
What is ADHD
ADHD is a neuro-developmental disorder that typically develops in childhood. It is characterised by symptoms of inattention, impulsivity and hyperactivity. Research into the prevalence of ADHD in the general population is still being reviewed, however the commonly quoted figure sits at around 6-10% for children and adolescents and 2 – 6% in adults (2). This number is an estimate, and some experts believe that the correct number may be much higher.
Some common symptoms of ADHD include Inattention, a lack of focus, poor time management, weak impulse control, emotional lability, hyperactivity, and problems with executive disfunction.
Can you have both?
It is relatively common for SAD and ADHD to co-occur. Often the presence SAD can mask the presence of ADHD and vice versa because of the similarities between several of their presentations. The reasons for this are still the source of investigation, however some leading theories point to a combination of genetic and environmental factors. There is a relatively high level of heritability for both ADHD and Anxiety disorders which could lead some individuals with ADHD to be predisposed to developing SAD in the future. Furthermore, the experience of ADHD symptoms may make it more likely for an individual to go on to develop an anxiety disorder like SAD due to the ostracising effect ADHD symptoms can have on an individual in settings where conformity is valued such as school yards, workspaces, and socialisation in general.
How do the symptoms overlap?
Although the diagnostic criteria for ADHD and SAD are strikingly different, the experience of ADHD and SAD can present itself in similar ways. A common concern of people suffering from ADHD is that they feel uncomfortable in social situations, or they find it hard to maintain relationships with others. This social deficit sometimes results from symptoms of inattention where a person appears to zone out of conversations or has difficulty following the typical structure of a social dialogue. Symptoms of hyperactivity can also negatively affect a persons social standing as they may be prone to interrupting others or communicating in a way that seems sporadic. In contrast a person with SAD will have difficulty sustaining or initiating friendships, however their fears typically revolve around a fear of rejection or evaluation by others. SAD may cause an individual to “zone out” during social situations because they are distracted by fears relating to being negatively evaluated or they may be hyper focused on their own behaviour in an attempt to stop themselves from making what they perceive to be a disastrous mistake. Although the underlying reasons for these symptoms may differ depending on the underlying diagnosis, people who experience these symptoms tend to withdraw from social situations, present with low self-confidence, engage in safety behaviours, and avoid social situations that make them anxious.
How are they diagnosed?
Fortunately, diagnosis of both conditions can be sought through properly trained ADHD professionals, psychologists and psychiatrists. This may involve an initial consultation where your concerns are explored and the mental health professional can begin to gain an understanding of your experience. Based on the information gathered, it may be appropriate to undergo an ADHD Assessment or to formulate a treatment plan that targets your anxiety symptoms. It may also be necessary to do both of these together.
What are the treatment options?
Understanding the cause of your symptoms is important in seeking the right kind of treatment. Treatment approaches can differ depending on the underlying cause of your distress. ADHD treatment typically involves engagement with an ADHD coach or therapist to develop an array of strategies to manage the symptoms of ADHD and to identify and remove barriers in your life. Medications can also be useful in increasing focus and organisation which may have a flow on effect in improving self confidence and lessening symptoms of social anxiety.
SAD is typically treated through a combination of cognitive behavioural therapy, (or some variant such as acceptance commitment therapy), gradual exposure therapy and/or anti-anxiety medication. Cognitive behavioural therapy involves learning to recognise the relationships between your emotions and physiological reactions to external or internal events. This could include identifying feared situations, challenging automatic assumptions about the likely outcome in these situations, self-esteem work and emotional regulation training. The most effective intervention for social anxiety involves the incorporation of exposure therapy, which rewires your brain to be more comfortable in social situations as you build up resilience and experience operating effectively in these situations.
Sometimes, a combination of both approaches will be needed, so it is important to understand the root cause of your symptomology in order to engage in effective treatment. Clinical Therapy offers comprehensive ADHD assessment, conducted onsite at Kogarah, as well as individual therapy to help clients understand their experiences and effectively treat ADHD and SAD symptoms. If you think your experiences sound similar to those described above, talk to your local GP about organising a Mental Health Care Plan so you can take back some control in your life through effective evidence-based intervention.
Content note: Unless otherwise labelled, all blog posts are intended as discussion pieces, and are not academic texts. Articles pertaining to research or making an academic argument will be labelled as such and include supporting evidence/references. All examples (including client names) are fictitious, to illustrate a point, and are not based on actual clients.
Koyuncu A, İnce E, Ertekin E, Tükel R. Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in Context 2019; 8: 212573. DOI: 10.7573/dic.212573