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It is believed that many people with attention deficit hyperactivity disorder (ADHD) are diagnosed with at least one other mental health condition throughout their lives.
Studies have found that social anxiety disorder is one of the most common comorbid conditions of ADHD (Kessler, et al., 2006).
What is ADHD?
ADHD, or Attention Deficit Hyperactivity Disorder, is a neurodevelopmental disorder that affects both children and adults. It is characterized by symptoms such as difficulty with focus, hyperactivity, and impulsivity.
ADHD can make it challenging to complete tasks, follow through on responsibilities, and interact with others.
What is social anxiety disorder?
Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by intense fear and anxiety in social situations.
People with social anxiety disorder often experience excessive worry about being judged or scrutinized by others, and may avoid social situations altogether or endure them with extreme discomfort. This disorder can significantly impair daily functioning and negatively impact quality of life.
It is not uncommon for individuals to experience co-occurring conditions, such as social anxiety and ADHD, as both conditions share some overlapping symptoms and can significantly impact social interactions and daily functioning.
Can ADHD and SAD Occur Together?
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 include a 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 both ADHD and SAD may find it incredibly difficult to make and maintain friendships and be uncomfortable talking to anyone outside their comfort zone who likely understands their symptoms.
Difficulty sustaining attention
Someone with SAD symptoms may become so preoccupied with their social 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 be very distracted or forgetful.
Restlessness
People with ADHD and social anxiety disorder may both exhibit physical signs of anxiety or nervousness, such as tapping their feet or fidgeting with their hands.
Difficulty completing tasks
Since those with SAD may find it hard to ask for help due to their social worries, 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.
Both ADHD and social anxiety disorder can contribute to a sense of overwhelm or avoidance of tasks, leading to procrastination or incomplete work.
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
SAD is characterized by a fear or avoidance of social situations, and people with ADHD may also struggle with social interactions due to difficulties with communication, impulse control, or reading social cues.
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?
There are several ways in which ADHD can be misdiagnosed as SAD, including:
Overlap in symptoms
Since ADHD and SAD share several common symptoms, including difficulty with attention and concentration, restlessness, and irritability, these symptoms can make it difficult to differentiate between the two disorders, leading to a misdiagnosis.
Focus on anxiety
Clinicians may focus on anxiety symptoms, such as fear of social situations or avoidance of social interactions, and overlook other symptoms of ADHD, such as impulsivity or hyperactivity. This can result in a diagnosis of SAD, even if ADHD is the underlying issue.
Social avoidance
People with ADHD may avoid social situations due to difficulties with social skills, leading clinicians to believe that the individual has SAD. However, in ADHD, social difficulties may arise from impulsivity or poor social skills rather than anxiety.
Masking
Masking in ADHD refers to the conscious or subconscious efforts of individuals to hide or suppress their symptoms in order to conform to social expectations or avoid negative judgments.
Individuals with ADHD may learn to mask their symptoms, especially if they have not been diagnosed and treated. This can make it even harder for clinicians to identify ADHD, as the individual may appear to be anxious or shy rather than displaying typical ADHD symptoms.
Why do ADHD and SAD occur together?
It is not known for sure why ADHD and SAD occur together. It could be that the social difficulties and performance anxiety due to ADHD symptoms, such as impulsivity, inattention, and hyperactivity, can lead to social isolation, low self-esteem, and anxiety, which can trigger or exacerbate symptoms of SAD.
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 (Koyuncu et al., 2016).
This implies that experiencing traumatic experiences may contribute to ADHD and SAD occurring together.
ADHD Vs 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.
| ADHD | Social Anxiety Disorder |
|---|---|
| Chronic disorder that affects attention, hyperactivity, and impulsivity. | Anxiety disorder characterized by excessive fear of social situations and intense self-consciousness. |
| Symptoms can include inattention, distractibility, forgetfulness, fidgeting, and impulsivity. | Symptoms can include fear of public speaking, fear of social situations, avoiding social situations, and physical symptoms such as sweating and blushing. |
| Likely to have many thoughts and difficulty focusing on one thought at a time. | Likely to have thoughts about social judgment and worries about social situations. |
| May have difficulty concentrating in many situations. | May have difficulty concentrating in social situations due to anxiety. |
| Often diagnosed in childhood but can persist into adulthood. | Often diagnosed in adolescence or early adulthood. |
| Stimulant medication, such as Ritalin and Adderall, are commonly used to manage symptoms. | Medications such as antidepressants and anti-anxiety drugs are commonly used to manage symptoms. |
| Social difficulties may arise from impulsivity or poor social skills. | Social difficulties arise from excessive fear of social situations. |
SAD can cause someone to be unable to concentrate in social situations that cause them to feel anxious, whereas those with ADHD may 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 ADHD Cause Social Anxiety?
ADHD, especially untreated, can lead to an exacerbation of symptoms, causing problems in daily life and potentially triggering comorbid conditions such as SAD.
When ADHD is left untreated, the person’s impulsivity may cause issues that can create overwhelming feelings, leading to anxiety.
Lack of understanding and social rejection from others due to ADHD symptoms may also contribute to social isolation and nervousness in social situations, potentially leading to SAD.
Furthermore, untreated ADHD has been associated with an increased risk of substance abuse, particularly alcoholism, which can further increase the risk of developing depression and anxiety.
It’s important to seek appropriate treatment for ADHD to help manage symptoms and prevent the development of additional mental health conditions such as SAD.
Treating ADHD and SAD together
If you suspect you have ADHD and you think you need further support, 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 manage whichever condition is causing the most disruptive of the 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).
Psychotherapy
While medication is usually the first line of treatment for people with ADHD, many people can also benefit from psychotherapy, especially if they live with anxiety.
Cognitive behavioral therapy (CBT) may be useful in addressing many of the underlying challenges of both ADHD and SAD, as well as the symptoms that can overlap. CBT involves identifying negative thought patterns and behaviors and restructuring them into healthier ones.
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.
Social skills training is a type of therapy that helps individuals with ADHD, and social anxiety disorder develop social skills such as communication, problem-solving, and assertiveness.
Mindfulness-based therapies, such as mindfulness-based stress reduction (MBSR), can help individuals with ADHD and social anxiety disorder increase their awareness and acceptance of their symptoms, improve their attention and emotion regulation, and reduce stress and anxiety.
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 achieved what you set out to achieve 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 fleeting 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 may be effective at helping to reduce anxiety and help calm down a lot of racing thoughts.
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/
