Dealing with Both ADHD and Social Anxiety Disorder

Over a third of people with ADHD also suffer from social anxiety, which further impairs their ADHD symptoms and multiple aspects of their lives. (van Ameringen et al., 2011). According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Social Anxiety Disorder (SAD) is characterized by excessive and persistent fear of social situations, along with avoidance of or intense distress during these situations. The presence of SAD alongside ADHD makes treatment more complex but also leads to shame and self-sabotage. Although treatment is complex, there are effective treatment options and various methods of handling this comorbidity. Through education on the comorbidity of ADHD and SAD, I intend to inspire understanding and a sense of control in people who are unaware of how these conditions interact.

As mentioned above, the comorbidity of ADHD and SAD worsens both conditions and leads to a more severe presentation, worse functioning, and a more complex treatment plan (Koyuncu et al. 2015). Researchers have observed that there is a higher rate of major depressive disorder with a lower age of onset, increased severity, and presented with atypical features; a possible link between ADHD, SAD, and Bipolar Disorder, specifically type II and Not Otherwise Specified. While this study doesn’t define the experiences of all individuals with ADHD and SAD, it does help quantify the impact of SAD on ADHD. 

This comorbidity can be seen from a more human perspective through examples of people managing it. In his book Smart but Stuck : Emotions in Teens and Adults with ADHD, Dr. Thomas E. Brown details his treatment of several patients, including ones with both ADHD and SAD. will use his patients Eric and Matt as my examples, because while their situations are unique to them, their struggles can be applied to others. Both patients sought the help of Dr. Brown after a crucial transition: the one from high school to college. This can make ADHD more severe because of lack of support, expectation of self-directed action, and stress. For many, college can be an intensely stressful transition for those with SAD because they often lose their social circle and are forced to interact with many new people. Despite being at different phases in college and different additional struggles (drug dependance, other health issues, and self-imposed isolation), Eric and Matt's experiences with SAD similarly impacted their social and academic success.

Eric is a 20-year-old student who took medical withdrawal to avoid being dismissed from his university. His lack of success in school was attributed to his excessive marijuana use, lack of support that he had in high school, lack of motivation toward long-term goals, and other related struggles. Despite his charming demeanor and popularity in high school, Eric struggled with social anxiety. Brown writes that Eric “worried chronically and intensely that other people…did not really like him.” These are common fears for people with social anxiety. Whenever Eric’s ADHD (exacerbated by his lifestyle) caused him to miss expectations, his fear of rejection caused him to self-sabotage. For example,  Eric stopped attending class “and eventually dropp[ed] some of his college courses when he did not hand in an assignment on time.” Not only did this fear jeopardize his academic success, but his health as well. When he lost his prescriptions for his colonic bleeding, “he felt too embarrassed to contact the physician.” This caused him to have another hospital visit for his bleeding colon. While Eric is a great example of social anxiety, there is another example that I would have to explore from Smart but Stuck. 

Matt is an 18-year-old college student who decided to withdraw from college after struggling with isolation and depression during his freshman year. In high school, Matt had a robust social network that he was comfortable around. However, when he went away to university, he avoided interacting with any of his peers. He stayed in his room as much as possible, only leaving to “go to classes, use the bathroom, and get meals.” This anxiety also affected his academics; Matt’s “strong fears of being embarrassed” caused him to stop attending classes. Brown goes on to note that “those with ADHD often live with considerable fear that their inattention problems will be noticed by others and cause them embarrassment.” Matt had a similar fear of public humiliation and condemnation from his professor; “a single missed class often led to another and another…[until Matt] thought it would be less shameful to withdraw from the course completely than to go back to the class and risk a humiliating confrontation.” His social anxiety magnified the threat of being chastised by professor and caused him to sabotage his success in college. For both Matt and Eric, perceived failures as a result of their ADHD caused them to disengage as a result of their fear of social embarrassment. However, the mechanics of ADHD itself exacerbates social anxiety as well.

While it is known that ADHD and SAD make the other more severe, there are theories about why. Dr. Thomas Brown explains that people with ADHD may be afraid of “chronic problems with self-management” or that their impulsive behavior will be harshly judged. Brown asserts that emotional regulation and difficulty with directing focus are two of the main executive function deficits that people with ADHD have. This causes someone with ADHD and SAD to struggle to both “divert their attention away from those specific worries and to remind themselves of other reasonable explanations for others’ behavior or attitudes toward them.” Another study theorizes that anxiety and executive function could worsen each other (van Ameringen et al. 2011). Difficulty with shifting focus and impairment in working memory can cause someone to fixate on evidence to support their fears and disregard any information of a disprove that. Interestingly, it has been noted that the inattentive type of ADHD tends to struggle more with social anxiety. Koyuncu and others (2019) found that the “ADHD-I group had higher scores of social anxiety and avoidance and was associated with an earlier onset of SAD than the ADHD-C group.” This suggests that the inattentive type of ADHD could have a unique relationship with social anxiety. This may be due to ADHD-I symptoms being internalized, causing them to ruminate and worsen their anxiety. However, there is not unchallenged support that ADHD causes SAD to develop. 

There exists a contradictory theory that proposes that ADHD may be a protection against social anxiety. Considering the 2019 study by Koyuncu and others, perhaps the symptomatology of hyperactive or combined type ADHD could cause social anxiety to be less likely. A 2012 study titled “Screening for ADHD in Adult Social Phobia Sample” by Mörtberg and others separates social phobia and social anxiety. Social phobia is defined by a fixation on “behaving in a socially acceptable fashion,” including manners and appearance. They tend to have better social functioning, including “significantly higher education” and marriage. Essentially, the researchers are suggesting that different mechanisms cause social anxiety versus phobia. They hypothesize several reasons, including, “people with ADHD are usually extroverts,” “impulsivity [can] protect a person from shyness,” and social phobia being correlated with organization and good executive function. Now these researchers define social phobia as independent of social anxiety; however, it is interesting to note that tendencies that exist in people with social phobia contradict many of the behaviors associated with and caused by ADHD. While this study has a contradictory narrative, there is a notable level of comorbidity between SAD and ADHD regardless of the type.

Despite the difficulty of managing this comorbidity, there are many ways it can be treated. However, treatment for ADHD or SAD may look different because of the presentation of both conditions. Under the care of Dr. Brown, Eric and Matt were able to address their social anxiety, along with ADHD and related struggles. For Eric’s social anxiety, treatment was therapy to allow him to address and challenge his fears. More specifically, Dr. Brown “help[ed him] recall other information, less self-focused,” that dispelled his anxious thoughts about a situation. For example, Eric might begin to believe that a girl he was interested in did not like him because she had not responded to his text. Dr. Brown would remind Eric that she may be busy or not on her phone because people with ADHD and social anxiety fixate on evidence that confirms their fears of rejection. By doing this, Dr. Brown bridges the gaps in Eric's executive dysfunction  by externalizing the thought process that Eric would have  come to by himself if he did not have ADHD and SAD. For Matt, treatment included talk therapy, an antidepressant along with ADHD medication, and intentionally facing situations that intimidated him (talking to a girl he had a crush on, applying for a job in person, etc.). One study recommends managing a patient’s ADHD symptoms before SAD (van Ameringen et al. 2011). They also cite other studies to assert that CBT and medication are the most effective treatment options. The medications, both stimulant and non-stimulant, that are used to treat ADHD often have anxiety as a side effect. Methylphenidate, a stimulant medication, has been shown to decrease anxiety in both children and adults with ADHD (D’Agati et al., 2019). Treatment for ADHD could cause one to be less likely to make a mistake that would cause them social anxiety or counteract the executive dysfunction that  exacerbate social anxiety (like inability to direct focus). There is always the option to use two or more medications to manage both conditions, like an antidepressant with a stimulant as Matt did. 

In conclusion, the combination of ADHD and SAD is a comorbidity that is both understudied and challenging to manage. Eric and Matt were examples of two people who had this comorbidity and received successful treatment. While there are opposing theories on the relationship between ADHD and SAD, they open questions about the type of ADHD influencing whether or not an individual develops social anxiety. Ultimately, it is treatable, especially when treatment is altered to manage both. Hopefully, there will be a rise in awareness as there was with adult ADHD. This may lead to more funding for research and more informed treatment options. 

References

Brown, T. E. (2014). Smart but stuck : emotions in teens and adults with ADHD (1st ed.).

D’Agati, E., Curatolo, P., & Mazzone, L. (2019). Comorbidity between ADHD and anxiety 

disorders across the lifespan. International Journal of Psychiatry in Clinical Practice, 23(4), 238–244. https://doi.org/10.1080/13651501.2019.1628277

Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed., American Psychiatric 

Association, 2013.

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. https://doi.org/10.1177/1087054715617533

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. https://doi.org/10.1177/1087054714533193

Mörtberg, E., Tilfors, K., & Bejerot, S. (2012). Screening for ADHD in an Adult Social Phobia 

Sample. Journal of Attention Disorders, 16(8), 645–649. https://doi.org/10.1177/1087054711423623

Ohnishi, T., Kobayashi, H., Yajima, T., Koyama, T., & Noguchi, K. (2019). Psychiatric 

Comorbidities in Adult Attention-deficit/Hyperactivity Disorder: Prevalence and Patterns in the Routine Clinical Setting. Innovations in Clinical Neuroscience, 16(9–10), 11–16.

Van Ameringen, M., Mancini, C., Simpson, W., & Patterson, B. (2011). Adult Attention Deficit 

Hyperactivity Disorder in an Anxiety Disorders Population. CNS Neuroscience & Therapeutics, 17(4), 221–226. https://doi.org/10.1111/j.1755-5949.2010.00148