Attention Deficit Hyperactivity Disorder (ADHD) and Social Anxiety Disorder (SAD) are two distinct conditions that often co-occur, with studies showing that around 30– 70% of individuals with ADHD also have SAD.
This high comorbidity rate highlights the importance of understanding both disorders and their interplay.
ADHD is a neurodevelopmental disorder characterized by persistent difficulties with attention, hyperactivity, and impulsivity, while SAD is an anxiety disorder marked by intense fear and discomfort in social situations, often accompanied by excessive worry about being judged or scrutinized by others.
While these disorders are different, they can share some overlapping symptoms and challenges, particularly in social settings.
The presence of both conditions can exacerbate difficulties in daily functioning and quality of life.
This article explores the relationship between ADHD and SAD, their similarities and differences, and approaches to managing both conditions effectively.
Understanding the nuances of how ADHD and SAD interact is crucial for proper diagnosis and treatment, as symptoms of one disorder can sometimes mask or complicate the presentation of the other.
By examining these conditions together, we can gain valuable insights into their combined impact and develop more effective strategies for support and intervention.
ADHD and SAD similarities
Although ADHD and SAD are two distinct disorders, there are many ways in which their signs can overlap:
- Difficulty with social interactions: Both can make social situations challenging, albeit for different reasons. People with social anxiety may avoid interactions due to fear, while those with ADHD might struggle with social cues and impulse control.
- Avoidance behaviors: Individuals with social anxiety often avoid social situations, while those with ADHD may avoid tasks requiring sustained attention or complex social interactions.
- Trouble maintaining focus in social settings: Social anxiety can cause excessive self-focus, making it hard to concentrate on conversations. ADHD can lead to distractibility and difficulty following social exchanges.
- Overthinking: People with social anxiety tend to overthink social situations, while those with ADHD may hyperfocus on certain thoughts or ideas, sometimes leading to excessive worry.
- Low self-esteem: Both conditions can contribute to feelings of inadequacy and low self-worth, often due to perceived failures or difficulties in social or academic/professional settings.
- Impulsivity: While more commonly associated with ADHD, impulsivity can also manifest in social anxiety as sudden urges to escape uncomfortable social situations.
- Executive function challenges: Both disorders can affect executive functions, including organization, time management, and decision-making skills.
Coexisting ADHD and SAD
Someone with both ADHD and social anxiety disorder may experience conflicting impulses and struggles.
Their ADHD might drive them to seek stimulation and social interaction, while social anxiety simultaneously makes them fear judgment and scrutiny.
In social situations, they may fidget or talk excessively due to ADHD, then become hyper-aware and self-conscious about these behaviors.
They might struggle to focus during conversations, miss social cues, and feel anxious about their performance.
Impulsivity from ADHD could lead to blurting out comments, followed by intense worry about how others perceive them.
Planning social events may be challenging – forgetting details due to ADHD, then obsessing over potential social mishaps.
At work or school, they might procrastinate on group projects, feeling overwhelmed by both the task organization and required social interactions.
This combination can lead to isolation, as the person yearns for connection but finds social situations exhausting and stressful.
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 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 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.
How can ADHD and SAD be treated together?
Treatment for co-occurring ADHD and SAD typically involves a combination of medication and psychotherapy, tailored to address symptoms of both conditions.
Medications:
- Stimulants (e.g., Ritalin) can help manage ADHD symptoms and sometimes alleviate anxiety.
- Non-stimulants, particularly SNRIs like Strattera, may target both ADHD and anxiety symptoms.
Psychotherapy:
- Cognitive Behavioral Therapy (CBT) addresses negative thought patterns and behaviors associated with both disorders.
- Exposure therapy, a CBT technique, helps reduce fear in social situations for SAD.
- Social skills training improves communication and assertiveness, beneficial for both conditions.
- Mindfulness-based therapies enhance awareness, attention regulation, and stress reduction.
A therapist can tailor treatment by:
- Addressing ADHD-related social difficulties that may exacerbate SAD.
- Teaching coping strategies for managing both inattention and social anxiety.
- Gradually exposing clients to social situations while providing ADHD-specific support.
- Combining anxiety management techniques with ADHD-focused organizational skills training.
The treatment approach should be personalized, considering the severity and impact of each condition on the individual’s life.
Managing ADHD and SAD
Below are some tips for helping someone manage both ADHD and SAD together:
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 strategically
While socializing is important, it can be overwhelming when you have both ADHD and social anxiety. Start with small, manageable social interactions:
- Begin with low-pressure situations, like texting or online chats with trusted friends.
- Gradually progress to short, structured in-person meetings (e.g., grabbing a coffee for 30 minutes).
- Use your ADHD strengths: If you tend to hyperfocus on interests, join groups or clubs related to your hobbies.
- Prepare conversation topics in advance to ease anxiety and help maintain focus.
- Set a time limit for social events to prevent overstimulation and anxiety build-up.
- Have an exit strategy ready, but challenge yourself to stay a little longer each time.
- After socializing, allow yourself decompression time to process and recharge.
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 an ADHD-friendly, anxiety-reducing schedule
Balancing ADHD’s need for structure with social anxiety’s need for predictability:
- Use a digital planner or app with reminders to help manage ADHD forgetfulness and reduce anxiety about missed commitments.
- Break your day into smaller time blocks (e.g., 30 minutes) to accommodate ADHD’s shorter attention span.
- Include “buffer time” between tasks for transitions and unexpected ADHD distractions.
- Schedule “worry time” – a specific period to address anxious thoughts, helping to contain anxiety throughout the day.
- Plan for regular, short breaks to prevent ADHD burnout and manage anxiety levels.
- Include self-care activities in your schedule, such as exercise or relaxation techniques.
- For social events, add preparation time beforehand (to reduce anxiety) and decompression time afterward (to process and relax).
- Use color-coding or symbols to categorize tasks, making the schedule more ADHD-friendly and less overwhelming.
- Review and adjust your schedule regularly, being flexible to accommodate both ADHD impulsivity and anxiety-related needs.
FAQs
Why do ADHD and SAD occur together?
ADHD and SAD often co-occur, though the exact reasons are unclear. ADHD symptoms like impulsivity and inattention can lead to social difficulties, potentially triggering SAD.
People with ADHD may face increased risks of bullying or social rejection, prompting withdrawal from social situations and potentially developing SAD.
Research suggests that those with both ADHD and SAD report higher rates of emotionally traumatic experiences compared to those with SAD alone, indicating that trauma may contribute to the co-occurrence of these conditions.
The social challenges and performance anxiety associated with ADHD can also lead to low self-esteem and anxiety, potentially exacerbating or triggering SAD symptoms.
Can ADHD cause SAD?
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.
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.
Koyuncu, A., Çelebi, F., Ertekin, E., Kök, B. E., & Tükel, R. (2016). Attention deficit and hyperactivity in social anxiety disorder: relationship with trauma history and impulsivity. ADHD Attention Deficit and Hyperactivity Disorders, 8, 95-100. https://doi.org/10.1007/s12402-016-0189-2
Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in context, 8.
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/
