Anxiety on the Surface. ADHD beneath.

Anxiety is a form of psychic pain. Worse, its presence is often looked down upon as a moral failing, a lack of faith and perspective, while its absence is considered a mark of life well-lived.

“Be not anxious for the morrow,” —Jesus.

“Our anxiety does not come from thinking about the future, but from wanting to control it.” —Kahlil Gibran

Anxiety can obscure underlying ADHD. It is very common in my practice to meet adults whose anxiety was diagnosed years ago, often within weeks or months of its appearance, but whose ADHD has been missed for their entire lives. Almost 40% of the people sent to a specialty anxiety clinic also had ADHD when their cases were carefully reviewed. Up to 60% of those with ADHD also have anxiety. The two seem to foster each other.

It’s widely assumed that those of us with ADHD bring anxiety onto ourselves from procrastination’s logjams and the clutter that surrounds us. There is some truth to that, but not enough to explain such numbers.

I think it’s more likely that people with ADHD cultivate anxiety to serve as motivational energy. What is procrastination, but the decision to schedule a task at the precise, final moment that fear of failure makes it engaging? Anxiety and desperation not to fail may be the only useful way for someone with ADHD to get things done.

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From ABC News ‘12 Signs You May Have Anxiety‘

Melissa is a busy mother of four children who has plenty of reason to be anxious if you are feeling dismissive and judgmental. Her kids are 4, 6, 8 and 9. They are rambunctious, energetic and loud. Their backyard is a magnet for their neighborhood friends, and neighborhood moms take some advantage of that. Melissa’s husband, Bill, travels several days each week, so homework and bedtime routine is often hers alone. The kitchen and family room clutter depress her, and an hour of cleaning hardly makes a dent. She is dead-tired when she collapses into bed each night.

If anyone deserves to sleep, it is Melissa, but no sleep comes. Her mind whirls. Is there bread for school lunches? Did I tell Jordan’s teacher that he has a doctor’s appointment? Was that Bill who called when I was too busy to check? Is he still up? Will he be angry that I didn’t call back? Why was Evelyn yelling at her playmates? Should I have intervened? She hasn’t been invited anywhere in a while; why can’t she keep friends? Should I find a therapist? Talk to her teacher?

Melissa’s heart pounds and her throat burns. She gets up to drink an unmeasured slug of antacid straight from the bottle. She checks the bread supply—almost gone. The kids can have school pizza. They won’t mind, but she had much higher aspirations for the nutrition she would provide them when they were conceived. Will’s math worksheet is on the floor. She puts it on the kitchen table. He didn’t finish it.

Explaining her insomnia to the nurse practitioner, she bursts into tears. No, she’s not depressed, just never far from panic. She is given an anti-depressant (“It’s for anxiety, too”) and referred to a therapist. The appointment is over before she can protest that she doesn’t have time to lavish on herself.

The therapist tells her to take more walks, try yoga, lean on Bill sometimes. With less anxiety, she should have more energy for her family.

The anti-depressant helps—less panic, better sleep, fewer antacids. Her heart doesn’t race when she forgets the appointment with Evelyn’s school counselor. She takes a prescribed walk and loves escaping the mess at home, so she takes a few more. One walk stretches so long she forgets to pick up the kids at the bus stop.

The therapist encourages her to write down her priorities, forgive herself, lower her expectations. It sounds wonderful. And impossible. She asks if things are getting better—less chaos, less frustration with the kids, better time with Bill?

“This medicine relaxes me, but now I’m useless,” blurts Melissa. It is meant to be a joke, except that it’s true. “I feel better, but I’m not getting anything done. Jordan’s inhaler is empty and it never crossed my mind until this second.”

Melissa is overwhelmed again, not by anxiety, but guilt. She still hasn’t talked to anyone about Evelyn, the house is still a mess and Will is now failing math. Without anxiety, she’s a worse wife and mother than with it.

She stops her medication, because she loves her family and accepts the psychic pain of anxiety as the cost of caring for them. Anxiety is not an unbidden, invader in Melissa’s life, but the only energy she can muster to fuel the endless repetition of raising a family.

It will be two more years until Evelyn’s teacher recommends ADHD testing. Melissa will see Evelyn’s inattention and forgetfulness and remember it in herself at that age. Evelyn’s doctor will urge her to undergo diagnosis, too. “Girls with ADD need attentive moms,” he will say. ADHD medication and therapy will bring mental clarity, and daily tasks won’t overwhelm her. The anxiety will fade away, unneeded.

Until then, Melissa needs the anxiety to keep her going.

She meets her friend for coffee and orders chai so she won’t feel more jangled. The friend has been meditating and wants Melissa to try. And there’s a new yoga studio. And she discovered aromatherapy which is also life-changing.

Melissa pulls an envelope out of her purse to jot some notes and pretend for a second that she could do so much for herself. The envelope is a cable bill she meant to pay last week. She forgot it was in there, It’s overdue, and her heart races. She writes ‘meditation’ at the top, then ‘PAY COMCAST’, then ‘INHALER!!!’, then ‘start laundry’. Her mind has left the coffee shop and she can’t sit there one more second.  “Gotta go,” she interrupts. “Let’s do this again,” she lies and rushes out.

For Melissa, anxiety is a solution more than a problem. Fear of failure is the energy behind every task. She never feels accomplishment—only relief at the disasters averted.

Sometimes, anxiety is ADHD, love and the desperation not to fail.

About Oren Mason MD

Physician specializing in diagnosis and management of attention deficit disorders and related conditions.

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