09 July 2023

6 Promising Signs Your Body is Releasing Trauma

Category: Trauma

signs your body is releasing trauma, PTSD dissociation, attunement, neuroception, trauma is stored in the body, complex trauma, complex relational trauma

Trauma, whether single-episode or complex relational trauma, lives in the body. Trauma-informed psychologists understand that in order to fully process and work through responses to trauma, therapy must address the somatic experience of the trauma. When this happens consistently, you will begin to see signs your body is releasing trauma.

In this blog article, we address how neuroception is influenced through the attachment process of attunement; how complex trauma becomes stored in the body, and expressed with flooding and dissociation in response to PTSD triggers; and how to recognize what trauma being released from the body feels like.

As a quick summary, here are the signs your body is releasing trauma:

Gut muscles relax and unclench
Breathing patterns change
Shoulder, neck, jaw, and head muscles can be engaged & upright, yet comfortably relaxed
Heartbeat slows, blood pressure decreases, and heart-rate variability increases
Hands and feet are more frequently warmer
Body experiencing is more present and at ease

Attunement and Neuroception

In healthy parent-child attachment, there is a natural cycle of attunement, misattunement & dysregulation, and repair. Attunement involves warm, soothing vocal tone of parents (e.g. cooing) and calm, engaged non-verbals that let the baby feel seen and safe (eye contact, physical touch). This connection soothes the baby’s immature nervous system.

However, it is natural that this attunement cannot last indefinitely. There are constant interruptions of attunement, whether through normal day-to-day distractions or disruptions, or through the baby’s own imature nervous system.

When this happens, babies will cry, since they can’t verbally communicate their needs. In response, parents will try through trial-and-error to figure out the ‘just right’ intervention to repair the baby’s distress.

According to Schore (2003), when this cycle of attunement through repair happens consistently enough, this early development environment helps shape the final wiring of the baby’s brain circuitry. This sensitive period of attachment is generally understood to occur in the first two years of the infant’s life. How this wiring develops will influence future emotional and social development and coping capacities of the person.

Stephen Porges (2011) calls this neurological perception of the surrounding environment neuroception. Neuroception influences our balance of seeking safety versus interpersonal engagement. Healthy attachment experiences allow for a neuroception that is more wired for engagement. In this respect, it become a reinforcing pattern, because greater amounts of positive social engagement lead to greater well-being.

How to Recognize Complex Relational Trauma

Trauma can occur in a single episode or repeated episodes over time. A single major traumatic episode is often referred to as ‘Big T’ trauma, whereas repeated ‘smaller’ traumas in a relationship are often referred to as ‘Little T’ traumas.

Complex trauma occurs when there are a series of repetitive, and sometimes escalating, traumatic events. These often occur a prolonged period of time, and usually in a specific context, such as in an attachment relationship (Courtois & Ford, 2013). In these instances, the traumatic experiences are referred to as complex relational trauma.

Complex relational trauma has many ‘Little T’ traumas with some ‘Big T’ trauma potentially occurring as well. While there is some subjectivity to differentiating between what is ‘Little T’ and ‘Big T’ in complex relational trauma, a good rubric is that the repeated gaslighting and emotional abuse that occurs in the traumatic attachment is ‘Little T’, whereas ‘Big T’ might refer to physical and sexual abuse, or severe neglect.

What is important to understand is that much of the damage in complex relational trauma comes from the accumulated effect of the repeated ‘Little T’ traumas. This is particularly the case when children are involved who don’t have a frame of reference or stable identity to be able to fully understand what is happening and why it is wrong.

There is variety to the type of ‘Big T’ traumas – from human trauma such as abuse, neglect or being victimized by war to natural disasters such as earthquakes. The impact of pervasive developmental abuse or neglect involves significant psychological harm to a survivor’s sense of personhood and the associated psychological functions that come with it (Courtois & Ford, 2013; Herman, 1992).

Signs You Are Traumatized

Now let’s turn to reviewing trauma presentation, including how to recognize the signs you are traumatized.

According to Courtois & Ford (2013), there are three central ‘features’ of complex relational trauma. They are (1) emotional and/or somatic dysregulation (2) dissociation and (3) compromised (e.g. damaged, dysfunctional, or problematic) interpersonal relationships.

Somatic dysregulation is the main focus of this blog post, specifically the somatic healing process from trauma and the signs your body is releasing trauma. Dissociation also can play an important role in the ‘problem’ and ‘solution’, so we cover this area as well in this article.

Trauma is Stored in the Body

Somatic dysregulation means that the trauma is stored in the body. You might imagine it as lying dormant or out of your awareness in everyday living. As part of this dysregulation, emotional or somatic responses to PTSD triggers (e.g. cues reminiscent in some way of the traumatic experience(s) tend to manifest in an ‘all-or-nothing’ manner.

Fisher (2022) states that the most important thing to remember is that when there is early attachment trauma, the trauma is remembered somatically. That means that the trauma lives or is stored in the body. This storing happens on a subconscious and autonomic level and may be experienced separately from conscious recall of the actual traumatic events that happened.

This bodily storing or remembering of trauma happens through visceral responses, autonomic and muscle memory and habits. This remembering has a good intention – we are trying to avoid what feels bad and move towards what feels safe.

The problem is that when we feel these somatic symptoms of the trauma, we may not realize we are remembering something from the past. Instead, it feels like something that must be happening right now. Essentially, we confuse the past for the present.

The opposite of somatic flooding is freezing, e.g. ‘shut-down’ mode. While expressed differently, freezing is still an expression of somatic dysregulation and trauma being stored in the body, and it is equally debilitating. In a freeze response, the person is immobilized and cannot martial appropriate internal resources to resume normal functioning.

Here it might feel like you are frozen or immobilized. It might feel like you can’t move. You might also feel numb or dissociated. This kind of response could follow the flooding, almost as a response to being flooded. On the other hand, it could also be the initial response, depending on how a person experienced the trauma and the trigger.

Overall, this kind of traumatic dysregulation means you don’t have the same internal resources to socialize or interpersonally related with others, as compared to someone who hasn’t experienced trauma. Porges (2011) explains that a traumatized person’s neuroception, or neurological perception of safety, is different than others. Stated plainly, you just don’t feel safe as easily.

There are still moments, however, where you may feel safe enough to engage with others. These limited moments for healthy engagement are referred to as a ‘window of tolerance’ (Fisher & Ogden, 2009). While traumatized individuals have smaller windows of tolerance, therapy can help to expand it.

Example: PTSD Triggers & Where Trauma is Stored in the Body

Here is an example of how trauma gets stored in the body and re-activated in the present when there are PTSD triggers. Suppose as a child your parent could become unglued seemingly at the drop of a hat (maybe they were a trauma victim, and/or had a substance addiction or significant mood disorder). When they would get upset, they would start yelling at the top of their lungs.

The experience of this would be terrifying, because you could hear the loudness of their voice and see their face getting flushed and veins in their neck bulging. Perhaps this signaled the possibility of other abusive behavior, but it also may have been significant in and of itself.

When this would occur, you would experience stomach clenching, a racing heart, and your muscles tensing. You might even feel like you were hyperventilating because you were so scared. You would instantly be in ‘fight or flight’ mode because it felt like your survival was at stake.

Now as an adult, you could be completely relaxed one moment and then be surprised to hear someone yelling. The moment you heard the yelling, e.g. PTSD trigger from your complex relational trauma, your body would immediately activate this somatic bracing. All the symptoms of living through that trauma would come back, and it would feel like your life is at stake.

In an instance like this, when the emotional and/or somatic response is physiologically over-reactive, the survivor will feel physiologically flooded and have difficulty functioning.

PTSD Dissociation

The second feature of complex relational trauma is dissociation, or a disruption to the experience of self-integrity. Potential expressions of PTSD dissociation could include experiences of loss of time, loss of consciousness, and loss of one’s sense of self.

Loss of time involves losing tracking of the passage of time while in a dissociative state. Loss of consciousness means not having conscious awareness of what you were doing during a dissociative state. Loss of one’s sense of self means ‘not feeling like myself.’

People with symptoms of dissociation often feel ‘out of it’, detached, and disconnected from how they normally feel and identify. The level of dissociation can vary significantly in complex relational trauma, ranging from dissociative amnesia to Dissociative Identity Disorder (DID).

Regardless of ‘how much’ dissociation you have or how it is subjectively expressed, there are certain general characteristics. As Van der Hart and colleagues (2006) describe in their structural theory of dissociation, any kind of dissociation involves a segregation and compartmentalization of personal experience across aspects of personality and functioning.

Van der Hart and colleagues call this traumatic or PTSD dissociation a separation between the ‘apparently normal part of the personality’ (ANP) and the ’emotional part of the personality’ (EP).

The ANP is associated with the left brain part of the self that goes about normal life in a more conscious goal-directed manner. The EP is connected to the right brain part of the self that stores the traumatic memories in the body and anticipates survival responses needed for ongoing survival.

Expressions of traumatic experience can become separated from other aspects of personality and daily functioning. As a result, PTSD triggers can often result in a profound disruption and shift to the survivor’s quality of self-integrity and self-experience.

What does dissociation have to do with signs trauma is being released from the body? People who experience significant dissociation are often highly disconnected from the stored trauma in their body. When PTSD triggers occur, they are often inundated and overwhelmed by the intensity of the somatic experiencing of the trauma.

In order to begin to heal, they need strategies to become more aware of and manage their dissociation, and to therapeutically heal the trauma stored in their bodies.

Signs Your Body is Releasing Trauma

Before we go through the signs your body is releasing trauma, it is important to understand that it is unlikely to occur without additional intervention. Trauma therapy and body-based approaches such as yoga help re-wire the mind and prepare the body to release the trauma that has been encoded and stored somatically over time.

This diagram we’ve created above illustrates the progression from trauma stored to trauma released. We’ll review each of these signs that your body is releasing trauma.

1. Gut muscles relax and unclench

When trauma-based anxiety is expressed through the gut, a common experience is stomach clenching and tight abdominal muscles. Being in a ‘fight or flight’ mode from trauma can show through symptoms of stomach pain and nausea, as well as intestinal cramping and diarrhea.

When a person has worked through trauma, one sign that trauma has been released is a diminishing of GI symptoms. These symptoms begin to decrease in frequency and intensity. Because a person feels safer and more at ease, the muscles in the gut (digestive system) are more relaxed. There is a calm, looseness to the abdominal muscles during breathing. The anxious clenching is gone.

2. Breathing patterns change

One notable sign your body is releasing trauma is a shift in breathing patterns. During trauma activation – in response to a posttraumatic cue or PTSD trigger – people typically respond in one or two ways.

Many people, especially when stressed or flooded, people will breathe rapidly and shallowly with quick breaths (e.g. hyperventilating). In this type of breathing pattern, the chest muscles are doing most of the work.

For others, a characteristic response is holding the breath, sometimes to the point of feeling like they are going to faint. This breath holding mirrors a ‘freeze’ response for trauma. Here the person startles and holds their breath, trying to figure out how to respond.

When trauma is released from the body, the breathing pattern shifts considerably. I want to point out a few important things here.

First, one reason the breathing pattern has changed is because the person has worked, or is well into the process of working, through their trauma(s) in therapy. If you feel less afraid, you are likely to breathe differently.

Second, many trauma-focused therapies feature somatic techniques and strategies. Identifying trauma-based somatic responses and teaching strategies to change them is an active part of many trauma-focused approaches. Breath work is a core component of many therapeutic approaches, as well as other related areas, such as yoga.

Healthy breathing involves more use of the diaphragm muscles (‘diaphragmatic breathing’). When it comes to breathing, one sign that trauma is being released from the body is that the breath more frequently tends to be fuller and slower. There are much fewer episodes of hyperventilation and/or breath holding.

To help clients develop healthy breathing, trauma-focused therapists focus on exhalation. A first step is becoming mindful of the exhalation and the important role it plays in activating the parasympathetic nervous system and getting out of ‘fight or flight’ mode.

There are different methods for doing this. To improve body awareness, a good starting place could be to lie down with a hand on your belly, and simply notice what the hand does as you breathe in and out. This begins to teach breath awareness by demonstrating how the hand moves with diaphragmatic breathing. Once someone understands this breath motion, it is easier to teach sitting or standing up.

A complementary approach involves the 4-6 (inhalation/exhalation) rule for every 10 seconds. Six seconds breathing out in a 10 second cycle primes the body for relaxation.

Some therapists teach a 4-8 variation (over 12 seconds), with 8 seconds for exhalation. This is a more pronounced way of emphasizing exhalation. Although this is not something that should be practiced for long periods of time, but can be helpful at changing problematic breath cycles.

As a side note, although there are some who teach a 4-7-8 rule, with 7 seconds of breath holding prior to the exhalation, I do not recommend this. The logic here is that the breath hold primes the person for the exhalation. This can be true. It is also true that holding one’s breath for short periods of time is not harmful.

However, because breath holding can be part of a freeze trauma response, I don’t recommend it here. There is nothing to be gained because the main emphasis is the exhalation. For this reason, I suggest a 4-8 practice.

As you can see, increasing diaphragmatic involvement in exhalation is an important part of healthy breathing. My colleague and renowned trauma expert Maggie Phillips (who sadly passed away a year ago) liked demonstrating deep sighs as a way of teaching exhalation. Watching her teaching a room of therapists how to sigh deeply still brings a smile to my face.

3. Shoulders, neck, jaw, and head muscles engage more naturally and openly

Tense muscle chains from the shoulders can be a somatic hallmark of anxiety. These muscles are often tensed or clenched as part of a physical bracing or hypervigilance against potential threats.

As we discussed earlier, trauma is remembered somatically. The tensing and bracing that occurs in these muscle groups is part of the subconscious, somatic expression of past trauma responses. This can be part of the day-to-day experiencing, or it can be a rapid response to PTSD triggers of past trauma.

How do these muscles appear in this tensed state? The head, neck, and shoulders can appear hunched forward or curved. Similarly, the spine can appear collapsed. Additionally, the jaw is often clenched. As a result, somatic symptoms such as headaches and bruxism (teeth grinding) are often present.

Amongst the signs your body is releasing trauma include a more relaxed and naturally engaged presentation of these muscle groups. What does this look like?When trauma has been released from the body, the jaw muscles are more loose, the lips and facial muscles are relaxed and smooth. Another sign is comfortable shoulders and upright spine, neck and head muscles.

To help teach clients this healthier somatic experience, Fisher (2022) asks clients whether they would be willing to lengthen their spine from the lower back up. One helpful visual for this is to imagine a string gently tugging on your head, pulling up the spinal column. An engaged core also helps with this upright stance. When I use hypnosis with clients who have bruxism, I will often give a suggestion of imagining a pillow of air in between the upper and lower teeth.

4. Heartbeat slows, blood pressure decreases, and heart-rate variability increases

When trauma is stored in the body, there can be several heart-related effects. Amongst these possibilities include hypertension and higher blood pressure; increased heart rate (e.g. racing heart) in response to trauma-related stress; and decreased heart-rate variability.

Although high blood pressure can be genetically inherited, living in a chronic state of fear from trauma can increase the probability of chronic hypertension and high blood pressure.

In the presence of PTSD triggers, trauma survivors are more likely to have a racing heartbeat. Heart-rate variability (HRV) describes the degree of variability in time between heart beats.

Generally, when there is a faster heartbeat, there is a lower HRV; and vice versa. Lower HRV scores are associated with more chronic stress and sympathetic activation of the autonomic nervous system (ANS).

In contrast, when trauma is released from the body, acute and chronic heart issues improve. There are less occurrences of racing heartbeat and acute stress. HRV increases and blood pressure issues can improve (decrease in BP).

5. Hands and feet get warmer

In general, when people experience stress, such as in a ‘fight or flight’ episode of posttraumatic stress, blood flow is redirected to internal organs. This sympathetic response of the autonomic nervous system (ANS) has evolutionary functions in that it allows us to be marshal all necessary resources to respond to the threat. Perhaps unsurprisingly then, in such a state, the hands and feet are conversely experienced as cold and clammy.

Part of somatic-focused therapy is training clients to use their imagination to elicit a parasympathetic response. In her book ‘The Affect Regulation Toolbox’ my colleague Carolyn Daitch (2007) utilizes the principles of an autogenic training approach in developing clinical hypnosis suggestions for over-reactive patients. Daitch explains that anxiety and trauma patients need quick strategies that can reset their bodies and turn around these episodes.

As part of this autogenic hypnosis method, varied and layered hypnotic suggestions are given to imagine the hands and feet warming. Incredibly, as clients are able to quickly learn and elicit this technique, they can make their hands and feet warm through the power of their own imagination.

This physiological process prompts the body to redirect blood flow and move from a sympathetic to parasympathetic response. As these bodily extremities began to warm and relax, heart rate slows down and a person moves out into a more relaxed state.

When clients learn techniques such as this in therapy, they become more adept at creating these states more frequently. This means that hands and feet are more commonly warm, relaxed and dry. This increasingly consistent physiological experience is one sign that the body is releasing trauma.

6. Body experiencing is more present and at ease

We’ve spent a considerable amount of time focusing on specific parts of the body, and what to look for as trauma shifts from being stored & expressed to being released from the body. We’ve also described many different examples of how the body expresses trauma during ‘fight or flight’ responses where a person experiences emotional and somatic flooding.

Although we covered dissociation earlier in this article, we didn’t talk about what it feels like (or, more accurately, doesn’t feel like). Many people who have experienced trauma, particularly complex relational trauma, are often highly out of touch with their bodies. This is like having an out of body experience, or being cut off or disconnected from your body. Some people describe this as often feeling numb.

What is really disorienting is that there can be rapid shifts in response to PTSD triggers – before and after dissociation. You can go from feeling numb to feeling flooded, back to feeling numb. As a therapist, I would argue that these big shifts are just as stressful as the individual states themselves.

Although we provide some examples in this article, it is difficult to get into the rich and complex process of trauma-focused and somatic therapies. But one way of describing it is like renewing and deepening your relationship with yourself, and with your body. Being connected with your body means mindfully feeling it – but in a way that is bearable.

One sign your body is releasing trauma is that there is a greater ease of being. You are more aware of sensations, what brings them on, the subtleties of what they feel like, and how they emerge and pass. People who are more somatically connected also are more comfortable moving between ‘parts’ and ‘whole.’ It feels easier to just ‘be’.

Before concluding this article, I’d like to note that trauma recovery (and posttraumatic growth) is not a linear process. There are positive milestones and setbacks. The hope is that for every one step back, we take two steps forward. Trauma recovery is about renewing your relationship with yourself, with presence and compassion. This happens in the mind, spirit and – as reviewed in this article – the body.

Sources:

Courtois, C.A. & Ford, J.D. (2013). Treatment of Complex Trauma: A Sequenced, Relationship- Based Approach. NY: The Guilford Press.

Daitch, C. (2007). Affect regulation toolbox: Practical and effective hypnotic interventions for the over-reactive patient. New York: Norton.

Fisher, J. (2022). Healing the fragmented selves of trauma survivors: Integrating somatic and ego state techniques. Presentation given to the Minnesota Society of Clinical Hypnosis.

Herman,.J. L. (1992). Trauma and Recovery. New York: Basic Books.

Ogden, P. & Fisher J. (2015) Sensorimotor Psychotherapy: Interventions for trauma and attachment. New York: Norton.

Porges, S. (2011). The Polyvagal Theory. New York: Norton.

van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. W W Norton & Co.

Published by:

Eric
Spiegel Ph.D.

Meet Eric

Eric- Spiegel - Attune Philadelphia Therapy Group

30 May 2023

ADHD vs Anxiety in Adults: How to Tell the Difference

“Do I have anxiety or ADHD?” ADHD and anxiety can be surprisingly hard to differentiate. As a psychologist, I have often treated adults with previous diagnoses of anxiety disorders where it turns out that undiagnosed ADHD has played a central role in that anxiety. In this article, we will discuss how to tell the difference between ADHD vs anxiety in adults.

Although there has been an uptick in diagnosis rates as more is known about Adult ADHD, the rates are still fairly low in the overall population, ranging from 2-7%. One study by Kessler and colleagues (2006) estimated a 4.4% prevalence rate.

In contrast, anxiety disorders are much more prevalent in the overall population. The National Institute of Mental Health (NIMH) estimates that 31% of adults will be diagnosed with an anxiety disorder at some point in their lives..

Also pertinent is the discrepancy in comorbidity rates. Approximately 50% of adults diagnosed with ADHD also have anxiety disorders. On the other hand, while there is limited data and variance in samples, estimates are between 10 and 27% of people with anxiety disorders also have ADHD.

What do these statistics mean? They tell us:

It is more common to have anxiety vs ADHD.
It is more common for people diagnosed with ADHD to have an anxiety disorder than the other way around.

Many people experience symptoms of anxiety in their lives that would qualify for one of the anxiety disorders. We review this generally in the section on anxiety disorders that follows. On the other hand, ADHD is understand to be related to structural differences in the brain. This type of neurodiversity is less common in the population.

Additionally, if you already have Adult ADHD, you are much more likely to have an anxiety disorder than someone with an adult with an anxiety disorder is to have ADHD. This is due to certain features of ADHD that make it more likely to be anxious.

Let’s first discuss the basics of anxiety disorders and then ADHD. In explaining the features of each, we’ll help you be able to tell the difference between ADHD vs anxiety. We’ll help you understand how ADHD can be misdiagnosed as anxiety. As part of this discussion, we’ll explain why people can often have ADHD and anxiety, not one or the other.

We’ll then examine ADHD and anxiety in women, particularly by reviewing how ADHD can present differently in women. We’ll consider how gender stereotypes lead to underdiagnosis of ADHD in women, and overdiagnosis of anxiety in women. As a spotlight of this discussion, we’ll differentiate between GAD vs ADHD in women.

Finally, we’ll move from diagnosis to treatment, and cover how to treat ADHD and anxiety in adults. In doing so, we’ll cover treatments for ADHD and anxiety, as well as ones that work better for one or the other.

Anxiety Disorders: What You Need to Know

Although there are many distinct anxiety disorders in the DSM-V, three frequent features include some or all of the following:

Somatic symptoms – symptoms of increased physiological distress (e.g. elevated heart rate, sweating, blushing, stomach clenching).
Cognitive rumination – frequent worry and mental preoccupation with a particular area of concern.
Affect dysregulation – runaway emotional distress and emotional lability. Although there are different types of emotional dysregulation, with anxiety disorders the person feels fearful and emotionally ‘flooded’ as they think/worry about a particular topics(s) or stimulus.

Anxiety often involves anticipation – whether physical, mental, or both. When something unpleasant or traumatic happens, people with anxiety disorders often become highly guarded against it happening again. This involves hypervigilance against stimuli, avoidant behaviors, and a rapid and intense reaction when presenting with these cues. You can think of this as a protective mechanism on steroids.

There is also a practical ‘if it walks like a duck and talks like a duck..” quality to anxiety. When someone is often anxious, their family and friends really ‘feel’ the anxiety in their day-to-day interpersonal interactions. It’s hard to say someone doesn’t ‘have’ anxiety when it looms large in their lives.

On the other hand, as we discuss ADHD, it will become more clear how ADHD can actually be the ‘driver’ of anxiety. Because there are misconceptions about ADHD, people often don’t understand the similarities and difference between ADHD and anxiety. As a result, ADHD is often misdiagnosed as anxiety.

ADHD Misdiagnosed as Anxiety

In the DSM-V, the main diagnostic criteria of ADHD are a ‘deficit of attention’, (e.g. hard to pay attention); and hyperactivity, as seen as excess amounts of energy and hyperactive behavior. While these criteria may be present in adults with ADHD, they are not the central component.

Restlessness

Perhaps surprisingly, most adults don’t display hyperactive behavior, in contrast to certain kids with ADHD. Rather they may have an overactive ‘internal motor’, as seen through restlessness and a creative drive.

Inconsistent Attention & Hyperfocus

Further, when it comes to attention, the main problem isn’t attention deficit but rather attention inconsistency. Adults with ADHD can be under-focused or over-focused, depending on the moment. And when they are hyperfocused, they have intense zones of attention. Said another way, in such moments, these adults are ‘locked in’ or ‘in the zone‘ with whatever they are focused on. In these periods, it is incredibly difficult to change focus and shift attention.

Emotional Dysregulation & Reactivity

Another predominant characteristic of ADHD in adults is emotional reactivity. People with ADHD feel deeply and have intense emotional responses. These can often come on quickly and intensely, and recede just as quickly, once the focus has shifted. To someone without ADHD, these emotional responses can feel more intense than the average person’s feelings.

Executive Dysfunction

Finally, and perhaps most importantly, executive dysfunction is a significant aspect of ADHD, and not treatable with medication. People with ADHD have structural differences from others in the frontal cortex regions of their brains. They have more difficulty proactively planning tasks, and have a hard time organizing and prioritizing the order of these activities. This can also involve difficulty resisting controlling impulses and delaying gratification and reward-seeking behavior.

Can ADHD Show up as Anxiety?

Now let’s come back to our understanding of anxiety. Often, ADHD is misdiagnosed as anxiety because there can be a hyperfocus on an anxiety-producing stimulus and emotional reactivity to related cues.

Also because people with ADHD have trouble organizing themselves and delaying reward-seeking activities, they are often out of rhythm and ‘playing catch-up’. They are trying to compensate for not having done the thing they should have done first.

For example, if you focus on a relatively minor task that seems interesting in the moment and forget another task that has a deadline, you will be anxious when you discover that you have missed the deadline.

Do I Have Anxiety or ADHD?

The question ‘Do I have anxiety or ADHD?’ is a misleading one. The real question is ‘do I have ADHD and anxiety’? If you do, chances are the ADHD has been misdiagnosed as anxiety. That means that your ADHD was not diagnosed earlier in your life, which is the case with Adult ADHD. It also may mean that you have high-functioning ADHD, where the impact of your ADHD is minimized because of your ability to be successful in other aspects of your life.

Step back and think about this for a moment. Anxiety is observable and more commonly understood than ADHD. Yet someone with ADHD can be emotionally reactive, hyperfocused, and suffering from executive dysfunction, all of which increases the likelihood of intense anxiety.

As a result, for adults diagnosed later in life with ADHD, there has been a long opportunity for narratives of anxiety to take hold, e.g. ‘I am an anxious person.’ This is not to minimize the legitimacy and reality of anxiety disorders. But the role of ADHD in anxiety is often misunderstood and minimized.

ADHD and Anxiety in Women

Although the prevalence rates are roughly equivalent by gender, Kessler and colleagues (2006) found in an empirical study that ADHD is diagnosed almost 70% more in men than women (5.4% in men vs. 3.2% in women). Another study by Mowlem and colleagues (2019) found that ADHD is more likely to be missed in women during the diagnostic process. ADHD and anxiety in women can often present differently than with men. We noted earlier that in adults, the ‘H’ in ADHD does not typically present as hyperactivity, but rather as restlessness.

Interestingly, women with ADHD often did not display hyperactivity as girls either. Rather, this comes across as talkativeness. These girls – and later women – may present as more talkative than others. This is due to the difficulty in self-regulation that manifests with ADHD.

There are also gender stereotypes about women and anxiety. Because women may be more vocal about their anxiety, women are often incorrectly perceived to be more anxious than men. This effect can be magnified in women with ADHD and anxiety, because of the reasons described above.

Spotlight: GAD vs ADHD in Women

Generalized Anxiety Disorder (GAD) is a type of anxiety disorder that features frequent worry and rumination about a variety of topics. Unlike phobias, there is not a specific area of fear, but rather general worry.

GAD and ADHD can overlap in their presentation. Although GAD has more of a general focus than other anxiety disorders, a common feature is mentally ‘locking in’ on a particular area of worry. When something elicits concern, people with GAD can become quite fixated in their worry and associated somatic symptoms of anxiety.

This type of mental fixation and rumination resembles the hyperfocus of ADHD. As we discussed above, people with ADHD can become particularly hyperfocused on something that captures their attention, including areas of fear, worry, and concern.

There are also areas of difference between GAD vs ADHD. For GAD, there may sometimes be an underlying and consistent theme to the seemingly unrelated general worry. For example, fears about bad weather and fears about driving may have the common element of death anxiety. This may in turn be related to negative early experiences around death and loss, coupled with an anxious disposition (e.g. hereditary component).

With ADHD, on the other hand, the emphasis is on the mechanism of attention – e.g. the hyperfocus. This hyperfocus can be on anxiety-provoking material or experiences, but it is not intrinsically related to them.

As with many other anxiety disorders, GAD tends to be overdiagnosed in women as opposed to men, due to gender stereotypes. As described above, ADHD in women is poorly understood in the general public. Thus, the combination of GAD and ADHD in women can lead to negative stigma. Women with GAD and ADHD may be ‘written off’ as anxious when there are underlying reasons for the anxious focus and vocal activity in expressing these experiences of anxiety.

How to Treat ADHD and Anxiety in Adults

There are a number of pharmacological and therapeutic treatments for ADHD and anxiety.

Please note that I write below about pharmacology from my vantage point as a psychologist who provides therapy services for many clients with ADHD and/or anxiety who take medication. I am not a psychiatrist and do not purport to have medical competency in pharmacology. My knowledge on this subject comes from the accumulated disclosures of my clients about their experiences on medication and from my own study of literature on the subject. (Read More: Should I See a Psychiatrist or Psychologist for Anxiety?)

Let’s look at a few treatment highlights for ADHD vs anxiety in adults:

Medication can make a big difference, but how you respond to medication can reveal a lot about your actual diagnosis.

The first-line pharmacological treatment for ADHD are stimulants. There are different types of stimulants and dosage levels which should be determined and carefully overseen by a psychiatrist. In theory, if ADHD is the main driver of the anxiety, the anxiety symptoms may not be negatively impacted by the stimulant. If anything, one might expect the anxiety to improve because the ADHD is improving.

On the other hand, if there is an underlying anxiety disorder that is independent from the ADHD, anxiety symptoms could worsen on a stimulant. How someone with ADHD responds to a stimulant can tell us a lot about the nature of their anxiety.

As an interesting comparison, from an anxiety standpoint, most people will see an immediate decrease in anxiety symptoms from an anxiolytic medication. However, there can be a number of side effects and issues resulting from taking these medications long-term. These medications also do not address non-anxiety symptoms that stem from ADHD.

One area of potential promise is the use of certain SSRIs ‘off label’ for both ADHD and anxiety. Some of these medications can effectively treat symptoms for both disorders, although the ADHD-related symptom improvements do not have as large of an ‘effect size’ as stimulants.

Therapy that teaches clients how to identify triggers for overreactions can be helpful for both ADHD and anxiety.

One shared treatment emphasis is on teaching clients how to identify the start of an emotional overreaction and learn how to take a time-out. This might involve visualizing a ‘stop’ sign or removing oneself from a stressful situation. Techniques to rapidly calm after the timeout and re-focus are also part of this process.

Therapeutic affect regulation strategies are beneficial for both ADHD and anxiety disorders.

These might include different types of deep breathing strategies; somatic grounding and parasympathetic activation techniques; visualization and sensory-based relaxation approaches. Carolyn Daitch, PhD, the Director of the Center for the Treatment of Anxiety Disorders has written books on affect regulation strategies and calming techniques that can serve as good resources. (Read More: Who Can I Talk to About My Anxiety?)

Exposure therapy can be helpful for treating anxiety for people with anxiety disorders and people who have ADHD with anxiety – but for different reasons.

Exposure therapy is an empirically supported treatment approach for many types of anxiety disorders. It works by extinguishing the fear response that is generated by the pairing of a stimulus that has become associated with anxiety.

For example, you liked dogs but then you had a traumatic incident with a friend’s dog and now are afraid of and avoid all dogs. The idea is that as someone has more innocuous interactions with dogs, the original traumatic pairing loses it’s intensity in the person’s mind – the fear-based response is ‘extinguished’.

This principle can also apply with anxiety that comes from ADHD. However, an ADHD-specific explanation is that the novelty and hyperfocus of the feared stimulus becomes less novel and thus less focused-upon with repeated exposure. It becomes less dopamine-producing with exposure.

Insight-focused therapy also has a role in the treatment of anxiety and ADHD – but that role can differ depending on the diagnosis.

Sometimes the anxiety is a symbolic recreation of a past trauma or unresolved psychological issue. Anxiety therapy that focuses on understanding the underlying issues behind the anxiety can be very helpful. In contrast to the CBT approaches described above, psychoanalytic or attachment-focused therapy can be helpful in eliciting insight that can lead to more meaningful changes.

With ADHD, on the other hand, insight-focused therapy will not resolve the core symptoms of the disorder. For example, it can’t improve some of the dysregulation around focus or the executive dysfunction.

However, it can be very helpful in increasing self-awareness around emotional reactivity that can help with managing it. It also can be of use in working through shame and other chronic emotions that have become a part of a person’s self-concept and self-esteem from living with ADHD. This can help a client with ADHD become more self-aware and have a better relationship with themself and others.

Meditation and hypnosis are also helpful for ADHD and anxiety.

For ADHD, research shows that meditation can improve dopamine levels and short-term focus and executive functioning. The induction phase of hypnosis can engage the frontal cortex functions for attention. While frontal cortex activity is ‘dampened’ during longer hypnosis, the process can be helpful in activating other parts of the brain that can compensate for ADHD-deficits.

For anxiety, both meditation and hypnosis can be helpful in creating calm and resetting the nervous system. Cognitive hypnotherapy can also apply some of the CBT approaches described above in a hypnotic state for added effect.

Exercise and sleep play important roles in decreasing symptoms of anxiety and ADHD.

Exercise produces short-term boosts in dopamine, which helps with symptoms of ADHD, and serotonin, which helps with mood. It can also help lead to better sleep, which will also improve mood and self-regulation.

Coaching and Apps work well for ADHD, but are not as important for anxiety disorders without comorbid ADHD.

Coaching and apps are helpful for building exectuive functioning skills in adults with ADHD. This helps with time management, organization, and prioritization, all of which are areas that are effected by the executive dysfunction that comes with ADHD. On the other hand, executive functioning isn’t understood to be impacted by anxiety disorders alone, so these activities are not as vital to someone who has anxiety vs ADHD.

ADHD vs. Anxiety: Conclusions

ADHD and anxiety symptoms can overlap, but the two disorders are unique. Understanding symptoms of ADHD vs. anxiety in adults will help you know which disorder may be impacting your life more prominently. We also provide some general treatment recommendations in this article for treating ADHD and anxiety in adults. If you have more specific questions, you might wish to consult with a psychiatrist or psychologist about an evaluation and treatment. At Attune, our psychologists offer comprehensive online psychological testing for ADHD in adults.