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. 2026 Apr 3;65(4):925–943. doi: 10.1111/bjc.70048

A qualitative investigation of the lived experiences of adults with anxiety and related disorders and ADHD: Interconnectedness of symptoms and implications for improving care

Arij Alarachi 1,2, Heather McNeely 1,3, Karen Rowa 1,3,✉, Randi E McCabe 1,3
PMCID: PMC13655950  PMID: 41930671

Abstract

Background

Attention‐deficit/hyperactivity disorder (ADHD) is highly prevalent in adults with anxiety and related disorders (ARDs). Quantitative research on this clinical population is mixed, with some studies suggesting that anxiety is protective against some symptoms of ADHD and others in which co‐occurring ARDs and ADHD are linked to poorer clinical and psychosocial outcomes. There are also several under‐researched clinical challenges, including missed or misdiagnosis and confusion around best treatment practices. Importantly, yet to be investigated are client perceptions of the relationship between ARD and ADHD symptoms, as well as the unique challenges co‐occurrence raises related to assessment and treatment.

Objectives

The current study utilized a descriptive phenomenological approach to qualitatively investigate the lived experiences of adults with co‐occurring ARDs and ADHD.

Design

Sixteen (N = 16) treatment‐seeking adults at a specialized outpatient ARDs clinic participated in individual semi‐structured qualitative interviews and completed a survey consisting of demographic, diagnostic and treatment history questions.

Methods

Qualitative data were transcribed verbatim, and Colaizzi's seven‐step approach for descriptive phenomenological thematic analysis was used to extract themes.

Results

Six themes were found, with the most common ones being (1) it's complicated: perceived relationship between ADHD and anxiety symptoms, (2) diagnosis experiences: validation, surprise and integration and (3) system overload and polarizing experiences with symptoms and impairment.

Conclusions

The current study provides insights on the shared perceptions individuals have on the interconnectedness of their symptoms of ARDs and ADHD, and implications for improving assessment and treatment practices to better suit the needs of this clinical population.

Keywords: ADHD, anxiety disorders, lived experiences, phenomenological, qualitative

Practitioner points.

  • Individuals perceive their co‐occurring symptoms of inattention and ARDs as amplifying each other, creating a cycle of distress.

  • Adults with ADHD may use anxiety symptoms to manage some symptoms of ADHD, such as impulsivity.

  • Late or missed diagnoses of ADHD contribute to internalized negative beliefs about the self, which could be addressed using when treating co‐occurring ARDs.

  • Assessment feedback for adults with co‐occurring ARDs and ADHD is a critical therapeutic opportunity to process complex responses, dispel misinformed beliefs, reduce stigma and highlight individuals' unique strengths and resilience factors.

  • More specialized treatments and resources tailored for adults managing both ARDs and ADHD are needed.

INTRODUCTION

Attention‐deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, hyperactivity and impulsivity (American Psychiatric Association [APA], 2022a, 2022b). ADHD has three presentations depending on the constellation of symptoms affecting the individual: predominantly inattentive, predominantly hyperactive/impulsive, or combined (APA, 2022b). An estimated 3% of adults have ADHD (Song et al., 2021), and it rarely occurs in isolation, as up to 80% of affected individuals have co‐occurring psychiatric conditions (Biederman et al., 1993; Fayyad et al., 2017; Seo et al., 2022; Sobanski et al., 2007). The most common co‐occurring conditions are anxiety and related disorders (ARDs, 34% co‐occurrence rate, Fayyad et al., 2017). ARDS comprise a broad and heterogenous category, including generalized anxiety disorder (GAD), social anxiety disorder (SAD), specific phobia, panic disorder, agoraphobia, obsessive‐compulsive disorder (OCD) and posttraumatic stress disorder (PTSD). Unifying the broad category of ARDs are similar underlying cognitive (e.g., worry, intrusive thoughts, rumination), behavioural (e.g., avoidance, checking, hypervigilance) and affective (e.g., fear, anxiety) components of the disorders (APA, 2022a), as well as a high comorbidity rate among them (Davies et al., 2023; Essau et al., 2018). In adults with ARDs, the prevalence of ADHD is approximately 10 times higher than it is in the general population (28%; van Ameringen et al., 2011). Despite the strikingly high prevalence of ADHD in adult ARDs populations, the psychopathological features, functional outcomes, and unique clinical needs of this subgroup are under‐researched.

The complex relationship between ARDs symptoms and ADHD

There is some evidence to suggest that the presence of ADHD in adults with ARDs is associated with more complex and severe clinical outcomes than in those without ADHD. For example, a study by van Ameringen et al. (2011) found that approximately 30% of the patients at an anxiety disorders clinic met criteria for ADHD. The presence of ADHD was associated with higher symptom severity scores for GAD, OCD, and an earlier age of onset for depression compared to those without ADHD (van Ameringen et al., 2011). Other studies have found that childhood ADHD in those with ARDs is correlated with having a higher number of co‐occurring psychiatric diagnoses, more difficulties with alcohol and substance use, and a higher risk of suicidality than in those without childhood ADHD (Mancini et al., 1999; Yoshimasu et al., 2019). A qualitative study by Ginapp et al. (2023) further illustrated this using first‐hand accounts from adults with ADHD, in which participants described experiencing an ‘all or nothing’ expression of emotions. Although the authors did not directly examine how ARDs contributed to emotional dysregulation in ADHD, 49% of the sample had a co‐occurring anxiety disorder (Ginapp et al., 2023).

Moreover, functional outcomes for this clinical population appear to interface with gender, as men with co‐occurring ADHD and ARDs had greater levels of impairment on measures of disability and quality of life than women with co‐occurring ADHD and ARDs (van Ameringen et al., 2011). Fredriksen et al. (2014) also found that long‐term disability was higher in adults with ADHD who had co‐occurring ARDs. Overall, research suggests that ADHD sequelae are moderated by complex relationships among gender, age of diagnosis, as well as ADHD presentation type (e.g., Bauermeister et al., 2007; Faheem et al., 2022; Taylor et al., 2019; Williamson & Johnston, 2015).

Other studies suggest the presence of ARDs attenuates some symptoms of ADHD (Lipszyc & Schachar, 2010; Maric et al., 2018). For example, Prevatt et al. (2015) categorized a sample of college students diagnosed with ADHD as having either low or high levels of inattention using a median split of their self‐reported symptoms. For those with low inattention, a high level of anxiety symptoms was associated with better performance on cognitive testing than for those with low levels of anxiety symptoms (Prevatt et al., 2015). Further, in the longitudinal Multimodal Treatment of ADHD (MTA) study, children with ADHD that followed a partial remission trajectory into early adulthood had higher rates of co‐occurring anxiety disorders than the stable ADHD persistence group (Sibley et al., 2024). A participant in a qualitative exploration of emotions in ADHD stated that their anxiety was helpful in preventing themselves from engaging in impulsive spending (Ginapp et al., 2023). Taken together, this suggests there may be a protective or functional aspect of anxiety, such that it enhances focus or motivation (Carver & Scheier, 2013; Cheng et al., 2009), however this may only be relevant for mild ADHD symptoms. The mechanism by which this occurs is unclear, however one potential explanation is that ARDs are linked to excessive response inhibition (Grillon et al., 2017), which may ameliorate ADHD‐related deficits in inhibitory control, and enhance self‐regulation (Cheng et al., 2009). Alternatively, it is possible those in Sibley et al.'s (2024) study who followed the partial remission trajectory had been misdiagnosed with ADHD at baseline, which is a significant challenge in this clinical population due to symptom overlap.

Assessment challenges in adults with co‐occurring ADHD and ARDs

Attentional difficulties are present in many ARDs (Leonard & Abramovitch, 2019; O'Toole et al., 2015; Spann et al., 2012; Tükel et al., 2012; Warren et al., 2021), which may contribute to misdiagnosis. Also, anxious individuals that actively seek a diagnosis may be driven by perfectionistic standards for their cognitive functioning or adoption of an ADHD illness identity to best explain their perceived cognitive and functional challenges, leading to a false positive diagnosis (Barkley et al., 2011; Sibley, 2021; Suhr & Wei, 2017).

Simultaneously, both quantitative and qualitative research has found that ADHD may be missed when adults with ARDs seek mental health care (e.g., Ginapp et al., 2022, 2023; Mancini et al., 1999; Pehlivanidis et al., 2014; van Ameringen et al., 2011). Specifically, individuals with lived experiences describe that their diagnoses of ARDs and depression that are secondary to ADHD are identified first by assessing clinicians, whereas ADHD‐related difficulties are often overlooked until later on in life (Ginapp et al., 2023). Further, qualitative research has identified that repeated negative feedback experiences in those with undetected ADHD can contribute to development of anticipatory anxiety about future criticism and maladaptive coping by socially withdrawing or avoiding situations that may elicit it (Beaton et al., 2022); symptoms that are commonly seen in ARDs. Taken together, these studies and others (e.g., Hansson Halleröd et al., 2015; Matheson et al., 2013) support the hypothesis that untreated ADHD may lead to anxiety symptoms, however, how frequently these symptoms reach clinical thresholds to warrant a diagnosis of ARDs is unclear. Also, there may be a subset of individuals with co‐occurring ADHD and ARDs who do not experience ARDs as secondary to ADHD.

Treatment needs for adults with co‐occurring ADHD and ARDs

The impact of co‐occurring ARDs and ADHD on treatment outcomes is also unclear. One study found that the presence of ADHD reduced effectiveness of first‐line interventions, such as cognitive behavioural therapy (CBT) for ARDs in children (Halldorsdottir & Ollendick, 2014). However, other studies with parent‐involved interventions have found that ADHD had no effect on CBT for anxiety outcomes, likely due to the parental compensation for the children's cognitive impairment (e.g., Gould et al., 2018). There is a dearth of research on how treatment outcomes play out in adult populations with co‐occurring ADHD and ARDs. One qualitative study found that adults with ADHD desire support beyond solely pharmacological intervention, including counselling to develop skills for reducing emotional and social impairment, managing stress, and improving organizational skills (Matheson et al., 2013). How co‐occurring ARDs further influence the treatment preferences and needs of adults with ADHD has yet to be investigated.

The present study

Some quantitative studies have investigated the clinical features and functional outcomes associated with co‐occurring ARDs and ADHD, although most of the available literature was conducted prior to the last decade. Further, quantitative methodologies may be too restrictive to capture important nuances (Pope & Mays, 1995) associated with co‐occurring ARDs and ADHD in adults, including delay between symptom onset and diagnosis, ADHD presentation type, type of co‐occurring ARD present, and treatment history. Qualitative research with samples of adults with ADHD (e.g., Beaton et al., 2022; Ginapp et al., 2023; Matheson et al., 2013) have corroborated the utility of using interviews to gather this rich, complex, meaningful data. Moreover, phenomenological approaches focusing on lived experiences (i.e., understanding phenomena through the reflections and descriptions of individuals beyond just focusing on the ‘diagnosis’), has been cited as critical to ensure psychiatric research is inclusive of subjective, complex and nuanced experiences (e.g., Larsen et al., 2022; Parnas et al., 2013; Sass, 2022). Therefore, descriptive phenomenological approaches which centre participants' voices are best suited for research aimed at improving clinical care (Ritunnano et al., 2023).

To our knowledge, no studies have applied a qualitative approach to investigate the perceptions of adults with co‐occurring ARDs and ADHD, despite the limits of quantitative research in capturing the complex experiences of those living with both disorders. As such, the aim of the current study was to apply a descriptive phenomenological approach to qualitatively describe the lived experiences of adults with ARDs and co‐occurring ADHD. The secondary research goals were to investigate the perceived relationship between symptoms of ARDs and ADHD and elucidate clients' experiences with receiving their diagnoses and navigating treatment.

METHODS

Participants

Sixteen (N = 16) participants were recruited from the Anxiety Treatment Research and Clinic, an adult outpatient ARDs clinic in Hamilton, Canada. Adults of ages 18–65 with a current diagnosis of GAD, SAD, panic disorder, agoraphobia or OCD and an additional established diagnosis of ADHD (at the current assessment or past diagnosis) were recruited from the clinic's research database using a criterion sampling approach. To qualify for the study, participants had to be able to verbally communicate in English.

Sample size

In line with Malterud et al.’s (2016) model, the concept of information power was adopted to determine the goal sample size. Sufficient information power is based on the aim of the study, specificity of the sample, application of theory, quality of dialogue and the data analysis approach (Malterud et al., 2016). Due to the broad study aim, average specificity of the sample and cross‐case analysis framework, the goal sample size of 16 was appraised as sufficient to provide information power.

Procedure

All clients were assessed at the clinic through a psychiatric consultation, nursing intake appointment or psychodiagnostic assessment using a validated, open access, semi‐structured interview, the Diagnostic Assessment Research Tool (DART; McCabe et al., 2017; Schneider et al., 2022). DART interviewers included psychologists, post‐doctoral fellows in clinical psychology, social workers and graduate‐level clinical psychology practicum students, all of whom received extensive training and supervision in conducting the interview. Comprehensive assessment and diagnosis of ADHD was not conducted as part of the routine DART interview process; however, previous diagnoses of ADHD made by another clinician (e.g., psychiatrist, physician or neuropsychologist external to the clinic) that were included in the participants' medical chart or referring documentation were recorded for clinical and research purposes. Psychiatry consultations at the ATRC may have included an ADHD assessment, depending on the referral question. Individuals with diagnoses of co‐occurring ARDs and ADHD were recruited from the clinic's research database. All participants provided written informed consent to participate in the research, and study procedures were approved by the institution's Research Ethics Board. Participants were also asked to provide consent for verbatim excerpts for be used for research purposes; only one participant of the 16 opted out of this. This study was not preregistered.

Demographic information was collected at intake using the clinic database to characterize the sample. Participants in the study were administered a brief survey related to diagnostic and treatment history for their ARDs and ADHD using the Research Electronic Data Capture software (REDCap; Harris et al., 2009, 2019). Participants then completed individual semi‐structured interviews with a graduate student researcher, lasting up to 120 minutes. A research assistant transcribed the audio‐recorded interviews verbatim, and a graduate student researcher reviewed them for accuracy.

Phenomenological approach, positionality and interview

The primary research goal was to capture the lived experiences of adults with co‐occurring ADHD and ARDs, with an aim of guiding further research and improving clinical care. Descriptive phenomenology is grounded in a transcendental realist ontology, which acknowledges the subjectivity and variability in experiences, yet emphasizes the common, distilled aspects of the phenomena (Giorgi, 1975, 2009; Moustakas, 1994). At the same time, the epistemological framework posits that researchers should aim to objectively describe the core features of the phenomena by engaging in bracketing and describing rather than interpreting data. Bracketing is when personal interpretations and preconceived understandings of an experience are withheld by the descriptive phenomenological researcher prior to the investigation and throughout data analysis (Crabtree & Miller, 1992; Husserl, 2012).

As such, a descriptive phenomenological approach was selected to purely describe the unique essence of the phenomenon as illustrated by participants (Giorgi, 1975), rather than interpreting the possible meaning behind it. This also allowed for the extraction of the shared, common experiences amongst participants. Further, given that descriptive approaches focus on stakeholders' experiences and withhold interpretation during the analysis stage, this was deemed most suitable to address research questions aimed at making clinical care client‐centred (e.g., inquiries related to ARDs and ADHD interactions, diagnosis experiences and treatment needs).

Bracketing was supported through thoughtful design of the interview questions with positionality in mind, extracting participants' direct quotes to drive thematic analysis and memo‐taking when personal interpretations presented during data analysis. Recognizing the limitations of bracketing in descriptive phenomenological research (Moustakas, 1994), the authors also elected to consider their positionality within the investigation (Bourke, 2014; Ozano & Khatri, 2018). The first author is a clinical psychology doctoral student who took the lead on study design, data collection and analysis. At the time of data analysis, she had engaged in some clinical work with adults with ARDs or ADHD. Her lack of lived experience with either condition positions her with an outsider lens on the phenomena, while simultaneously adopting an insider lens as she shared vested interest in improving access to mental health services as well as common identity and experiences with some participants with respect to gender, ethnicity and education. The co‐authors provided supervision with all aspects of the study process, including data analysis. They include two clinical psychologists (with specialized knowledge of ARDs) and one neuropsychologist (with specialized knowledge of ADHD) within an academic teaching hospital. All co‐authors acknowledge having a vested interest in accurate and timely diagnosis of co‐occurring conditions with likely bias related to differing levels of expertise of each co‐occurring condition. As such, the positionality of the research team shaped the research objective of elucidating the needs of this population and improving clinical services. This influence is reflected in the methodology selected, interview questions and emphasis on themes related to individuals' perceptions of symptoms, diagnosis experiences and treatments.

Bevan's proposed method (2014) for descriptive interviewing was adopted, in which broad, open‐ended, contextual questions were first proposed, followed by apprehending the phenomenon with detailed descriptive questions and finally clarifying the phenomenon using imaginative probes (Table S1). Participants were prompted to share all thoughts and feelings until their perspective was fully communicated to the interviewer to support data saturation (Legard et al., 2003). The mean interview length was 41 minutes with a range of 16.5–86 minutes.

Data analysis

NVivo (Version 14) software was used to support data analysis and to generate frequencies for themes (Lumivero, 2023). Colaizzi's (1978) seven‐step approach for descriptive phenomenological thematic analysis was used, which included (1) reading the data several times to become familiar with it, (2) extracting in vivo (i.e., verbatim) significant statements that describe participants' lived experiences with co‐occurring ADHD and ARDs, (3) developing formulated meanings from these statements (i.e., codes in NVivo), (4) organizing themes (i.e., moving codes into groups), (5) arranging all themes into a comprehensive description (developing major themes for each code group), (6) describing the fundamental nature of the phenomenon and (7) returning to participants to ensure they are in agreement with the description of their lived experiences. In line with the seventh step, preliminary themes were shared with participants through a video‐recorded slideshow in a REDCap survey. Their feedback on accuracy was incorporated to enhance validity. Memos documented the bracketing process, including reflections on biases and coding decisions.

RESULTS

A summary of demographic and diagnostic information in the sample is provided in Table A1. Fifty per cent of the sample held full‐time paid employment at the time of the study, with the remaining participants reporting their employment status as part‐time, student, unpaid employment (e.g., volunteer work or homemaker) or unemployed. All had at least one ARD (GAD = 10, SAD = 7, PTSD = 5, OCD = 5) and a diagnosis of ADHD. Participants had on average 3.19 diagnoses total (SD = 1.52), with the most frequently co‐occurring ones being major depressive disorder (MDD) and persistent depressive disorder (PDD; n = 6 and n = 4, respectively). A little over half of the sample reported being diagnosed with ADHD in the developmental period (e.g., before age 18, n = 9, M age = 10.22), while the remaining participants reported they received an ADHD diagnosis as an adult (e.g., after age 18; n = 7, M age = 32.86). With respect to treatment, 15 participants indicated taking medication for ADHD at some point in their life, and 13 reported taking it at the time of the study. Only six participants reported participating in psychosocial treatments for ADHD at some point in their life, while 12 participants reported participating in psychosocial treatments for their ARD. Six themes were found in the interviews (Table A2), which are described in detail below.

It's complicated: Perceived relationship between symptoms of ADHD and ARD

Participants reflected on their perceptions of the relationship between symptoms of ADHD and ARDs, with four subthemes describing different perceived relationships between the two conditions. Subthemes were not mutually exclusive for each participant. Most participants described a synergistic relationship between ARDs and ADHD (Synergistic relationship; n = 15), in which each condition made the other more severe, with consequences of emotional dysregulation, agitation and perfectionism. Participants emphasized the perceived causal effects of ADHD‐related difficulties (e.g., inattention at work, excessive caffeine use, over‐spending and procrastination) on later experiences of anxiety. One participant stated, ‘the anxiety is not first. It's not the first‐class citizen, it's the second‐class citizen; it's a side effect of untreated and unmanaged ADHD’ and another reported, ‘I really don't picture one existing without the other. […] Because I have ADHD, it brought my anxiety into existence’.

ARDs and ADHD were also perceived to be opposing (Opposing relationship; n = 12), which for most participants was reported as neutralizing in nature though a couple endorsed experiencing internal conflict. In regard to the concept of neutralizing, some participants described recruiting their worries and concern about negative outcomes to regulate their ADHD‐related impulsivity. One participant stated, ‘I kind of jokingly say this, that I treat my ADHD with anxiety’ and another sharing this sentiment reported ‘the anxiety keeps me in check and allows me to be reminded that I want to not feel like that […] I have that second wave of discomfort that arises [after the impulsivity] and if I can plan to avoid it, then I can plan to be better every day. That's the way I look at it’. Another participant described their anxiety as a parent to their ADHD, ‘It's not pleasant but it sort of keeps me from having too much fun, maybe. Reckless fun, thoughtless fun’.

Alternatively, some participants characterized their conditions as driven by different mechanisms (e.g., ARDs told them to stop, while ADHD told them to go). One participant stated that their ADHD ‘thrives in chaos’ whereas their anxiety does not and described, ‘what is good for my ADHD is not good for my anxiety and vice versa. So that causes a lot of frustration’.

Two participants (context‐dependent relationship; n = 2) also described that the relationship between ADHD‐related difficulties and ARDs symptoms is fluid and context‐dependent. For example, a participant shared, ‘at home, I don't notice them overlapping, but at work when I have to be on the ball, […] they do overlap’. Another participant noted the differences in their worries, depending on their relationship to ADHD ‘when [my anxiety is] related to my ADHD, it's more of like how anxiety really is, like a bit irrational […] when it's not related to my ADHD, there is usually a more situational component to it, […] a way to rationalize it’.

The fourth subtheme (Some overlap; some distinction; n = 5) related to the perceived relationship between ADHD and anxiety symptoms was overlap versus clear distinctions between the two disorders. This was described as challenging, as one participant reported ‘sometimes I wonder if there was a way to pinpoint which symptom belonged to which […], like, “oh this symptom, that goes to my ADHD pile”’. Participants provided different reflections related to this subtheme, with some reporting that symptoms such as worries about being negatively judged by others, experiencing panic attacks, fidgeting and hyperactivity were unrelated and clearly corresponded to one of the two specific disorders. Others reported having difficulty distinguishing whether their challenges are related to ADHD, ARDs, both or neither.

Diagnosis experiences: Validation, surprise and integration

When asked about receiving a diagnosis of ARDs and ADHD, participants generally shared more content related to their diagnosis experiences of ADHD. As with all the themes, subthemes were not mutually exclusive, and at times, participants shared different sentiments when reflecting on their ARDs diagnoses versus their ADHD diagnoses. Most individuals described a sense of clarity, relief and validation upon receiving their diagnoses (Clarity, relief and validation; n = 10). For example, one individual described ‘the value in having an official diagnosis, […], it does wonders for my anxiety, because even if I knew what it was already, it's just confirmation; it's just proof’. Participants reflected on how receiving their diagnoses helped reduce self‐blame or shame ‘it made me realize that ultimately, I wasn't just crazy or weird, that there was an actual reason for what was happening in my head’; ‘it is reassuring to know that I'm not just lazy’.

Another subtheme was related to initial disbelief and surprise (n = 8) upon receiving diagnoses of ADHD and ARDs, with most participants discussing this sentiment in response to their ADHD diagnoses. Participants cited different reasons for their disbelief, including it going undetected for years (e.g., ‘I went through […] years of them trying to figure this out when I was a kid, and they didn't figure it out then. So, how is this person who talked to me twice figuring this out?’). Three participants reported a sense of grief related to receiving late diagnoses of ADHD (Grief due to late diagnosis; n = 3). For example, a participant described ‘it's been so frustrating; […] I could've done a lot better earlier on in life to have this diagnosis earlier’. Participants' perceived reasons for their late diagnosis included identifying as a woman, being racialized, and not presenting with hyperactive/impulsive‐related difficulties.

Other comments participants shared in relation to surprise or disbelief at their ADHD diagnosis referred to ‘oversaturation’ of ADHD on social media and beliefs about personal inadequacies (e.g., ‘there's this aspect of, is it really ADHD or am I just crappy at life?’). Others shared comments regarding a perceived overdiagnosis of ADHD, lacking hyperactive/impulsive‐related difficulties and seeing ADHD as an extension of personality as contributing to their disbelief.

Lastly, some participants indicated that they had a minimal to no reaction or could not recall their reaction to their ARD or ADHD diagnoses (Integration and acceptance, n = 9), reflecting a sentiment of integration or acceptance. Reasons for this included receiving a diagnosis early in life, or always knowing they were experiencing ARDs or ADHD. For example, one participant stated, ‘I remember feeling not surprised by the results. Friends, my family, and I knew I was being mentally crushed by something in my life’.

System overload and polarizing experiences with symptoms and impairment

Participants described a sense of system overload and polarizing experiences while living with both ADHD and ARDs. Some participants explicitly tied difficulties to one of their conditions, while others did not. Most commonly reported experiences included time management difficulties (n = 8), ‘overwhelm’ or ‘overstimulation’ (n = 6) and perfectionism (n = 4). One participant stated ‘You feel like a frozen computer and it's really overwhelming. And you're like, “I just want one thing at a time, or I want nothing. I want everyone out of my brain so I can focus”. That's hard’. The pervasiveness of the impairment was captured in one participant's comments, ‘because of the extent of my ADHD and anxiety, […] it's difficult to shower, to brush my teeth, to put makeup on; to do all of that. It's difficult to just wake up, exist, and live my life’. Lastly, four participants (n = 4) reported that living with co‐occurring ADHD and ARDs was ‘chaotic’, with both positive (e.g., ‘I tend to kind of thrive in chaos’) and negative sentiments (e.g., ‘it just takes a lot of effort to keep my life from being chaotic’).

Impact of co‐occurring ARDs and ADHD on the self: Underachievement and stigma

Participants described the sentiment that living with co‐occurring ADHD and ARDs is challenging and has a significant impact on beliefs about the self. Several individuals described a sense of underachievement, self‐criticism and shame (n = 6). One participant reported that having longstanding untreated ADHD led to a lack of self‐trust in their abilities to be reliable and complete tasks ‘you have all this evidence in your mind that you're not good at anything and you can never finish anything. And to make it worse, you also have the view of what everyone else is doing and say, “ok, well I'm the odd person out”’. Another participant stated, ‘I feel like I left a lot on the table in the last 12 years, by being without strategies to just do the work when the work was necessary’. Some participants stated that this sense of underachievement was related to feeling their environment did not accommodate for their difficulties, while others specified this experience was related to delays in receiving their diagnosis and accessing treatment.

Participants also described experiencing stigmatizing attitudes from others (Stigma, n = 4), and feeling judged, othered and generally treated differently due to their diagnoses of ADHD and ARDs. Some participants described avoiding disclosing their diagnoses specifically within education or workplace settings to avoid experiencing stigma and discrimination, with one stating ‘There's a stigma about it in the workforce […] you can't talk about it, because all of a sudden if you're that person with a disorder of some sort, you're not fit for the role’. Another individual described that even when others have appeared to be accepting, there is a lack of follow‐through on being supportive and accommodating for their neurodiversity, ‘everybody is okay with you having ADHD in the abstract. But there's a big difference between being okay someone has ADHD versus being okay that you have to deal with them having ADHD’.

Lack of support and treatment incompatibility

The fifth theme was related to treatment and supports. Participants reported that there was a lack of psychosocial resources for ADHD specifically (n = 5) and that available services for ARDs or ADHD are less effective or particularly difficult to navigate (n = 4) due to the presence of the other disorder. For example, one participant commented on ADHD interfering with CBT for ARDs, ‘I tend to derail the conversation, or just by getting distracted, or having to follow up after with homework or stuff like that, it's not great’. Participants also commented on how taking ADHD medications increased symptoms of anxiety, ‘the side effect of it is added anxiety, so it doesn't help with the anxiety. But if I also don't treat my ADHD, then the anxiety is also really bad. So, it's kind of, you're damned if you do, you're damned if you don't’. Participants also expressed that their ADHD diagnosis was handled poorly by clinicians, ‘I felt like I had been slightly misunderstood by the medical system, because it was it was either one diagnosis or the other. [They] didn't seem to fully understand that I was experiencing a combination of both’.

Coexistence and focusing on strengths

The final theme that participants described was related to a coexistence and acceptance of living with the ADHD and the anxiety. Some participants stated they were ‘used to’ either or both the disorders, ‘I don't really notice it anymore. It's part of life’ and had less to share in response to the interview questions. Some participants (n = 6) also described positive aspects of their lived experience, stating that ADHD helped ‘fuel them’ at work (e.g., being present with others or completing tasks quickly), have unique or exciting experiences and be creative.

DISCUSSION

The current study elucidates the phenomenon of living with co‐occurring ADHD and ARDs in adulthood using qualitative interviews with participants with lived experience. Although commonly reported themes were identified in the interviews, participants shared varied perspectives on the relationship between ADHD and ARDs, highlighting the heterogeneity in participants' experiences and how these conditions co‐occur.

The synergistic experience of ADHD and ARDs‐related difficulties converges with several previous studies identifying poorer psychological and psychosocial outcomes when both conditions are present rather than one (e.g., Quenneville et al., 2022; van Ameringen et al., 2011; Yoshimasu et al., 2019). Participants in the current study particularly emphasized the exacerbation of anxiety symptoms due to ADHD. Research suggests that individuals with undetected ADHD are at risk of experiencing recurrent negative feedback from parents, peers and teachers throughout development, which may be internalized without the knowledge about the psychopathological source of symptoms (Bramham et al., 2012; Young et al., 2008). These internalized beliefs may interface with executive function deficits common in ADHD (e.g., poor cognitive‐emotional regulation) to contribute to the development of ARDs (Nigg et al., 2004). Participants also shared that their anxiety symptoms may exacerbate symptoms of ADHD, consistent with another potential pathway of the development of ARDs‐ADHD co‐occurrence, in which high levels of anxiety increase cognitive load, leading to executive function deficits (Nigg et al., 2004), greater challenges or perceived failures and increased anxiety as a result. More research investigating how ARDs and ADHD co‐occur is warranted to fully parse out the neuropsychological mechanisms at play, and whether or not this is stable across development.

Some participants in the current study also described symptoms of both conditions as neutralizing one another, particularly with anxiety acting as a preventative parental figure, treatment tool or consequential emotion for impulsive behaviour. This result converges with the finding in Ginapp et al.'s (2023) study, in which individuals with ADHD stated that anxiety is a tool they use to inhibit impulsive behaviours. The neutralizing relationship between ARDs and ADHD has also been corroborated by empirical data, as research suggests anxiety attenuates hyperactivity and some symptoms of impulsivity, such as response inhibition (Epstein et al., 1997; Maric et al., 2018; Pliszka, 1992). Other types of impulsivity, such as negative urgency (e.g., the tendency to act impulsively when experiencing negative emotions; Whiteside & Lynam, 2001), may be linked with higher anxiety symptom severity (Pawluk & Koerner, 2016) and could be exacerbated when it co‐occurs with ADHD. Emotional lability was also described in a qualitative study of adults with ADHD (approximately 50% had co‐occurring ARDs; Ginapp et al., 2023). Thus, the specific type of impulsivity present may interact differently with ARDs symptoms. Taken together, the results of the current study and previous qualitative studies suggest there are a constellation of ways in which the two conditions interact, depending on the specific symptoms at play, as well as the context (e.g., work versus home).

A common lived experience shared by participants was related to difficulty differentiating between the two conditions, and missed or mis‐diagnoses. This finding converges with experiences shared in numerous previous qualitative studies of adults with ADHD (e.g., Ginapp et al., 2022, 2023; Hansson Halleröd et al., 2015; Matheson et al., 2013). Several factors may contribute to challenges in assessment and diagnosis, including symptom overlap (Tannock et al., 2000; Weiss et al., 2011); use of non‐specific measures (Alarachi et al., 2024; Grogan et al., 2018), reliance on self‐report or incomplete assessment (e.g., Nelson et al., 2019; Suhr et al., 2017), and masking of ADHD symptoms. Symptom masking may involve leveraging ARDs symptoms to manage ADHD‐related impulsivity or may suggest a primarily inattentive presentation, rather than hyperactive/impulsive or combined type of ADHD where impulsive behaviour is more prominent. Importantly, the inattentive presentation of ADHD may be most at risk of being undetected in ARDs populations (e.g., Koyuncu et al., 2015). Furthermore, participants in the current study cited identity‐related factors that may not fit with the ‘prototypical’ individual with ADHD as perceived reasons for delayed diagnosis. One of these factors included identifying as a woman, which has been repeatedly cited in the literature as being associated with a missed diagnosis of ADHD (e.g., Attoe & Climie, 2023; Huynh et al., 2024). For example, girls are more likely to present with inattention such as distractibility or being forgetful, whereas boys are more likely to present with hyperactivity/impulsivity, such as being disruptive in class, leading to a gender difference in detection of ADHD in childhood (Gershon & Gershon, 2002; Waite, 2010).

Participants described complicated diagnosis experiences, reporting disbelief, frustration, grief, clarity and accommodation, depending on various factors, such as self‐awareness of difficulties and challenges with being misdiagnosed. The complex, multilayered responses to diagnoses align with Murphy and LeVert's (1995) six‐stage model of the psychological adjustment process to receiving an ADHD diagnosis. Experiences of anger, grief and rumination may be particularly relevant for those who receive a diagnosis of ADHD later in life (Young et al., 2008). Moreover, this may be a core aspect of co‐occurring ARDs and ADHD, as Beaton et al. (2022) found that repeated negative feedback from the environment led individuals to anticipate future negative outcomes and even avoid situations to mitigate this. As such, early and accurate diagnosis may help individuals reattribute some of their perceived ‘failures’ to untreated symptoms of ADHD.

Moreover, participants' descriptions of assessment experiences varied according to the perceived quality of feedback received. Feedback offers a therapeutic opportunity for clinicians to enhance clients' clarity, self‐understanding, motivation and empowerment (Gruters et al., 2021; Longo, 2024; Ward, 2008). Particularly given the complex experiences described by participants in the current study (e.g., ‘chaos’, ‘underachievement’), it is imperative that clinicians providing feedback about co‐occurring ARDs and ADHD emphasize nuance in conceptualizing symptoms, based on context, development and stage in diagnosis and treatment. Further, given the significant misinformation on ADHD on social media platforms (e.g., 52% of the top TikTok videos on ADHD are misleading; Yeung et al., 2022), well formulated and sensitive feedback provides a critical opportunity to provide psychoeducation and dispel misinformed beliefs about the disorders.

Participants reflecting on their lived experience also described neutrality, acceptance and positive sentiments related to both conditions. For example, they noted the adaptive benefits of anxiety, which converges with some studies (e.g., Ginapp et al., 2023). Furthermore, they shared a sense of coexistence with their conditions, reflecting resilience and self‐acceptance. Lastly, several individuals described the impact of positive aspects of ADHD on domains of productivity in work, creativity and having meaningful, exciting experiences, which converges with both qualitative and quantitative literature highlighting strengths related to ADHD (Nordby et al., 2023; Schippers et al., 2024; Sedgwick et al., 2019). As such, assessment and feedback experiences that emphasize individuals' strengths are recommended to help reinforce positive beliefs, improve self‐esteem and reduce stigma (Hargitai et al., 2025; Newark et al., 2016; Schrevel et al., 2016).

With respect to treatment, participants overwhelmingly described a lack of services that are tailored to unique challenges encountered by adults with both ARDs and ADHD. Moreover, some participants in the current study reported that treatments for either disorder were less effective due to the presence of the other disorder. Unfortunately, there is a dearth of research investigating how treatments for each disorder affect, and are affected by, the other diagnosis in adult samples. Nonetheless, treatment planning and consideration of the relative impact of each disorder, tailored to the client's individual needs is likely to be helpful. For example, participants stated that they experienced verbal impulsivity and difficulties with homework completion which interfered with their uptake of Cognitive Behavioural Therapy (CBT) for ARDs. As such, adaptations to first‐line interventions for ARDs, such as CBT, may be implemented as needed (e.g., shorter sessions, more breaks, incorporation of strategies to aid with homework completion between sessions) to increase accessibility for clients with ADHD. Also, CBT focuses on examining evidence for and against unrealistic, biased thinking patterns (e.g., worries); as participants raised in the current study, clients may have evidence to support some of these beliefs due to a history of untreated ADHD. As such, similar to providing strength‐based feedback, it is recommended that treating clinicians emphasize individuals' resilience and coping as they navigated life with undetected or untreated ADHD to help increase self‐compassion, reframe their difficulties with their strengths in mind and improve self‐esteem (Newark et al., 2016; Paley et al., 2025). Moreover, research investigating an integrative approach for treating ARDs with co‐occurring ADHD is lacking, however it appears to be a promising approach in other co‐occurring conditions, such as for co‐occurring substance use disorders and ADHD (van Emmerik‐Oortmerssen et al., 2013; van Emmerik‐Oortmerssen et al., 2015; van Emmerik‐Oortmerssen et al., 2020) warranting future investigation.

Considerations of positionality and limitations

As noted in the methods section, best efforts were made to engage in bracketing throughout the study design, data collection and analysis. Still, the contributions of the current study to understanding the lived experiences of adults with co‐occurring ARDs and ADHD should be interpreted with the authors' positionality in mind. For example, the professional identities of the co‐authors (e.g., as a clinical psychology trainee and clinical and neuropsychologists within an academic teaching hospital) centred participants' descriptions of symptom perception, functional impairment and challenges with mental health services, while experiences related to identity and structural contexts (e.g., socioeconomic structures, mental health systems) were less salient. Consideration of these biases led to inclusion of a theme focused on coexistence and strengths related to participants' lived experiences to expand beyond a medicalizing or deficit‐focused framework. Further, the clinical orientation of the researchers facilitated interpretation of the results with respect to implications for improvements to screening, assessment, feedback and treatment for adults with co‐occurring ARDs and ADHD, ultimately supporting the overall research aim.

There are also some important limitations to the current study. Firstly, the sample comprised of treatment‐seeking individuals; as such, these findings may not generalize to individuals in the community with ADHD and ARDs who are not seeking treatment. Also, while the descriptions of participants' experiences converged to yield themes, there was heterogeneity between participants. This heterogeneity may be attributed to the broad inclusion criteria of ‘ARDs’, which includes a number of different ARDs that may differ in the extent to which cognition is directly impacted by the anxiety disorder. For individuals with OCD, PDA and PTSD, there may be discrete cognitive symptoms that can be identified as separate and non‐interactive with ADHD symptoms (e.g., intrusive thoughts related to contamination concerns, worries about future panic attacks and avoidance of trauma‐related memories, respectively). However, for those with GAD or SAD, there may be more general symptom overlap (e.g., irritability, concentration difficulties and rejection sensitivity, respectively). Another contributor to the heterogeneity is that participants were at various stages in treatment for their ARDs and ADHD (e.g., prior to, during or after treatment for ARDs), and there were differences in when the ADHD diagnosis was determined (e.g., childhood, youth, adulthood). Moreover, most participants had additional mental health diagnoses as is highly common in those with ADHD or ARDs (Choi et al., 2022; Davies et al., 2023; Essau et al., 2018; Fayyad et al., 2017; Ruscio et al., 2017), supporting the ecological validity and generalizability of the findings. The interview questions were focused on ARDs and ADHD, and however, it is likely that the presence of these other co‐occurring mental health difficulties influenced participants' descriptions of their lived experiences, particularly because depressive disorders are also associated with cognitive deficits (e.g., Rock et al., 2014).

CONCLUSION

Despite these limitations, the current study provides an exploration of the understudied phenomenon of living with ARDs and ADHD as an adult, using qualitative descriptions from clients with both diagnoses. Participants' descriptions demonstrated convergence with respect to complicated perceived relationships between symptoms of the two conditions, challenges with respect to diagnosis, intervention and living with both. The current study elucidates several clinical areas that necessitate further investigation and development.

AUTHOR CONTRIBUTIONS

Arij Alarachi: Conceptualization; investigation; writing – original draft; formal analysis; methodology. Heather McNeely: Writing – review and editing; formal analysis; supervision. Karen Rowa: Writing – review and editing; formal analysis; supervision; resources. Randi E. McCabe: Writing – review and editing; supervision; resources; formal analysis.

CONFLICTS OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Table S1

BJC-65-925-s001.docx (16.7KB, docx)

ACKNOWLEDGEMENTS

The authors would like to acknowledge Inaya Tariq and Marly Mikhail for supporting with the transcriptions of interviews and sharing preliminary themes with participants to elicit their feedback.

APPENDIX A.

TABLE A1.

Demographic and clinical information for the study sample.

Characteristic n M ± SD or %
Age 16 28.75 ± 9.50
Gender identity 16
Woman 9 56.25
Man 6 37.50
Transgender 1 6.25
Ethnicity 16
White/European 14 87.50
Other, not specified further 2 12.50
Main diagnoses 16
ADHD 16 100
Age of diagnosis 16 20.13 ± 13.85
GAD 10 62.5
SAD 7 43.75
PTSD 5 31.25
OCD 5 31.25
MDD 6 37.50
PDD 4 25
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TABLE A2.

Qualitative interview themes.

Theme n
It's complicated: Perceived relationship between ADHD and anxiety symptoms
Synergistic relationship 15
Opposing relationship 12
They neutralize one another 10
This leads to internal conflict 2
It depends on the context 2
Some overlap; some distinction 5
Diagnosis experiences: Validation, surprise, and integration
Clarity, relief and validation 10
Initial disbelief and surprise 8
Grief due to late diagnosis 3
Integration and acceptance 9
System overload and polarizing experiences with symptoms and impairment
Time management difficulties 8
Overwhelm/overstimulation 6
Perfectionism 4
Chaos 4
Impact of co‐occurring ARDs and ADHD on the self: Underachievement and stigma
Underachievement, self‐criticism, and shame 6
Stigma 4
Lack of support and treatment incompatibility
Lack of resources for ADHD 5
Services are less effective due to presence of other disorder 4
Developing strategies and habits to manage symptoms and relying on loved ones 10
Using cannabis to cope 3
Coexistence and focusing on strengths
Positive aspects of their lived experience 6
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DATA AVAILABILITY STATEMENT

Study data are not publicly available, as participants did not provide consent for the broader sharing of their interview transcripts.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Table S1

BJC-65-925-s001.docx (16.7KB, docx)

Data Availability Statement

Study data are not publicly available, as participants did not provide consent for the broader sharing of their interview transcripts.

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