The average patient goes into the average psychiatrist’s or psychotherapist’s office, or even more likely into the average internist’s office, complaining that he or she doesn’t feel right. They may talk about physical anxiety, either constant hyperarousal, or intermittent explosions of panic and dread, or perhaps they just can’t relax, don’t feel themselves.
Depending on the biases of the practitioner involved, the patient might get tranquilizers like Xanax or Klonopin. They might get an SSRI like Lexapro. They might get any of a number of psychotherapies: behavioral, supportive, experiential, psychodynamic, or psychoanalytic.
What they probably won’t get is someone who understands the powerful role that attentional factors can play in the creation of this broad group of anxious/depressive disorders.
And that’s too bad. In my view, undiagnosed milder forms of the badly named entity we now call “Attention Deficit Disorder” are at the heart of a truly staggeringly high percentage of anxiety disorders. When the attentional component is not recognized (and believe me folks it almost never is), the medication will be wrong, the therapy won’t ring true, and the treatment will be ineffective.
What’s Really Going On?
ADD is an iceberg. Only about a third of it is above the surface. If it isn’t noticed in preschool or at the switch to middle school, it may not be recognized at all. Remember that ADD is extremely variable in its presentation and that a person may or may not have trouble in any one particular area.
The essential question in anyone with an ADD brain, one that prefers higher levels of stimulation and action over reflection, is how they train for and perform tasks that they do not find inherently appealing (for a much fuller discussion of my thoughts on the nature of ADD, please see Chapter 3 of my new book, Getting Unstuck: Unraveling the Knot of Depression, Attention and Trauma now available).
Stimulants like Ritalin and Dexedrine can be used to improve focus, to make it easier to stay on uninviting tasks. It turns out that we have our own internal stimulant, adrenaline, and an arousal system built around it. The way we use or misuse adrenaline lies at the core of the relationship between ADD and anxiety.
Attention, Arousal, and Anxiety
A person with ADD seeks high arousal. They can do that by putting themselves in inherently arousing situations or by training their adrenaline/arousal systems. The experience of arousal, as measured by things like blood pressure, heart and respiratory rate, muscle tension and the like, can be pleasant or unpleasant. It can involve fear, or joy or anger. Some people love roller coasters.
What matters here is that when we arouse ourselves too highly for too long, we change two important nervous system settings: our resting nervous tone and our “fight or flight” response trigger. If the “fight or flight” response to danger occurs when no immediate danger is present, and especially if it doesn’t go away rapidly enough, it is often perceived as a “panic attack.
It’s people with milder sorts of ADD, people who grew up with adequate resources, people with a dollop of smarts, with engaged and generous parents, who are going to find useful and reliable ways to arouse themselves, and these folks can often focus quite well most of the time.
Nevertheless they often run into what might be called the Peter Principle for ADD: they rise to the limits of their attentiveness. Unfortunately, modern lives are quite complex and often jobs we want entail aspects that are distinctly unappealing. Smart, ambitious, what I call “high bar” people, when shooting to maintain the high level of stimulation required for comfortable focus, can easily tax their attention and arousal systems until they unbalance their nervous systems creating anxiety, chronic hyperarousal, and panic.
Why This Matters
Identifying mild ADD underneath anxiety disorders is important because it directs psychopharmacological treatment in completely different directions.
These sorts of nervous system changes are mediated by the norepinephrine neurotransmitter system, rather than the serotonin system. SSRI’s (like Lexapro), which bring with them weight gain and sexual dysfunction, are not terribly effective. The norepinephrine reuptake inhibitor (NRI) Desiprimine is a much better choice. It resets the nervous system, assists in attention in many cases, all without the side effects.
Likewise, minor tranquilizers are a terrible but all too common choice in these cases. They seem to help at first, but work less and less well over time, essentially making the problem worse, and are addictive to boot. If underlying attentional problems are recognized, small doses of stimulants, often applied only at times when intense attention to difficult tasks is required, can actually decrease the pressure on the nervous system and, in some cases, result in the complete elimination of anxious symptoms.
Apart from the implications for medication, there are a host of psychotherapeutic interventions that are specific for high functioning adults with ADD. The approaches that I believe are required are discussed in much further detail in Getting Unstuck. Suffice it to say that they differ substantially from those that would be applied to an anxious person who does not have ADD.
The Attention Doctor is in.