A recent review of 41 research articles suggests that people with social anxiety disorder should be screened for attention-deficit/hyperactivity disorder (ADHD) and vice versa. The article, published in the Journal of Attention Disordersfound that having both social anxiety disorder and ADHD is linked to more severe symptoms and higher levels of impairment compared to having just one of the conditions.
Social anxiety disorder is a mental health disorder characterized by an intense fear of social situations due to fear of being judged, embarrassed, or humiliated. People with this disorder often experience significant anxiety and distress when interacting with others, which can lead to avoidance of social situations, difficulty forming relationships, and impairment in daily functioning.
ADHD, on the other hand, is a neurodevelopmental disorder characterized by persistent patterns of inattention, impulsivity, and hyperactivity. People with ADHD may have difficulty focusing on tasks, following directions, organizing activities, and controlling impulses, often resulting in disruptive behaviors and difficulty maintaining attention. The disorder is usually diagnosed in childhood, but symptoms can persist into adulthood.
This study was motivated by the need to understand the overlap between these two common but seemingly different disorders. By systematically reviewing existing research, the study aimed to shed light on the prevalence, symptom severity, and potential subtypes of this comorbidity.
“As a clinical psychologist with a background in child and adolescent psychiatry, the intersection of ADHD with co-occurring anxiety represents an important and underexplored area in clinical practice,” said study author Siri Jakobsson Støre, assistant professor at Karlstad University and postdoctoral research associate at Örebro University.
“Throughout my training and clinical experience, I have observed the profound impact that these comorbidities can have on adolescents, affecting their academic performance, social interactions, and overall quality of life. This research provides an opportunity to contribute to a better understanding of comorbid ADHD and social anxiety disorder (SAD), which can ultimately inform future interventions and provide more comprehensive and effective care for these individuals.”
The analysis followed PRISMA guidelines for systematic reviews. The researchers searched databases such as PsycInfo, PubMed, Scopus, and Web of Science for articles published since 2000 that examined the relationship between ADHD and SAD. They included studies that used quantitative methods and met specific criteria, such as focusing on adolescents and adults and being peer-reviewed. The final sample included 41 studies conducted in various countries, mostly using cross-sectional designs.
Data extraction focused on the number of participants, age range, gender, diagnostic criteria used, and outcome measures related to ADHD and SAD. Study quality was assessed using the Effective Public Health Practice Project tool, which assesses aspects such as selection bias, study design, and data collection methods.
The prevalence of ADHD in people with social anxiety disorder varied widely across studies, ranging from 1.1% to 72.3%. Similarly, the prevalence of social anxiety disorder in people with ADHD ranged from 0.4% to 46.7%.
“This variation may be partly due to differences in how studies define and measure social anxiety and ADHD (clinical and subclinical conditions, diagnostic interview and symptom scale, clinical and general sample, etc.),” Støre explained.
The study also found that people with both social anxiety disorder and ADHD tend to have more severe symptoms and greater impairments than those with only one of the disorders. This increased severity translates into higher levels of social anxiety, more pronounced attention deficits, and greater difficulties with social functioning.
For example, people with both disorders showed greater difficulties in their social interactions, such as generating fewer optimal solutions on social problem-solving tests and lower levels of empathy. This suggests that the presence of both disorders compounds the difficulties associated with each condition, leading to a higher overall symptom burden.
“Having both social anxiety disorder and ADHD was associated with more severe symptoms and higher levels of impairment than having only one of the two diagnoses,” Støre told PsyPost. “Therefore, individuals with one diagnosis should be screened for the other to allow for earlier detection of possible comorbidity. Clinicians should also note subclinical symptoms of both social anxiety disorder and ADHD, as even subclinical symptoms can worsen the prognosis regarding treatment outcomes.”
“Further research is needed on social anxiety subgroups in general, and specifically on the social anxiety subgroup characterized by high impulsivity, particularly in adolescents and adults with comorbid ADHD.”
Another important finding was the identification of a specific subtype of social anxiety disorder characterized by high impulsivity. This subgroup, although less frequently studied, had higher levels of externalizing behaviors and ADHD symptoms. This impulsive subtype of social anxiety disorder includes individuals who, in contrast to the typical presentation of social anxiety involving shyness and inhibition, exhibit impulsive actions that may appear as assertiveness, aggression, or risk-taking behaviors.
The study also noted that the relationship between social anxiety disorder and ADHD is particularly relevant during adolescence, a critical period for the development of both disorders. Adolescence is a time when social relationships become increasingly important, and the social challenges associated with both disorders can have profound impacts on an individual’s development. However, most of the studies reviewed focused on adults.
“Most of the included studies were conducted in adults, which is surprising given that adolescence is a critical developmental stage and a vulnerable period for both adolescents with social anxiety disorder and those with ADHD,” Støre said.
Finally, the review highlighted several limitations in existing research.
“The quality scores of the included studies were particularly low, suggesting that our conclusions should be considered preliminary,” Støre noted. “However, the assessment tool used was not suitable for cross-sectional studies, which constituted the majority of the included studies. Excluding the confounding aspect, as well as the three aspects initially excluded (due to the non-interventional nature of the studies), improved the overall quality scores from remarkably low to moderate, indicating more reliable conclusions than initially expected.”
“Another limitation was inconsistent terminology, where different terms for underdiagnostic and diagnostic social anxiety disorder (such as ‘social phobia’) and ADHD were used in the included studies, which could affect the consistency of the results.”
These gaps highlight the need for more comprehensive and inclusive research to fully understand the complexities of social anxiety disorder and ADHD comorbidity.
“My long-term goal is to evaluate psychological interventions for adolescents and adults with neurodevelopmental disorders,” Støre says. “Although pharmacological treatments are commonly used to manage ADHD symptoms, they are not always effective in treating comorbid anxiety. Additionally, traditional treatments for anxiety may not be fully effective for people with ADHD because of differences in cognitive functioning and behavioral patterns.”
“There is therefore a need for interventions specifically designed or tailored to this population. A study is underway on NeuroACT, a psychological intervention based on the principles of acceptance and commitment therapy, which has already been evaluated in adults with autism spectrum disorders by another research group. Our study will focus on adolescents diagnosed with ADHD and/or autism spectrum disorder, suffering from psychological distress.”
“The intervention aims not only to reduce anxiety, depression and stress, but also to improve functional levels, psychological flexibility, mindfulness and acceptance, going beyond just reducing symptoms,” Støre said. “This is in line with my therapeutic philosophy of empowering patients to lead more fulfilling lives despite their difficulties.”
The review, “The relationship between social anxiety disorder and ADHD in adolescents and adults: a systematic review,” was authored by Siri Jakobsson Støre, Nejra Van Zalk, Wilma Granander Schwartz, Victoria Nilsson, and Maria Tillfors.