ADHD: Bottom-Up Triggers of Social Anxiety

Adult clients who present with attention-deficit/hyperactivity disorder (ADHD) often describe a social anxiety spiral of thinking that leads to subjugating, masking, reassurance seeking, and/or overcommitting to things. These behaviors are particularly adverse for mental health. The values people hold (e.g., authenticity, loyalty, fairness, and kindness) may spiral into unrelenting expectations of the self, feeling guilt, and the self-limiting belief of not feeling good enough. Rejection-sensitive dysphoria and emotional hyperarousal precipitate clinically significant symptoms of distress.

Traditional talk-based methods of therapy that are cognitively oriented (i.e., that focus on logic and reasoning) are viewed as a top-down approach to treatment. Dr. Bruce Perry states, "despite the well documented effects of fear and anxiety on the ability to reason, often programs tend to ignore the need to engage the safety system of the brain and focus instead on recruiting the cognitive capacities of the mind" (Perry, 2021). Polyvagal theory has enabled us to become more conscious of combining top-down approaches (i.e., that promote new ways of thinking) with bottom-up methods. A bottom-up approach addresses mechanisms underlying social anxiety (i.e., somatically driven and oriented toward body-up triggers).

Bottom-Up Triggers of Social Anxiety

Neurodivergent individuals are susceptible to emotional contagion (the tendency to absorb, catch, or be influenced by other people's feelings) and can distinguish very subtle cues that others would not. Professor Tony Attwood described this as a sixth sense and likened the experience to the analogy of a negative tone of voice infecting a neurotypical person at the strength of a cold. In contrast, a neurodivergent individual is infected at the strength of the flu. This can be an overwhelming experience that cannot be easily bypassed. Emotional dismissal can be crippling.

Dr. Stephen Porges has coined the term neuroception, which describes how our neural circuits distinguish whether stimuli are safe or dangerous. Specific areas of the brain detect and evaluate an impression of safety and trustworthiness. For example, at a subconscious level, you may immediately feel dysregulated (anxious) and disconnected from people at an event. Dysregulation can then trigger survival mode thinking (socially anxious thoughts) and an increased sense of self-focus. Thoughts may include, "Am I doing or saying the right thing?" or "Am I enough?" (interesting/funny). A neuro-biologically informed approach can feel comforting for clients as they are not expected to reason their way out of anxious thoughts. Rather, the goal is to defuse from thoughts (as triggers are considered to be instinctual and require understanding, compassion, and actively helping the individual to feel safe) and tune into your neuro-biological needs (Delahooke, 2019).

5 Questions to Help You to Tune Into Your Neuro-biological Needs

1. What is my baseline? (Consider quality of sleep, hormonal cycle, stress, and fatigue levels.)
2. Consider environmental triggers; is an accommodation needed (e.g., emotional rest)?
3. Am I feeling a neuroception of safety and connection (at a subconscious level, am I feeling dysregulated and disconnected from the people in the room)?
4. How are my subconscious urges impacting me? (Is your vulnerable child within needing a healthy adult perspective to soothe unmet psychological needs or unprocessed emotions?)
5. Am I listening to my neuro-biological needs (e.g., Is there a need for a movement break)?

9 Techniques to Center the Mind and Body

1. Learning to be mindful of your emotions in a curious and nonjudgmental manner (acceptance and commitment therapy) allows you to change how you pay attention to an emotion and sets the framework for managing distress in a healthy way.
2. Neuroscientist Dr. Bruce Perry's pioneering model of sequential engagement and processing highlights the importance of regulating (calming the stress response) and connecting through a relational approach before reasoning (e.g., attempting to feel self-assured).
3. When the autonomic nervous system has moved into a dysregulated dorsal vagal state (shutdown, numbing, disconnection, or dissociation) or sympathetic state (mobilization of fight or flight, survival mode thinking), a quest for safety and connection can be realized by co-regulation (Dana, 2020). Co-regulation is defined as the way in which one's autonomic nervous system interacts with another person's autonomic nervous system in a way that facilitates connection and safety. This involves a recognition of a shift in one's autonomic state, which is met with a responsive, warm, calming presence and tone of voice. Co-regulation is dependent upon how the person is seen, heard, and held and the ways they are offered safety and connection (Dana, 2020).
4. Subconscious urges have a distinct sense of urgency to them and may trigger the vulnerable child within. Conscious thought and taking action may not produce change. Rather, change may require you to memorize that feeling and move what you have learned from the conscious mind to the subconscious. Schema therapy is a powerful treatment approach that allows people to identify psychological defenses and self-defeating patterns that begin early in life.
5. Embracing the authentic self (e.g., checking in with what you feel and need at any given moment in time) fosters a genuine connection with the self and others.
6. Activities that are regulatory, rhythmic, and/or involve movement are beneficial to completing stress cycles (to help the body move out of survival-mode thinking).
7. Neurodivergent minds need to rest and recharge. There are many different types of rest, including sensory rest, creative rest, emotional rest (having the time and space to freely express how you feel), and social rest.
8. Positive traits of ADHD—of which there are many—include being kind, passionate, creative, honest, curious, innovative, and good in a crisis. Clients with ADHD often report their innate ability to thrive in situations of variety, of rapid change, and that reward innovative thinking.
9. Neurodivergent minds benefit from feeling the flow of operating within their own space and time. Flexibility (accommodations) allows people to minimize the negative and leverage the positive.

To prevent the adverse impact of ADHD burnout (chronic stress causing disturbance to our physical autonomic nervous system and mental functioning), it is important that we move toward a neuro-affirming and neuro-biologically informed approach.