A patient once told me, “I don’t think I’m anxious. I think I’m just failing at life.”
She was a working mother of two, highly capable and organized on the surface, but deeply overwhelmed underneath. She described constant mental noise, difficulty initiating tasks, and a persistent sense of falling behind no matter how hard she tried.
She had already been treated for anxiety. Twice. Her medication list included an SSRI and a beta blocker. She had tried therapy, mindfulness, sleep hygiene, and stress reduction. None of it worked. Because anxiety wasn’t the primary problem.
In primary care, anxiety is one of the most common diagnoses, and for good reason. Patients present with racing thoughts, restlessness, irritability, sleep disruption, and a sense of being constantly on edge. These symptoms are real, impairing, and often responsive to standard treatments.
But not always.
There is a subset of patients who do not improve with typical anxiety management. In these cases, we may be missing the underlying driver. In my practice, many of these patients meet criteria for attention-deficit/hyperactivity disorder (ADHD), often the inattentive presentation.
Adult ADHD rarely looks like the stereotype most of us were trained to recognize. These patients are not necessarily hyperactive. They are often high-functioning, intelligent, and motivated. Many have developed compensatory systems that allow them to perform well in structured environments, particularly earlier in life.
What they describe instead is internal chaos.
They struggle with task initiation, organization, prioritization, and follow-through. Their thoughts move quickly, often in multiple directions at once. Daily responsibilities require disproportionate effort, leading to chronic mental fatigue. Over time, this creates a predictable pattern: overwhelm. And overwhelm, when persistent, feels like anxiety.
This distinction matters because the treatment approach is different.
When ADHD is the underlying driver, treating anxiety alone can feel ineffective or even frustrating for patients. They may experience partial relief, but the core issue — the inability to consistently manage cognitive load — remains.
As a result, they continue to feel behind, disorganized, and mentally exhausted. That ongoing strain reinforces the anxiety, creating a self-perpetuating cycle.
There are often subtle clues. Many of these patients describe lifelong patterns of procrastination or disorganization. Their anxiety tends to spike in response to task demands or mental overload rather than purely emotional triggers. They may report repeated burnout despite high effort, or difficulty “shutting off” their thoughts at night, not from fear-based rumination, but from cognitive overactivity.
When prior anxiety treatments have provided only partial or inconsistent benefit, it is worth pausing to reconsider the diagnosis.
Sometimes even a brief screening conversation can open the door. Tools like the Adult ADHD Self-Report Scale can help structure that discussion, but more importantly, they validate what many patients have struggled to articulate for years. When patients begin to understand that their experience may be related to executive dysfunction rather than a primary anxiety disorder, something shifts. The narrative changes from “What is wrong with me?” to “My brain is overwhelmed.”
That shift alone can reduce shame. From there, treatment can become more targeted, addressing both executive function and nervous system regulation. Not every anxious patient has ADHD. But when anxiety is chronic, treatment-resistant, and closely tied to overwhelm, it is worth considering whether we are treating the symptom rather than the source.
Because sometimes, the most anxious patients in our clinics are not anxious at their core. They are overloaded.
Linda Rowan, PMHNP-BC, is a psychiatric nurse practitioner providing telehealth care across multiple states, specializing in anxiety, ADHD, and nervous system regulation. Her work focuses on integrating evidence-based psychiatric care with a deeper understanding of brain physiology and autonomic function.
This article is part of the Medical Insights vertical on Op-Med, which features study breakdowns, resources, and insights from Doximity members on popular topics in medicine. Want to submit to Medical Insights? See our submission guidelines here; note that we are especially interested in articles covering oncology, dermatology, or rheumatology.
Image by Master1305 / Shutterstock
