Managing Panic Attacks in Patients with ADHD: Best Practices
ANXIETY+ADHD
by Dr Tiongko
April 2025
Introduction
Attention-deficit/hyperactivity disorder (ADHD) and anxiety disorders frequently co-occur, creating complex clinical scenarios. Studies indicate that up to 50% of children with ADHD also meet criteria for an anxiety disorder and similar high comorbidity rates are seen in adults. Panic attacks – sudden episodes of intense fear accompanied by physical symptoms – can be especially challenging when they occur in a patient with ADHD. The overlapping symptoms of inattention, restlessness, and irritability can muddy the diagnostic waters, and treatment must address both conditions in an integrated way. This article outlines evidence-based strategies for pharmacologic and psychotherapeutic management of panic attacks in patients with ADHD, with considerations for different age groups, and offers clinical pearls for frontline providers.
Differentiating ADHD and Anxiety Symptoms
Careful assessment is the first step in managing co-occurring ADHD and panic/anxiety. ADHD and anxiety share several symptoms – for example, trouble concentrating, restlessness, sleep problems, and racing thoughts – but the reasons for these symptoms differ. In ADHD, an individual’s mind may race due to “mental chatter” and distractibility, jumping from one thought or stimulus to the next. In contrast, an anxious person’s racing thoughts are often focused on specific worries or fears (e.g. dread of a panic attack or anxiety about performance). A person with ADHD might appear fidgety or impulsive in any setting due to neurodevelopmental disinhibition, whereas an anxious person might fidget or act out only when feeling overwhelmed or threatened.
Similarly, both ADHD and anxiety can lead to task avoidance, but for different reasons: the ADHD patient avoids sustained mental effort because of difficulty with focus, while the anxious patient avoids situations that trigger fear (for instance, a person with panic attacks may avoid crowded places or presentations) Recognizing these distinctions is crucial for accurate diagnosis and treatment.
Pharmacological Management Strategies
Managing a patient with both ADHD and panic attacks often requires a balanced pharmacological approach. The key questions are: Should we use stimulant or non-stimulant medication for ADHD? And how do we treat the panic/anxiety component without exacerbating either condition? Evidence-based guidelines and studies support a thoughtful, case-by-case strategy:
Stimulant medications for ADHD: Stimulants remain first-line for ADHD in most cases – even when anxiety disorders are present. Proper ADHD treatment can itself reduce anxiety; as ADHD symptoms improve, patients often feel more in control and less anxious. In fact, studies have found that treating ADHD with stimulants frequently not only improves concentration and behavior but also alleviates comorbid anxiety symptoms in many patients. Stimulant treatment (e.g. methylphenidate or amphetamine formulations) is generally safe and well-tolerated in individuals with ADHD and co-occurring anxiety.. However, caution is warranted: a subset of patients may experience heightened anxiety or jitteriness on stimulants. For example, stimulants can cause side effects like increased heart rate, insomnia, or nervousness, which might feel like a panic attack or amplify an underlying anxiety disorder. The clinical consensus is to start with low doses and titrate slowly, closely monitoring anxiety symptoms. If one stimulant exacerbates anxiety, switching to a different class (e.g., from an amphetamine to methylphenidate or vice versa) is an option, as individual responses vary. Some experts recommend using “lower-potency” stimulants or long-acting formulations in anxious patients to avoid sharp peaks that could trigger panic. The bottom line is that stimulants can be used in most ADHD+anxiety patients, as long as the clinician is vigilant and ready to adjust the plan if anxiety worsens. Always reassess: if ADHD symptoms improve but panic attacks continue or intensify, then additional interventions targeting anxiety are needed.
Non-stimulant options for ADHD: In patients whose anxiety is severe or who do not tolerate stimulants, non-stimulant ADHD medications offer an alternative. Atomoxetine, a selective norepinephrine reuptake inhibitor, is a prime option – it treats core ADHD symptoms and has shown efficacy in reducing anxiety in ADHD patients. A 2022 systematic review found that atomoxetine not only did not exacerbate anxiety, but actually led to reduced anxiety symptoms in children and adolescents with ADHD. This dual benefit makes atomoxetine a valuable choice in co-morbid panic or generalized anxiety, especially if there are concerns that stimulants provoke panic attacks. Clinically, atomoxetine may take a few weeks to reach full effect, so it’s less rapid than stimulants; during that time, covering the patient’s acute panic symptoms with therapy or short-term medication (see below) may be necessary. Alpha-2 agonists (guanfacine and clonidine) are another non-stimulant class for ADHD that can be useful in anxious patients. These medications reduce hyperactivity/impulsivity and can have a calming, sedative effect that might indirectly help anxiety (they’re sometimes used off-label for PTSD-related hyperarousal or insomnia). Guanfacine extended-release, for example, is FDA-approved for ADHD and can be given at night to help with sleep and evening anxiety. Keep in mind alpha-2 agonists can cause drowsiness or low blood pressure, so titrate carefully.
SSRIs and SNRIs for panic/anxiety: For a patient with true panic disorder or significant anxiety, antidepressant therapy is often indicated alongside ADHD treatment. Selective serotonin reuptake inhibitors (SSRIs) are considered first-line pharmacotherapy for panic disorder and other anxiety disorders. SSRIs such as sertraline, escitalopram, or fluoxetine can substantially decrease the frequency and intensity of panic attacks over time, and they also help generalized anxiety and social anxiety if those co-occur. Serotonergic medications have no direct effect on ADHD symptoms, but by relieving anxiety they may indirectly improve attention (an individual no longer preoccupied by worry can concentrate better). In moderate to severe cases of comorbid anxiety, experts recommend adding an SSRI to stimulants if stimulant alone doesn’t resolve the anxiety. This combination is commonly used in practice, but it requires monitoring. Start SSRIs at a low dose and increase gradually, because some patients experience transient activation or heightened anxiety in the first couple of weeks of SSRI therapy – which could potentially trigger a panic attack if not anticipated. Counseling the patient that initial side effects (e.g. jitteriness, upset stomach) typically subside can improve adherence. Serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine are also effective for panic and generalized anxiety and can be considered, particularly if an SSRI is not effective. Venlafaxine at higher doses has mild dopaminergic effects that might even help ADHD a bit, though it’s not a primary ADHD treatment. SSRIs are often effective for anxiety but must be monitored for any behavioral activation or suicidal ideation (per the black-box warning). In anxiety disorders, SSRIs and cognitive-behavioral therapy are the evidence-based treatments of choice and this holds true when anxiety coexists with ADHD – treat both, and do so safely.
Acute and adjunct anxiety medications: While SSRIs/SNRIs take weeks to work, patients with frequent panic attacks may need acute relief options. Benzodiazepines (such as lorazepam or alprazolam) can quickly abort a panic attack by enhancing GABAergic inhibition, but use them sparingly and judiciously. In an ADHD patient (child or adult), benzodiazepines carry risks: sedation can undermine attention and learning, and there is potential for dependence or misuse (especially if the person has impulse control problems or a history of substance use). Benzos are generally avoided in children and used in adults only as a short-term bridge or PRN for very severe panic episodes. If used, long-acting agents like clonazepam might be preferred over short-acting alprazolam to reduce peaks and troughs of anxiety. Buspirone is a non-sedating anxiolytic that might benefit generalized anxiety and is sometimes added for adults with ADHD/anxiety. While buspirone does not treat panic as robustly as SSRIs, it has the advantage of not affecting attention or having abuse potential. It can be considered if mild anxiety persists or SSRI is only partially effective. Beta-blockers (e.g. propranolol) can be helpful for performance or situational anxiety by controlling the physical adrenergic symptoms (tremor, heart racing). They won’t prevent a panic attack per se, but in someone with ADHD who gets panic attacks in specific scenarios (e.g. public speaking), a beta-blocker taken beforehand might reduce the chances of spiraling into panic. Finally, some tricyclic antidepressants (like imipramine) have historical evidence for treating panic disorder and ADHD, but due to side effects and safety profile, they are third-line at best. Bupropion, an atypical antidepressant, is occasionally used off-label to tackle both adult ADHD and depression/anxiety. It can be useful if an adult patient cannot tolerate stimulants and also has depressive symptoms; however, bupropion is not typically effective for panic attacks and can actually worsen anxiety in some cases (because it has stimulant-like properties). Thus, it’s reserved for specific situations and usually managed by psychiatry.
Choosing the right medication(s): Tailor the plan to whichever condition is causing the most impairment, while keeping the big picture in mind. If ADHD symptoms are wreaking havoc on school/work and the anxiety is relatively mild, it may make sense to start with an ADHD medication (stimulant or atomoxetine) and see if the anxiety improves when the patient’s life becomes more organized and focused. On the other hand, if panic attacks are frequent and disabling, an SSRI (plus therapy) might take priority initially, since uncontrolled panic can itself impair concentration and daily functioning.
In many cases of true comorbidity, a combination approach is warranted: for example, starting a low-dose stimulant and an SSRI together, or continuing an ADHD medication while initiating CBT for panic, rather than waiting sequentially.
Remember! no one-size-fits-all sequence, and primary care providers should use clinical judgment and, when needed, consult psychiatry for complex medication regimens. Importantly, integrating therapy with medication (discussed next) has been shown to yield superior outcomes compared to medication alone.
