Understanding the ADHD and Anxiety Overlap with Dr. Mona Potter
Distinguishing between ADHD and anxiety can feel a bit like trying to figure out if you're sneezing because of a cold or because your neighbor just started mowing their lawn - or maybe it's a bit of both, the symptoms look the same, but the solution is very different. This week, I’m talking with Dr. Mona Potter, a Harvard-trained, board-certified child and adolescent psychiatrist and the Chief Medical Officer and Co-founder of InStride Health. Dr. Potter spent years at McLean Hospital pioneering treatments for anxiety and OCD, and has a unique perspective on how we can manage the specific brand of exhaustion that comes with being neurodivergent in a world that never stops moving.
Today, we’re exploring the bio psycho social model—which is just a fancy way of saying we’re looking at your sleep, your stress, and your chemistry all at once. We discuss the "optimal zone" of anxiety and how it can actually mask ADHD symptoms until you find a treatment that works, the difference between a "crutch" and a tool, and why parents (and adults) should stop trying to be the "external executive function" for everyone around them. We also take a deep dive into the specific mechanics of OCD and why the structure that saves an ADHDer might actually feed an obsessive loop.
If you'd life to follow along on the show notes page you can find that at HackingYourADHD.com/269
YouTube: https://tinyurl.com/y835cnrk
William Curb: I am so glad to have you here. And with our pre-conversation, you know, I've found that we just have this like great jumping off point of going into this idea of what's this distinguishing like ADHD and anxiety, because they can often look very similar if you're just looking at symptoms.
Mona Potter: Yeah, and I see this clinically all the time where somebody will come in with a diagnosis of ADHD, and they've done all this ADHD treatment, and they are so frustrated because they're not getting better in that things continue to be hard. They're really struggling. They're exhausted because they're trying hard, but it's not working. What I really I've learned clinically to say is when you come in, when you're having a hard time focusing, and when you think about inattention, think about it like a fever. There can be a lot of different causes. There can be a bacterial infection, a viral infection, even hyperthermia. And so instead of saying let's immediately say inattention is ADHD, let's really be curious about what could be causing it. Inattention can be caused by ADHD, absolutely, but also by anxiety, by depression, by trauma, learning difficulties, even our basic biological needs like sleep and nutrition and movement and exercise and even chronic stress. And so I think that before we dive into diagnosis and treatment, we need to make sure that we truly understand all of the parts that might be leading to the symptoms that the person's coming in with.
William Curb: Oh yeah, absolutely. Because even within ADHD, you go like there's this inattention, but what is driving that inattention? Because like I could be like, I'm not focused here because I can see stuff happen out my window or I'm really uncomfortable or all these other things. Yeah, figuring out the root of what's causing that I feel is such an important piece of treatment.
Mona Potter: Yeah, it's easy for us to sit here and kind of say, well, this and this and this and you so any I want to have a caveat that people do not read the DSM, which is our psychiatry like manual and people come in with all of their complications.
And that being said, I think as we're talking, it is nice to kind of try to have like put in some rules, put in some simplifications. So when somebody comes into me saying, gosh, I'm having a really hard time focusing, I'm having a really hard time physically sitting still, I'm also being anxiety. And so a few things that I ask about to kind of help me make that differentiation is one kind of when when you're distracted, when you're noticing your thoughts are not where you need or want them to be, what is causing that distraction with ADHD? Oftentimes, it's external. It's kind of like the world is tapping you on the shoulders multiple times, like there are all these things that are just interesting or just grabbing your attention and your attention goes. Whereas with anxiety, oftentimes it's more of an internal distraction. There's kind of the you're hearing what's going on. But then there's this all the side commentary of what could go wrong, the uncertainty, all of the worst case scenarios, the ways in which you've messed up the judgments. And those can get really distracting and make it hard to focus on what's in front of you.
William Curb: Yeah. And then I can also see that being like different from like the inattentive side of ADHD where it's inattention, but not because of, you know, it's just like, oh, I'm just somewhere else kind of.
Mona Potter: I mean, I think that oftentimes we think about ADHD is just like pure hard time having attention. It's more of an attention regulation. It can be due to different distractions. It can also just be that the brain has just kind of like just kind of settled into itself and you're just focused elsewhere and not on the task at hand. The ADHD brain, it's just it has a higher threshold for latching on. The anxious brain, on the other hand, almost has that hypervigilance, it latches on almost too tightly. And so you can have almost similar kind of presentations, but very different underlying brain processes that lead to it.
William Curb: Yeah. And I feel like it's also important to add into this that you can definitely have both at the same time. Absolutely. And that can have different ways that that manifests and some interesting things. Absolutely.
Mona Potter: Well, I mean, and so this is, I'm like, they're going kind of three buckets. There's the one bucket of misdiagnosis where I've seen ADHD and misdiagnosed as anxiety and vice versa. Anxiety, misdiagnosed as ADHD. And then there's the bucket of somebody comes in with ADHD. Their ADHD is not well managed.
And so they are still symptomatic. Life is hard. They're feeling they're having kind of difficulty remembering things, difficulty keeping on top of things, meeting deadlines. And then there's kind of this internalisation of like, I'm not good enough. I'm a failure.
I can't do these things. And then of course, you're going to feel anxious about responsibilities. Of course, you're going to feel anxious about all the things that on your plate that you need to get done. And then there's kind of the third category of ADHD and anxiety both exist together. And I'd say that all three of them have some overlapping interventions, and then some very different ways that you would want to manage them.
So I think it is important to be able to say which bucket is this person in so that I can make sure that the intervention I'm putting in place is actually matching the needs of this individual.
William Curb: A couple of years ago, I had done a switch up in my medication, and it helped with some of my anxiety, which I had then realized was what had kept me from being late all the time. Like that was, I was very good at being on time, but it was just like all anxiety driven. And so then the medication helped with that.
And suddenly I was getting, I was like late all the time again. And I was like, Oh, I actually have to use some of these strategies. Like I knew all the strategies to do. And I was like, okay, I just actually have to do them now.
Mona Potter: Yeah, it's like that zone of like optimal anxiety. I mean, I talk about this all the time in my clinic and actually remind myself of this even in my own personal life of like anxiety is a really important emotion. And there are times where it is actually very motivating and it helps us know what's important to us. And it helps drive behaviors that matter. And at the same time, anxiety can get to a point where it becomes overwhelming and it's no longer helpful.
But I think when it's in its optimal zone, it can almost sometimes even mask some of the symptoms of ADHD because it kind of counters or protects again some of that distractibility and attention of ADHD. So I think that's a really interesting point and interesting experience you've had.
William Curb: Yeah. Yeah, I was with this friend that like I met through a coaching group that just he was like, yeah, I don't have anxiety. And we're like, everyone's like, Oh, that sounds so great. He's like, No, I don't worry about anything. And he's like, it's a problem. I can't it makes it really hard to have any motivation.
Mona Potter: I'm laughing because I have this picture that I show when I when I talk about anxiety and anxiety on a spectrum. And I have, I don't know where I found this picture, but it's a picture of this woman sitting on a plank in the middle of the ocean reading a book with a bunch of sharks all around her. And she has no anxiety. And it's like, Yeah, no, a little bit of anxiety in a moment like that would be great.
It would motivate, it would help you know that something's important and and help you choose behaviors that you need in the moment. And so it is kind of finding that optimal zone though, because again, when it kind of goes into the into the more what we call anxiety disorder zone or the more severe zone, it gets overwhelming, it gets exhausting, it starts distracting kind of that body fight, fight, freeze comes in where it can paralyze or cause you to just avoid things that really do matter.
William Curb: You can also have like some really negative like physiological symptoms too, from what I understand.
Mona Potter: Yeah, so anxiety is a very both physical and emotional and cognitive experience. And we talk about this all the time or like the interventions need to match kind of all of the different parts of it. Oftentimes with the really younger kids and actually even with adults, sometimes the first thing that somebody notices is actually a physical symptom, whether it's their like stomach aches or headaches or chest pain or body tension. And that's very much part of anxiety and and something that is a really important part to to make sure that you intervene on as well.
William Curb: Yeah, it's really funny was that too with I've talked to people about like the different places they feel their anxiety, like because I know a lot of people feel their stomach, I feel like my shoulders neck and then you have the I've done a hard workout and my shoulders neck are feeling tight. Am I anxious or am I just sore?
Mona Potter: Yeah, well, anxious or sore, anxious or excited, because a lot of the same hormones that get released when you're anxious also can get released when you're excited or when you're when you're when you're doing something that's really important to you. And so what we talk about is like short bursts of that stress hormone of the kind of whatever comes along with anxiety is absolutely okay.
Again, it prepares your body to do something to be more attentive to be more motivated to be able to like really focus on that thing you need to get done. The problem is is that anxiety has now become this chronic thing. You have an anxious moment, you get through that, but then the next moment causes anxiety or the next thought causes anxiety and now your body's just getting flooded nonstop. And it's when it's that kind of chronic flood that causes and just wreaks havoc on the system.
William Curb: Yeah, my friend Brenda describes anxiety as being the only emotion that you can burn for energy that creates more anxiety. It's like it creates itself. Yeah, oh. You're like, oh, yeah, I'm going to run on anxiety and it's like, oh, that just makes more anxiety.
Mona Potter: Yeah, it can be really helpful in the short run. It becomes problematic when it just becomes chronic, unrelenting. It just keeps beating down on you. You're running a marathon after a marathon after a marathon. And that is just way more to ask of your body and your mind than is reasonable.
William Curb: Yeah. And I feel like that's something that neurodurgened individuals really suffer from is they're like, oh, I found this key to getting stuff done. And then not really thinking about the long-term negative effects of just being like, when I was like, oh, I'm going to keep myself on time all the time by just being anxious about being late. And it's like, oh, that's also very distracting.
Mona Potter: It is. And eventually it gets exhausting. Right. But I think that is where even with anxiety, we talk about setting reasonable expectations, understanding when what is on your plate is just beyond what is reasonable, given all the different things going on, whether it's your coping skills, the competing requirements and needs.
And to really try to be able to break these expectations down and to be able to ensure that you're taking pauses, you're taking breaks, you're giving yourself a chance to refuel. We talk about just putting coins back in the piggy bank. Although I guess we don't use piggy banks so much anymore.
William Curb: I could have won, but I always forget to give them their allowance because my parents' expectation was like, oh, you come to us for allowance. And I'm like, yeah, that's not great with ADHD kids. I mean, it wasn't great for me. I basically always forgot.
Mona Potter: But I like that, actually. It's like, it's a small way to kind of build a habit. It's like trying to teach a life skill and you're coupling it with something that can be important.
So it's like, it's not, I like being able to teach skills with things that are not earth shattering if they don't happen. So I love that parents were like, okay, the allowance is important to you. And so if you want your allowance, then you need to find a way to remember to come to me to ask for it. Because what that's teaching you, it's helping your brain build that muscle of there's something important to me. I tend to forget to do things.
What do I need to do in order to remember? And you might try four or five different things until you find the thing that works. And that thing that works might work for a little while. And then it might stop working because we know that the ADHD brain likes novelty. And so it might just be like, okay, this work, this will, I'll do this for a month.
And then maybe I'll try something new. But it's, it's deliberately thinking about what is it that I need to do in order to ensure that this thing that matters to me happens.
William Curb: Absolutely. Because there is so much, especially with like kids, I'm like, I don't want to become their external executive function for everything where they don't learn the skills behind doing that themselves.
Mona Potter: I think that's something that we've been seeing. So this is not super scientific, but this is kind of observational. Just I've been a child psychiatrist now for over 20 years. And what I've seen is that as we've gotten better with our middle and high schools of really supporting kids and all of the ways in which they show up and need to learn again, we're by far perfect at it. But, but they're with more, with more accommodations, more support, what we're finding is that they'll go to college. And then kind of there's a big step up and the demands of college are more than they can manage. And so these are the kids I'm seeing in my clinic.
And so it might be that I'm kind of over indexed on this. But when I think about my own kids, I feel this like absolute pressure to say, how am I teaching you the executive functioning skills? Because it is so much easier for me to just rescue you. It's so much easier for me to plan out your day for me to do all of this. Because while it's exhausting on my end to have to think about it, it's faster. And life is full of so many competing demands that it at least gets the morning done, it gets the evening done. And so I'm having to catch myself constantly and finding that balance of how am I coaching you to learn to do this eventually on your own?
William Curb: Yeah, it's like making dinner, not my favourite. And then if I'm adding in, oh, yeah, I'm also having my kids help me make dinner, which is great for them to learn it.
But it's like, this makes it so much harder, but worth it in the long run, probably. Well, I guess one place we can go into the medication aspect of this, because one thing I try to always remind listeners to the show from, I am not a doctor. And so I try not talk about medication too much, because I'm like, I don't know what I don't know, and I don't want to give people bad advice there. So medication shortage has been something that has been an issue for a while, although they, from what I understand, that has been, production has been okay to increase recently.
Mona Potter: Yeah, it seems like we are in way better shape. I actually just looked it up before, it's just in preparation. And it looks like they're a handful of some generics, but overall, it seems like we're, and I personally in my clinic have been okay now. But I think it was, it was an interesting thing that happened. The shortage for, of the stimulants was an interesting thing in that, when, in that kind of the pandemic era, there was a loosening of the regulatory laws where there was the ability to prescribe via tele-health, which increased access to prescribers. And there was simultaneous kind of social media and just general education happening. And so there was also a decrease in stigma and an increase in awareness, especially of adult ADHD. And so what we've seen in the past several years is that there, while the kind of paediatric ADHD diagnosis has stayed pretty constant, the adult ADHD diagnosis has gone up. And so what we've had is like a supply and demand issue, where the demand for medications for ADHD, specifically the stimulants, went up because of the increased awareness, the decreased stigma, the more access. But the supply did not meet, did not meet that demand because their controlled substance is unregulated. So the quota for how much can be produced did not match the production, there were some shortages in the material.
And so it really was a supply demand issue. But for as a clinician, it was interesting to me in that I'm, just hearing more about adult ADHD, more people in my personal life are asking me about it as well. And so it's been an interesting conversation to have. And then like you said, in my anxiety clinics, like we're constantly thinking about the overlap, and is this really ADHD or yes, this part is ADHD. But if we don't also manage the anxiety, then life is still going to be really hard.
William Curb: At the 2025 ADHD conference that was in Kansas City, they had Bill Dobson gave a great keynote talking about how often people are sticking with treatment options, and it's like incredibly low, except for women, because often they're seeking out the treatment on their own rather than being pushed into it. And so then when you have this increase of so many women getting diagnosed, it's like, well, now there's actually a real demand here, because initially you have people like, oh, I'm going to try this for a month and it didn't change anything, so I'm going to drop.
Mona Potter: Yeah, yeah, it's a really great point.
William Curb: So yeah, it's interesting with also with ADHD medication, and especially with anxiety, because I do know some people do experience that, especially with stimulants, having that increased anxiety response.
Mona Potter: Yeah, and I've seen the full gamut. And so I've seen where somebody comes in with ADHD and anxiety. And so what I'll say is that whenever I'm prescribing a medication, I'm looking at, we're talking about the risk and benefit of medication and the risk and benefit of not medication, of not medication, right? And it's really important to have that kind of very thorough conversation, because sometimes you might choose to take on a couple of risks because the benefits are still bigger.
And sometimes you might say, you know what, even if there is some benefit, the risk is bigger and it's or it's a risk that I don't want, so I'm done with, I'm going to do a different option. And with stimulants and anxiety in particular, what I've seen is that for many, it's more that it causes a little bit of a physiological arousal. We talked about both ADHD and anxiety already having kind of a physical aspect to them. The stimulant might cause a little jitteriness, which could be mistaken for anxiety. I think that's unfortunate when it could actually be a helpful medication, you just need to get through that initial phase of it. Because I have seen situations where somebody has ADHD and anxiety, we use the stimulant and their anxiety actually gets a lot better.
In those cases where the anxiety is really secondary to the ADHD, where just a little bit of improvement in executive functioning, ability to like attend and sit still and kind of do the things that were really hard and start feeling like they could actually show up in a way that they want to actually help the anxiety get better. And so I think in those situations to me, it's a shame to not use a stimulant. And then even when I've had people come in with both ADHD and anxiety, I've still been able to use stimulants successfully. And sometimes I will also use a medication to target the anxiety along with it.
But so I think I want to, what I want to make sure people know is that every individual is different. And so I don't think it's fair to have a blanket statement of stimulants raise anxiety, therefore, don't prescribe a stimulant if you have anxiety along with it. I think more stimulants can cause some individuals to feel more physiological arousal, or maybe even some more anxiety. And in that case, just work through it with the person who's prescribing for you. There are many different options that you can go through in those cases.
William Curb: I know my experience talking with my own doctor, I always feel somewhat apprehensive about like asking for medication changes and being things because I'm like, I don't want to seem like I'm med seeking or anything.
Because there is still the stigma that exists. And I've worked through a lot of that and like, let my doctor, hey, I am worried about coming off this way. So I just want to let you know that.
But so when people are approaching their doctor about getting stimulants or stuff, are there ways that they can help themselves make sure that they're going to be getting the right medication without having their own anxiety here about the stigma aspect of that Medicaid.
Mona Potter: It makes me sad to hear you say that. And I won't counter you because I understand what you're saying and I've seen it. And so it still makes me feel sad because as a doctor, it's our responsibility to make sure that we are being very open-minded and collaborative. And that's only going to happen if when you come in for help, you feel comfortable and you feel like you can be upfront and honest.
I like how you did it. I think it's even reasonable to say, hey, there's a lot of stigma around this. I feel nervous to talk about this because I don't want you to think that I'm like seeking meds. I think the most helpful thing to lead with is just what you're experiencing. So as much as you can observe in your own life, how your symptoms are showing up and how they're then impacting your life and across different settings.
And to be as descriptive as you can about what you're experiencing, my hope is that then the doctor will be able to ask questions to follow up and together you'll go down the path to really understand, is this really ADHD, in which case we really do want to talk about a stimulant, or is this a little messy or could this be more anxiety related? And let's talk through other options. I would say that also I rarely like to, well, I really don't prescribe without also saying, hey, medication does not build skills.
It doesn't build the brain muscles. And so being very open to saying, hey, here are non-medication things I'm trying, or here when you're given advice to try something just being open to it and actually demonstrating that openness. So I think that can help make it more of a collaborative relationship.
William Curb: Yeah, I love the pills don't teach skills, but they've really helped develop them.
Mona Potter: So I talk about the biopsychosocial model all the time, the biological, the psychological, and the social. So there is a biology here that is absolutely important to address. And the biology is both kind of like our natural core needs that everyone has. Like, are we getting enough sleep? How's our nutrition?
Are we moving enough? I think sensitive brains are more sensitive to not sleeping enough, not eating well, not moving. And so know your body and know what your threshold is for being more vulnerable when you're not getting those basic biological needs. And then there's the biological need of your system, just like with diabetes or asthma or cardiac. There is a systems issue that needs to be addressed. And that's where I talk about the medications as an opportunity to turn down the intensity of the symptoms. So if you are so anxious that the moment you walk into room, you're entirely flooded by fear and by thoughts of all the things that can go wrong by physiological arousal where your stomach is turning and your heart is racing. It is really hard to practice a skill no matter how well you know the skill.
And that's where the medication can turn down the volume. So then you can practice interacting with the world in a different way. You can make decisions based on what you know and you know you need to do. But it is really hard to do that when the biological volume is just turned up. And so that piece is really, really important.
William Curb: Yeah, there's so much that goes into getting the right medication too. Because I've known, I think the thing that you mentioned earlier is the effects of medication, but the effects of not taking medication is often overlooked because people are like, oh, there are going to be side effects or there could potentially be side effects. But they're not thinking about, well, what are the side effects of not medicating?
Mona Potter: Generally speaking, stimulants and SSRIs, which are the category of medications we most commonly use for anxiety, are pretty well tolerated. And if you have a hard time with one, oftentimes switching to another can actually work pretty well. And so generally speaking, I will say that if you've prescribed a lot, I talk through the side effects, I watch carefully for the side effects, but they're pretty well tolerated when used correctly.
And that being said to your point, I think that there's a huge risk of not using all the tools on your tool belt to address ADHD or anxiety. Because then you're living in the world and interacting with the world in a way that's not completely, you almost have goggles on, you're seeing the world in a different way. The world is seeing you a different way too, and that starts becoming part of how you see yourself. It changes your self-concept, which that's where I get most worried is where it's, this is very treatable. And I know some of the interventions can feel uncomfortable, but when you're not being able to live the life that you want to live, that you are capable of living, I owe it to you to make sure that you're trying all of the tools that are available.
William Curb: And there's things like, oh yeah, unmedicated ADHD has a higher risk of just injury, like running into traffic or something. And it's like, oh, that is a very serious side effect there of being unmedicated.
Mona Potter: Yeah, some of my colleagues are actually pretty against doing stimulant holidays for ADHD for that very reason. They're like, well, it's not just about, am I producing at work or at school? There are also other really serious risks associated with ADHD that you want to make sure somebody is protected on. And so, again, it's a very individual conversation because we are all different and our circumstances are different. So we have all the research studies that look at the population and their good guidance.
But in the end, the decision has to be one where you're really thinking about what is important to you, what are the ways in which the ADHD or the anxiety or whatever it is are showing up, and what are all of the different options you have, again, in the biology, in the psychology, again, with therapy, with kind of skills. And then also in the social aspect of like, what supports are you bringing in? How is your environment helping or interfering with your ability to get on top of things?
William Curb: And it's funny with like the diagnostic criteria for ADHD requiring both it being at work, school, or at home, like you're not just is not just one place. And then being like, well, we're only going to worry about treating it at work in school.
Mona Potter: My hunch is that it's because we think about consequences. It's like, and it's saying, well, when you go home, there are not as many external consequences as there are or you won't lose your job. There are a lot of consequences to having ADHD show up at home as well, whether it's in your, like your relationship with your partner or your kids or with friends or just being able to just manage like your calendar and get out to social events. And so there are a lot of consequences, again, based on quality of life and just continued development of yourself in the world. And so I think it is really, I don't want to diminish how important other aspects of life are as well. Yeah.
William Curb: And I also don't want to tell people that they shouldn't be that the only solution is medication either. Like I know many people that manage very well without medication, but also I don't think it should be something people write off immediately either.
Mona Potter: I really appreciate that you said that because I think because I'm a psychiatrist and because I talk so much meds, I think I sometimes run the risk of seeming that way. And in fact, I will think of non-medication interventions first. And I think what's happened for me when I started prescribing or when I started as a psychiatrist decades ago, I was super, super conservative. And I was kind of like, all right, let's try all of the behavioral treatments, all of the therapy, let's make sure you have done it all before we go to meds, because I don't want to introduce your system and your developing brain or your brain to something that it doesn't need. And I've really shifted over the course of just seeing and living and breathing this and seeing how there's also exhaustion. And when you work so hard, you can only do that for so long before, again, it's human to just get too exhausted to keep going. And so what I want to do is just reduce the shame or reduce that feeling of like, I'm using a crutch if I use medication, I hear that a lot.
And I'm like, well, use glasses if your eyes are not sharp. And when you break your leg, you use a crutch, why is a crutch even bad? A crutch allows you to be able to do the things that are important to you. And so I think I want to shift the thinking around medication. It is not the end all be all, and it can really be useful as a tool in the toolkit.
William Curb: Yeah, absolutely. It's not the only tool, but it is one of the first tools that we should look at if we have that available to us. So I kind of want to switch gears here and talk a little bit about one of your other specialties in OCD, because that's something I know a lot of people don't have a good understanding of what OCD is. Some of the first times I've had like real conversations, I'm like, oh, yeah, that's some of my thoughts.
Mona Potter: So obsessive compulsive disorder, it's characterized by having obsessive thoughts that are intrusive or recurrent. And then in order to neutralize those thoughts or in an order to calm those thoughts, you'll do a compulsion or a behavior in response to that thought. And that then creates a loop in that doing that behavior then calms the thought, but it only calms it temporarily.
And so then you get caught in this loop. And it can show up in a lot of different ways. I think the hard part about OCD is we kind of use it as a day to day term, like, oh, that's just my, like, I'm just kind of like when we're kind of rigid or fixed on something or when we, and I'll say that even I like, I was thinking about OCD and I'm like, oh, like, I have a little kind of with my daughter, every day I want to watch her walk to the bus. And whatever reason, it's like, because I worry about my daughter, I worry about her health, I worry about her safety, and she's going off into the world. And so there's something about that I have this thought of, like, this worry thought that my daughter can get hurt or can and or is going to have a bad day. But if I sit, if I stand and watch her, there's something very comforting to me, and it calms my mind. And I was like, gosh, is that part of OCD?
So what separates kind of just having little rituals or having behaviors that that kind of help calm some kind of distressing thoughts is how important are they and how much time do they take up? And so with my daughter, there was a day where I'm like, okay, I can't I have to get back I have to get in the shower, get ready for work. And so I couldn't and I was like, that's fine.
I'm not going to. So it wasn't something that I had to do in order for that thought to go away or in order for me to feel calmed. But in OCD, that thought is so sticky.
And it is so strong that not being able to do whatever the OCD tells you to do in order to calm it down, develops a life on its own, it gets very distressing. And so we'll have somebody, for example, with contamination, who might have the thought that if I don't wash my hands thoroughly for five, 10 minutes, then I will not have gotten all the germs off. And if you interrupt that cycle, that is incredibly distressing for them. And they cannot do anything else until they wash their hands.
William Curb: And one of the interesting things I've seen about the differences with ADHD and OCD, because you can have some of the like similar symptomology, they're often very helpful to like, just kind of grease the groove, make things easier for yourself to like, this is gonna like, oh, I'm gonna make this a seamless process. And from what I understand, that's kind of like the opposite of what you want to do for OCD. Yeah.
Mona Potter: No, I mean, so you're right, like adding rituals, adding structure, adding predictable pathways is incredibly helpful for ADHD. Feeding into rituals can actually feed the OCD. And so what we're often talking about with OCD is we want to break the accommodation.
With ADHD, we're thinking about what accommodations in the environment are we going to use in order to kind of help structure and break down the day to day. With OCD, we're breaking, we're saying we are no longer going to accommodate. We're going to ask for you to sit with distress, to sit with intolerance, to sit with not actually being able to do the thing that that your OCD is telling you.
And we're not going to give you reassurance. Because if we do that, we're just feeding the OCD, we're telling it that what it's asking you to do is important is the most important thing, and it has to win over everything else. And so it is a really interesting difference. What we're trying to teach with OCD is flexibility of thought, flexibility in action, and that ability to then sit with the distress that comes with that flexibility.
William Curb: Yeah. And so then the treatment you were describing, that's the exposure and response prevention, right? The ERP. Exactly.
Mona Potter: And what you'll find is that ERP is kind of like the gold standard treatment for OCD and also for avoidance-directed anxiety. So whenever OCD and anxiety are really like what fuels them is avoidance. You have a thought or feel a feeling, it's uncomfortable, you just don't want to feel it anymore, you avoid, and then you feel better. And so what the brain learns is, oh, I have a thought, I have a feeling, I avoid, life is good again in this moment, and it creates that loop. And so exposure and response prevention is gradually teaching your brain that you can handle it. That approach rather than avoidance is what's going to help you get back to living the life you want to live. And it is way easier said than done because nobody likes to feel uncomfortable.
And even therapists don't like making patients or making people, I mean, to ask for help feel uncomfortable. And so what we even find is like we can even find ourselves getting distracted and just talking about the day or talking about what was hard rather than saying, all right, you know what, we're going to get very behavioral here, we're going to get very active here. Let's talk about the ways in which your anxiety or the ways in which your OCD showed up. And let's talk about what you want to do that your anxiety or OCD are not letting you do because it's easier to avoid than it is to do the things that are required to do what you want to do. And let's gradually work our way to being able to approach those things.
William Curb: And I imagine for people that have the like a comorbid ADHD, that's like an even harder proposition where they're just like, I really don't like discomfort. Yeah.
Mona Potter: Yeah. Well, what I find is that it's just it's cumulative. I mean, again, any one of these is exhausting because even if you're able to do it all, it takes work. It takes more work than somebody who is not contending with some of these difficulties.
And so they're just additive. And so what I say to people when they come in for treatment, I'm like, this is not going to be pleasant. And I'm really sorry, I wish I wish that we could like if it were easy to deal with anxiety or ADHD or OCD, you wouldn't need to come in for help. This is really hard exhausting work.
And it is even more exhausting when you have ADHD on top of the anxiety, or along with the OCD. And so what we do is that's where pace matters. And that's where it's really important to get aligned. I think when treatment is least effective is when we as a clinician are say have one expectation and we're trying to move at a certain pace. And the person who's coming in and asking for help has the same desired goal. What we're asking is just overwhelming.
And so it seems like they're like treatment resistant or not working hard enough when in fact, it's just overload. And so it's really important that we that we are making sure to say like, what is our shared goal? What like what is a reasonable expectation for for what we want to accomplish? And how do we break it down into small steps and work on those small steps? We're creating new habits in the brain. It's really hard to create a new habit. And so the more we can simplify, the more we can set expectations that are reasonable so that you have little wins.
So when you have little wins, then you're more likely to keep going. I really despise exercising. I just it's not I just whatever reason I just don't like to exercise. I mean, I think I'm probably not alone in that. And as I'm getting older and I'm feeling my hips and my left, all of this, I'm like, I need to exercise, I need to be more consistent. And so one way I tried was like, okay, well, I do things very intensely when I do them. So I was like, okay, I set this huge regimen and huge plan, even had an accountability buddy, all of the above, it did not work. So instead, I said, okay, I'm going to expect myself to exercise five minutes three times a week. That's all I'm expecting of myself. And when I when I did that, I set a goal. I mean, it's a smart goal, right?
And it's really thinking about what can I do easily? What am I willing to do? What will I not be? What will I not talk myself out of? And then once you develop that new habit, you can build more and more habits on top of that.
William Curb: There's definitely a lot to try in. Get yourself to the point where you're happy where you're at and happy with your progress. Because that's always my fear with ADHD is I'm not going to be happy enough with this progress.
So I need to do more, but then doing more is too much. So one of the things I was just thinking here too is when should someone actually think about coming in for help? Like what are some of the things that are clues to them that like, oh, I'm not doing well enough on my own, I would do much better if I went in for help. What are some of the clues people could look for there?
Mona Potter: And help is along a spectrum. So I would say that we're humans, we're not built to worry alone. So if there's something that's on your mind, if you're worried about something, ask for help.
You can start with just kind of your social circle or start with your PCP or your child's pediatrician if it's your child. And so it's not kind of either you're going in for clinical help or you're kind of trying to do this all on your own, which I know is a statement of the obvious, but I still feel important to say because sometimes we're reluctant to ask each other for help because we don't want to bother a friend or we're worried that we're going to be a burden or there's shame in what we're experiencing. And I think more often than not, when you talk about it, you'll realize there are lots of other people who are kind of going through very similar things. But I think when it reaches threshold for asking for help clinically is when you notice that it is really getting in the way of functioning, that when your symptoms are driving your decisions, rather than your decisions being driven by what matters to you, what you value, kind of what you want to get done.
Or you've tried some things at home, you've tried things that you've read online and you're not getting the results that you had hoped. I think all of those are reasons to go in for help. And I said this before, but because what I've seen is that it might start off as some symptoms, but over time it can start becoming part of how a personality or how to like self-concept.
And I really want people to come see me before it gets to that. Because the more we practice something, the more it becomes part of who we are. So for practicing, engaging in the world in a highly anxious way, it starts becoming more of the way we, it just becomes our habit.
And so asking for help to shift that and to try to get to that, it's easier to shift that earlier in the course than when it's been going on for a long time.
William Curb: I was wondering if there were any final thoughts that you wanted to leave the audience with?
Mona Potter: We're living in a world that is so beautiful and it can also be just incredibly exhausting and overwhelming. And especially when, especially for those of us with sensitive brains, that it's really easy to lose ourselves in that overwhelm. And so I think my final parting words are to just really accept yourself for all of the wonderfulness, all of the messiness that makes you you and human.
And also keep challenging yourself to build on your strengths and manage those vulnerabilities so that you can build a life that is truly worth living in which you're making decisions, you're choosing behaviors based on what matters to you rather than what your symptoms are kind of telling you to do in that moment.
William Curb: And if people wanted to find out more about you and what you do, where should they go?
Mona Potter: I'm a chief medical officer and co-founder of Instride Health. So people can go to instride.health to learn more about the work that I'm doing clinically.
William Curb: Okay, great. Well, thank you so much for coming on the show and there's just so much in here. This is fantastic. Thank you so much.
Mona Potter: Thank you so much for having me. I really appreciate it.
This Episode's Top Tips
To tell ADHD and anxiety apart, look at what’s pulling your focus. ADHD distractions are often external (the world "tapping you on the shoulder"), while anxiety distractions are typically internal (a "side commentary" of what could go wrong).
Remember that medication can turn down the biological "volume" of symptoms, but it doesn't build skills or "brain muscles." Use the quiet provided by medication as a window to practice the executive function habits you need.
While structure and rituals are helpful for ADHD, they can feed OCD. If you have both, you must learn to sit with the distress of not performing a ritual (Exposure and Response Prevention) rather than making things "seamless".