Substance Abuse and
Anxiety Disorders/Panic Attacks

Individuals with a dual diagnosis of substance abuse and anxiety are expected to exhibit more functional impairments, which include negative impacts on both their occupational and social functioning. Moreover, dually diagnosed individuals pose unique treatment difficulties to professionals.

This guide will discuss the comorbidity of substance abuse disorders and anxiety disorders, as well as commonly used interventions for treating patients who present with substance abuse problems and co-occurring anxiety.

Anxiety disorders are a serious psychiatric condition. For individuals who suffer from an anxiety disorder, their feelings of nervousness, worry and fear have become so overwhelming that they are no longer able to do the things that they used to.

There are many types of recognized anxiety disorders and the symptoms of each will vary across disorders.

Common Symptoms of Anxiety

Individuals who suffer from panic attacks frequently describe that they felt as though they were having a heart attack, which can be pretty frightening for most people.

While a small portion of individuals who have suffered from a panic attack may not have any concerns about the recurrence of these symptoms, it is not uncommon for individuals to become very nervous about future episodes of panic.

Further, these individuals may attempt to stay away from certain situations where they may have experienced a past panic attack or where they may feel trapped and unable to escape, should they experience a future panic attack.

Common Symptoms of a Panic Attack

The use of substances can increase the risk of developing anxiety disorder symptoms or make pre-existing symptoms worse.

While alcohol and other central nervous system (CNS) depressants, including benzodiazepines—such as alprazolam (Xanax) and lorazepam (Ativan)—as well as barbiturates, may initially appear to have calming effects on an individual’s degree of stress, excessive use of these drugs can lead to impairments in an individual’s physical and mental functioning, which can be a major source of stress.

More commonly, though, withdrawal from alcohol and other CNS depressant drugs may trigger rebound anxiety and even panic attacks. Further, this can increase the individual’s risk for relapse.

For instance, marijuana use can lead to symptoms that mimic that of a panic attack, such as:

• A racing heart.
• Difficulty breathing.
• Lightheadedness.
• Feeling of being detached from oneself.
• Poor motor coordination.

In particular, individuals with a history of panic attacks are more likely to have these symptoms triggered with marijuana use.

Moreover, withdrawal after a long period of marijuana use is associated with the onset of temporary anxiety; however, with time these symptoms tend to subside, as the individual is able to successfully abstain from marijuana use during the withdrawal phase.

Withdrawal from stimulant medications is characterized by a sudden drop in neurotransmitter levels, which also leads to symptoms of anxiety.

Examples of Stimulant Drugs

• Amphetamines and similar drugs (e.g., Adderall, Ritalin)
• Caffeine
• Ephedrine
• MDMA (street name: Ecstasy)
• Mephedrone or MDPV (street name: bath salts)
• Methamphetamine
• Cocaine

As such, individuals in highly stressful jobs or who regularly feel unable to relax because of anxiety are at risk for developing problems with alcohol. In most instances, the psychological need to have a drink whenever you feel a little stressed or uncomfortable is a clear warning sign that you may have a problem with alcohol.

Effects of Substance Abuse

Most professionals will agree that a substance abuse problem is defined by the excessive use of substances, such as alcohol or drugs, which leads to clinically significant impairment on the individual’s ability to function on a day-to-day basis.

Catching and treating substance abuse problems early can reduce the risk of long- term negative impacts.

Substance abuse can have detrimental impacts on the individual’s ability to function at work, home, or school, and can even cause problems in terms of friendships.

It is typical for individuals who were functioning very well prior to the onset of their substance abuse to have exhibited a much more gradual course of onset— this can mask the condition somewhat, rendering it much more difficult to identify and treat early.

Indeed, it is well known that catching substance abuse problems early is the best.

Rates of Substance Abuse and Anxiety

In fact, the lifetime prevalence rate for a substance abuse disorder has been estimated to be around 14.6% and the lifetime prevalence rate for an anxiety disorder has been estimated to be about 28.8%.^[1]

Further, findings from studies using samples drawn from both the community, as well as clinical populations, have indicated that being diagnosed with either a substance abuse disorder or an anxiety disorder places the individual at an augmented risk for developing problems with the other.^{[2] [3]}

Though nearly all of the anxiety disorders have been linked with substance abuse problems, panic disorder—with or without agoraphobia—is the second leading anxiety disorder related to substance abuse (odds ratios = 1.0-9.2).^{[4] [5]}

More specifically, both paroxetine (brand name: Paxil) and sertraline (brand name: Zoloft) have been explored among samples of individuals who have been diagnosed with alcohol abuse and anxiety.^{[6] [7]}

Findings from these studies, however, remain mixed with some finding support for reduced symptoms of both anxiety and alcohol dependence, while others do not. As such, more work is needed to explore the role of selective serotonin reuptake inhibitors on symptoms of comorbid substance abuse and anxiety.

One anti-anxiety medication, buspirone (brand name: BuSpar) has received support for its role in treating both alcohol abuse and symptoms of anxiety.^[8] Further, the anticonvulsant medication topiramate (brand name: Topamax) has demonstrated potentially positive results in treating individuals with cocaine dependence and symptoms of anxiety.^[9]

In fact, behavioral therapy is often the preferred method of treatment, given that prescribing medication—particularly the benzodiazepine anti-anxiety medications, with their high propensity for dependency and abuse—is a major concern for many substance abuse professionals.

Cognitive Behavioral Therapy

The most commonly referred behavioral approach for individuals suffering from comorbid substance abuse problems and anxiety is cognitive behavioral therapy (CBT). The goal of this approach is to change an individual’s maladaptive beliefs and unhelpful behaviors.

Individuals who undergo cognitive behavioral therapy are taught:

• To recognize their thoughts, feelings and physiological responses to certain situations.
• Skills in relaxation practice that they then use during graded exposure exercises.

Exposure exercises:

• Are clinician-guided.
• Encourage individuals to face feared situations in a stepwise fashion.
• Allow the individual to experience success and mastery, in order to face increasingly challenging situations.

CBT, in particular, has received empirical support for its role in treating substance abuse, both among adult and pediatric populations, as well as anxiety problems.

CBT has received much support for its role in treating substance abuse and anxiety problems.

While most studies have supported the use of CBT for individuals with substance abuse and anxiety,^[10] other studies have actually shown that exposure—a specific intervention component of cognitive behavioral therapy—can have detrimental impacts on the individual’s progress with regard to their substance abuse problems.^[11]

Targeting Treatment for Co-occurring Conditions

The treatment of individuals with dually diagnosed, or co-occurring, substance abuse problems and anxiety brings about important considerations.

In most cases, professionals will attempt to treat both co-occurring conditions simultaneously; however, this may not actually be the most beneficial for individuals with substance abuse problems and anxiety. For instance, some individuals may be more ready to make changes with regard to one disorder over the other.

As such, it may actually be beneficial for these individuals to target treatment accordingly, rather than attempting to focus treatment on both.

Further, individuals undergoing behavioral treatment for anxiety may impede their progress by using alcohol to cope with feelings of distress that may come up as the result of undergoing treatment.

Thus, it is important for professionals treating these conditions to be mindful of the course of symptoms of the comorbid condition and to engage in continual monitoring of the individual’s progress in treatment.

Indeed, there is very little information regarding outcomes from treatment approached in this way. Thus, more work is necessary in order to clearly identify the ideal approach to targeting symptoms of co-occurring substance abuse problems and anxiety.

References

1. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62(6):593–602.
2. Kushner, MG.; Krueger, R.; Frye, B.; Peterson, J. Epidemiological perspectives on co-occurring anxiety disorder and substance use disorder. In: Stewart, SH.; Conrod, PJ., editors. Anxiety and Substance Use Disorders: The Vicious Cycle of Comorbidity. New York: Springer; 2008. p. 3-17.
3. Kushner MG, Sher KJ, Beitman BD. The relation between alcohol problems and the anxiety disorders. Am J Psychiatry 1990;147(6):685–695.
4. Compton WM, Thomas YF, Stinson FS, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 2007;64(5):566– 576.
5. Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 2007;64(7):830– 842.
6. Thomas SE, Randall PK, Book SW, Randall CL. A complex relationship between co-occurring social anxiety and alcohol use disorders: what effect does treating social anxiety have on drinking? Alcohol Clin Exp Res 2008;32(1):77–84.
7. Brady KT, Sonne S, Anton RF, et al. Sertraline in the treatment of co-occurring alcohol dependence and posttraumatic stress disorder. Alcohol Clin Exp Res 2005;29(3):395–401.
8. Kranzler HR, Burleson JA, Del Boca FK, et al. Buspirone treatment of anxious alcoholics. A placebo-controlled trial. Arch Gen Psychiatry 1994;51(9):720–731.
9. Johnson BA, Ait-Daoud N, Bowden CL, et al. Oral topiramate for treatment of alcohol dependence: a randomised controlled trial. Lancet 2003;361(9370):1677–1685.
10. Brady KT, Dansky BS, Back SE, et al. Exposure therapy in the treatment of PTSD among cocaine- dependent individuals: preliminary findings. J Subst Abuse Treat 2001;21(1):47–54.
11. Randall CL, Thomas S, Thevos AK. Concurrent alcoholism and social anxiety disorder: a first step toward developing effective treatments. Alcohol Clin Exp Res 2001;25(2):210–220.