Anxiety Disorders, Substance Use Disorder, and Integrated Treatment

The most common mental health disorders diagnosed alongside substance use disorders are mood disorders, such as anxiety disorders that can include generalized anxiety disorder (GAD) and post-traumatic stress disorder (PTSD). Others include Major Depressive Disorder (MDD), Bipolar I disorder, Bipolar II disorder. One of the most challenging aspects of treating substance use disorder (SUD) is a phenomenon called co-occurring disorders. That’s the term mental health professionals use when an individual receives a diagnosis for a substance use disorder (SUD) and a mental health disorder at the same time. 

Although many people with depressive disorders misuse substances, and many people who misuse substances have clinical depression, anxiety is the most common mental health disorder associated with SUD.

Research that examines the interaction between anxiety and addiction reveals that in many cases, the negative symptoms of both anxiety and addiction combine to create problems that are more difficult to address than the symptoms of one or the other when they occur in isolation. In addition, it’s often difficult to distinguish between the symptoms of anxiety and the symptoms of SUD. To complicate matters further, the symptoms of clinical anxiety disorders are similar to the symptoms of withdrawal for many substances of misuse.

We’ll discuss that in more detail below.

It’s important to understand that identifying which disorder appeared first, anxiety or addiction, can be problematic for both the individual in treatment and the clinicians providing care. Some individuals develop anxiety as the result of addiction, while some individuals use substances to mitigate the uncomfortable emotions associated with an anxiety disorder.

That’s called self-medication, which we’ll also discuss below.

First, though, we’ll discuss the prevalence rates for anxiety disorder and substance use disorder. Then we will talk about the interplay between anxiety and addiction, and finish by offering information on the most effective treatments for co-occurring anxiety and SUD.

Prevalence of SUD and Anxiety: The Latest Data

A large-scale epidemiological study of 12-month and lifetime prevalence of SUDs and anxiety among U.S. citizens reports that both have increased in the past 15 years. The measure of a 12-month prevalence of SUDs determines how many individuals presented the symptoms of a SUD in the 12 months prior to the study, which researchers conducted between 2012 and 2013. The lifetime prevalence measure, on the other hand, captures how many people have been diagnosed with a SUD during their lifetime.

Here’s what the researchers found:

• 12-month prevalence of SUDs increased 100% over a decade (that’s double)
• Lifetime prevalence increased by 50% over the same period
• Lifetime prevalence of SUD was associated with:
  • Severe generalized anxiety disorder (GAD)
  • Mild generalized anxiety disorder (GAD)
  • Posttraumatic stress disorder (PTSD)

While it may be surprising to read, this is the most recent a large-scale study on the prevalence of anxiety and SUD was conducted. Data from an earlier study shows the following:

• 15% of people diagnosed with AD had past-year SUD
• 18% of people with SUD had past-year SUD
• 38% of people in treatment for SUD has past-year AD
• 46% of people with SUD meet criteria of PTSD
• 60% of people diagnosed with opioid use disorder and sedative use disorder meet criteria for lifetime AD (not including PTSD)

Given that data – there is a significant national increase in the prevalence of SUDs accompanied by the high prevalence of co-occurrence of SUD and AD – research into the relationship is important. Understanding the details of anxiety and addiction can help clinicians, the people who operationalize research, treat both. It will also help clinicians resolve the complicated question of whether an anxiety disorder most often precedes an addiction disorder, or an addiction most often precedes an anxiety disorder.

First, let’s take a closer look at anxiety and anxiety disorders.

What is Anxiety?

When an individual receives a diagnosis of an anxiety disorder, what it means is that, at a very basic level, that individuals experience intense worry about or fear of situations that are common in everyday life. Here’s a short, helpful primer on anxiety and anxiety disorders:

“Anxiety refers to anticipation of a future concern and is more associated with muscle tension and avoidance behavior. Anxiety disorders can cause people to try to avoid situations that trigger or worsen their symptoms. Job performance, school, work, and personal relationships can be affected. In general, for a person to be diagnosed with an anxiety disorder, the fear or anxiety must be out of proportion to the situation, age-inappropriate, and hinder the ability to function normally.”

A confounding fact about anxiety disorders is that anxiety isn’t all bad; nor is fear. In fact, anxiety and fear are useful emotions. Fear helps us navigate the world we live in by alerting us to imminent danger or potential harm – fear typically refers to a reaction to something that’s happening right now. Anxiety, on the other hand, can help us by alerting us to upcoming events in the future – either specific or non-specific – that we need to take action to either prepare for the best we can, or avoid at all costs.

Fear and anxiety are good – when they’re appropriate.

Here’s an example of appropriate fear: you’re in a boat on the ocean, and you see the fin of what you’re sure is a shark swimming near the boat. You don’t jump off the boat to go swimming because you’re afraid of the shark. In that case, fear is helpful and lifesaving.

Here’s an example of appropriate anxiety: you’re an adult returning to college, and you have your first algebra test coming up in several days. Your anxiety causes you to prepare – perhaps overprepare – for the test, because you haven’t taken math since 11^th grade, and you want to do well. In that case, your anxiety is helpful, and can result in something positive: a good grade.

That information is helpful to everyone, not just people with SUD, anxiety, or both: it helps us understand the function of fear and anxiety in our lives. But let’s get back to the main question:

How do the symptoms of anxiety and withdrawal from addiction overlap?

Why does this cause problems for treatment?

Types of Anxiety and Their Relationship to Addiction

Researchers have identified three types of ADs that most often precede addiction in people with co-occurring anxiety and addiction. These include:

• Social phobia
• Panic disorder
• Agoraphobia

They’ve also identified one type of AD that most often develops after an addiction disorder in people with co-occurring anxiety and addiction:

• Generalized anxiety disorder

In addition, researchers have identified two types of anxiety disorder that may appear before an addiction disorder, but may also develop after an addiction disorder in people with co-occurring anxiety and addiction:

• Obsessive-compulsive disorder
• Post-traumatic stress disorder

It’s easy to understand why social phobia and panic disorder most often occur before substance use disorder: it’s common for both these disorders to develop during childhood, before most people encounter alcohol or substances of misuse. While panic disorder may not be diagnosed until early adulthood, many people with panic disorder report first experiencing symptoms during childhood.

Now it’s time to circle back and talk about how the symptoms of anxiety and the symptoms of withdrawal – for many drugs of misuse – often overlap and can be confused for one another. First, let’s look at the most common symptoms of a generalized anxiety disorder, as published by the National Institute of Mental Health (NIMH):

• Excessive restlessness
• Feeling wound-up or on edge
• Fatigue
• Difficulty concentrating
• Racing heart
• Irritability
• Headaches, muscle aches, stomachaches, or other “unexplained ailments”
• Excess, uncontrollable worry
• Problems with sleep
• Nausea, diarrhea, or other gastrointestinal distress

Next, let’s compare those symptoms to the common symptoms of withdrawal:

• Restlessness, agitation, anxiety
• Muscle aches, headaches, stomachaches
• Phantom aches and pains
• Irritability
• Difficulty thinking or concentrating
• Diarrhea
• Nausea
• Increased heart rate

Those lists make it clear that the symptoms of anxiety disorders – specifically generalized anxiety disorder – overlap with the symptoms of withdrawal. In some cases, they’re identical. And they’re different than the symptoms of an early onset anxiety disorder, such as social anxiety, which is – to oversimplify – characterized by fear of embarrassment, fear of making mistakes in social situations, and/or the fear of meeting new people.

Now we have answers to both the questions we pose above. The symptoms of anxiety and addiction overlap in physical, psychological, and emotional ways, which often make it impossible for a clinician – or the person in treatment – to understand which is which.

That’s why research is important, and that’s why treatment professionals understand the integrated model of treatment is essential in creating the best outcomes for individuals diagnosed with co-occurring SUD and anxiety.

Integrated Treatment and Compassionate Care

The mental health experts at the Substance Abuse and Health Services Administration (SAMHSA) understand the relationship of mental health disorders and substance use disorder and recommend integrated care for people with co-occurring disorders.

Here’s how they describe the necessity of integrated care:

“The presence of two or more disorders can complicate diagnosis and treatment. Integrating both screening and treatment for mental and substance use disorders leads to a better quality of care and health outcomes for those living with co-occurring disorders by treating the whole person.”

In the integrated treatment model, an individual receives support and care for the physical, psychological, and emotional aspect of mental health and substance use disorders, while also receiving support and guidance for lifestyle changes that promote recovery.

Here are the primary components of the integrated treatment model, as defined in the SAMHSA publication “Integrated Treatment for Co-Occurring Disorders”:

The Seven Essential Components of Integrated Care

1. Clinicians combine mental health and substance abuse treatment to meet the needs of people with co-occurring disorders
2. Treatment centers employ specialist clinicians trained to address and support patients with both substance use disorders and serious mental illnesses
3. Clinicians treat co-occurring disorders in a step-wise fashion, and offer different services at different stages of the recovery process
4. Providers use motivational interventions that are used to treat patients in all stages of care, but especially in the early stages of recovery
5. Clinicians use a cognitive-behavioral approach to counseling and therapy during the treatment and relapse prevention stages of recovery
6. Treatment centers make multiple service formats available, including individual, group, self-help, and family therapy/treatment/support
7. Physicians and other qualified clinicians coordinate medication services with psychosocial services

Those are the components. Here are the evidence-based benefits of integrated treatment, as defined by SAMHSA:

• Reduced substance use
• Discontinued substance use
• Improvement in psychiatric symptoms
• Improvement in psychiatric functioning
• Increased likelihood of recovery from SUD
• Increased likelihood of recovery from mental illness
• Improved quality of life
• Decreased hospitalization
• Reduced medication interactions
• Increased housing stability
• Fewer arrests

In other words, the integrated treatment model can improve all aspect of life for a person diagnosed with co-occurring disorders. It takes work and commitment from everyone involved: the individual in treatment, their family members, and the doctors, nurses, counselors, and therapists on the treatment team. Recovery from addiction is a challenge. Recovery from an anxiety disorder is a challenge. Integrated treatment can help an individual meet and exceed those challenges, manage the symptoms of addiction and anxiety, and live a full and productive life in recovery.

By Ryan Greene, PhD, LPC, Clinical Director, Pinnacle Treatment Services of Roanoke in Virginia

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