Constant worry. Difficulty sleeping. Muscle tension. Troubling thoughts that don’t stop. Irrational beliefs that make every day a challenge.
These are some of the telltale signs of anxiety.
Anxiety disorders affect around 40 million adults in the U.S. each year.
Some people with anxiety receive a timely, accurate diagnosis and seek proper treatment. Far too many, however, never receive an accurate diagnosis and don’t have the resources for treatment – which means they don’t get the help they need when they need it most. These individuals may self-medicate with alcohol or drugs in order to experience temporary relief from the uncomfortable symptoms of anxiety. This is one of the most common reasons why many individuals living with a substance use disorder also live with an anxiety disorder: their substance use began as a way to manage their anxiety, then became a second disorder itself.
What is Anxiety?
Anxiety is a feeling of uncertainty, apprehension, nervousness, or fear about something that hasn’t yet happened. It’s normal to experience some degree of anxiety about an upcoming event or what the future holds in general. We typically feel anxious when we’re faced with a dangerous situation, such as encountering a large, growling dog baring its teeth just a few feet away or driving on an icy road in winter. We may also feel anxious in response to a situation we perceive as dangerous or threatening, as well, such as seeing a spider crawling on the wall across the room, or walking into a social gathering where we’re worried that we won’t fit in and no one will talk to us.
Anxiety disorders are more than everyday fears, though. They’re diagnosed when anxiety causes significant problems, or when the irrational thoughts and beliefs associated with anxiety create enough distress to cause impairment in one or more areas of life, such as relationships, family, work, or school.
Types of Anxiety Disorders
Anxiety can manifest in a variety of ways. The Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-V) – the go-to diagnostic manual used by mental health professionals to diagnose mental health disorders and conditions – identifies several different types of anxiety disorders. They include:
Generalized Anxiety Disorder (GAD)
This is one of the most frequently diagnosed types of anxiety. The primary feature of GAD is persistent and excessive worry about situations and events that are unlikely to occur. Symptoms must last for a minimum of 6 months. Additional symptoms – at least 3 of which must also be present in adults – include poor concentration, sleep problems, muscle tension, frequent fatigue, irritable mood, and feeling restless or on edge.
Panic Disorder (PD)
People who experience panic attacks often receive a PD diagnosis. In addition to the panic attacks themselves, they typically experience ongoing anxiety about future panic attacks and/or the possible implications or consequences of having an attack (e.g. being humiliated/embarrassed). Panic attacks are highly distressing, relatively brief experiences of very intense anxiety, often triggered by an irrational, fearful thought. People with PD report their panic attacks seem to come out of the blue, with little or no warning whatsoever.
Panic attacks involve both psychological symptoms (e.g. fear of going crazy, feeling outside of one’s body or having the sense that nothing is real) as well as physical symptoms (e.g. racing or pounding heart, dizziness, shallow breathing, sweaty palms). They’re usually accompanied by an intense dread that something very bad is about to happen.
Panic disorder may be accompanied by agoraphobia, which is an intense fear of being in open, crowded places, especially those that are difficult to escape from. People with PD and agoraphobia may have the fear they will end up in a place where they will have no help or means of escape should a panic attack occur. Individuals with PD and agoraphobia are often terrified to leave their home as a result. The two phobias together often prove to be significantly debilitating.
Social Anxiety Disorder (SAD, or Social Phobia)
This anxiety disorder involves having an intense fear of any type of social situation, such as having to speak or perform in front of an audience (e.g. giving a presentation at work or school), being in a large crowd or small gathering (e.g. a concert or wedding), or being the center of attention in any situation.
The primary fear for those with social phobia is that they will be judged, scrutinized, embarrassed, criticized, or humiliated. As a result, individuals with this disorder tend to go out of their way to avoid social situations. If they’re unable to avoid the social situation they fear, they experience incredible anxiety and distress while they’re there. Sometimes SAD creates exactly the circumstance the individual wants to avoid. It may cause a sub-par performance during a work presentation, for instance, which causes embarrassment and more intense anxiety about the next work presentation, which causes another sub-par performance – and the cycle continues, reinforcing itself with each iteration.
A specific phobia involves an irrational, excessive, or extreme fear of a specific situation/circumstance (e.g. undergoing a dental procedure, flying in airplanes, or being in small, confined spaces) or things (e.g. dogs, needles, clowns). Any exposure to the feared object or situation elicits intense distress and anxiety. Individuals with this anxiety disorder will go to great lengths to avoid the thing or situation they fear, and sometimes what they do to avoid their phobias can be counterproductive. Typical examples include avoiding the dentist for years or bypassing job opportunities that might require frequent air travel.
Other Related Disorders
Although no longer classified as anxiety disorders in the DSM-V, it’s worth mentioning posttraumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD), since anxiety plays a significant role in both.
Posttraumatic Stress Disorder (PTSD)
For some individuals, experiencing an extremely traumatic event can lead to PTSD. Symptoms may develop soon after the trauma or not appear until some time has passed. To receive a PTSD diagnosis, symptoms must be present for at least a month. They include nightmares, flashbacks, anger outbursts, being easily startled, hypervigilant behavior, and poor sleep. Untreated, these symptoms can last for months, years, decades, or an entire lifetime. Individuals with PTSD often experience intense distress in response to anything associated with the trauma, which is why they strive to avoid anything – activities, people, or places – that remind them of it.
Obsessive-Compulsive Disorder (OCD)
Individuals with obsessive-compulsive disorder experience persistent and intrusive thoughts, urges, or images – their obsessions – that cause significant anxiety. They engage in rituals and behaviors – their compulsions – to reduce the intolerable anxiety. Extreme urges, the need for everything to be neat and orderly, and fear of germs or some sort of contamination are common examples of obsessions found in people with OCD. Compulsive behaviors often seen in individuals with OCD include constantly putting items (e.g. clothes, canned goods) in a specific order, checking something multiple times, and excessive washing or cleaning.
The Connection between Anxiety Disorders, Substance Misuse, and Addiction
It’s not difficult to imagine why someone living with anxiety might be vulnerable to developing an alcohol or substance use disorder. Alcohol, marijuana, and sedative-hypnotic drugs such as benzodiazepines are the most commonly abused substances people use to alleviate anxiety symptoms, since they can provide temporary relief from negative feelings and distress. Every time the troubling symptoms are alleviated, even if only for a short while, the connection between the substance and the relief it provides is reinforced. This creates a cycle that becomes difficult to break, and can lead, ultimately, to disordered use of that substance.
Research confirms that anxiety often goes hand in hand with an alcohol and/or substance use disorder. A massive 2004 study– The National Epidemiologic Survey on Alcohol and Related Conditions – conducted by the National Institutes of Health found that nearly 18% of the 43,000+ respondents who had a substance use disorder at the time also met the diagnostic criteria for an anxiety disorder. The study also indicated that the specific type of anxiety disorder tends to play a role in specific substance most likely to be misused.
Generalized Anxiety Disorder (GAD)
Individuals with generalized anxiety disorder may turn to alcohol to self-medicate their anxiety and sleep difficulties. They may also self-medicate with benzodiazepines and other sedative-hypnotic drugs, including marijuana. A confounding factor for individuals struggling with GAD and other anxiety disorders is that short-term pharmacological treatment using benzodiazepines can be effective in reducing symptoms, but the risk of dependence is high.
Like GAD, individuals with social anxiety disorder may turn to alcohol to self-medicate, but they may also abuse drugs such as GHB or benzodiazepines for temporary relief. Alcohol often seems to provide what they need to make social situations feel more tolerable. However, alcohol, GHB, and benzodiazepines may worsen social phobia, especially if their use leads to behavior that may prove embarrassing either in the social setting or later, upon reflection.
Panic Disorder (PD)
Individuals with this disorder may turn to alcohol to alleviate symptoms, resulting in the development of an Alcohol Use Disorder (AUD). The relationship of PD and AUD is further complicated by the fact that panic attacks are one of the symptoms of alcohol withdrawal. Other substances often used in the effort to self-medicate panic symptoms include benzodiazepines and marijuana. However, for some people, the side of effects of cannabis use include anxiety, paranoia, and panic attacks. Benzodiazepines, which are often prescribed to manage panic attacks – and work very well – also carry a significant risk of misuse.
Posttraumatic Stress Disorder (PTSD)
Posttraumatic stress disorder creates a high vulnerability to alcohol and substance use disorders. Problems with alcohol, marijuana, and prescription sedatives may develop, since these substances help mitigate sleep disturbances and temporarily reduce anxiety. Military veterans often develop PTSD after deployment to a war zone or high-risk area. Upon returning home, some develop disordered alcohol and substance use in order to mitigate the symptoms of PTSD. Studies show that over 20% of veterans with PTSD also have a substance use disorder.
In some cases, it can be difficult to determine which developed first: the anxiety disorder or the substance use disorder. Symptoms of withdrawal – as well as effects of some types of substances – are often similar to anxiety symptoms, particularly those associated with generalized anxiety disorder. This makes diagnosis difficult, especially if someone is actively using alcohol or drugs. Chemical imbalances in the brain play a role in the development of many psychiatric disorders, and since drugs and alcohol affect brain chemistry, the clinical picture becomes more complicated.
Treatment for Comorbid Anxiety Disorders and Substance Use Disorder (SUD)
Treatment for comorbid SUD and anxiety requires specialized knowledge and skill. When SUD and anxiety disorders occur together, both disorders typically worsen over time – unless they’re treated. Research shows the most effective approach to treating comorbid anxiety disorder and substance use disorder is to treat them simultaneously. Dual diagnosis treatment helps reduce both the risk of relapse and the recurrence of anxiety symptoms.
Evidence-based treatments for comorbid anxiety and SUD include:
- Cognitive Behavioral Therapy (CBT)
- Exposure Therapy
- Prolonged Exposure Therapy (PET)
- Eye Movement Desensitization and Reprocessing (EMDR)
Cognitive Behavioral Therapy (CBT) is one of the most well-researched and effective treatments for both anxiety disorders and SUD. CBT therapists focus on identifying and changing the underlying beliefs and thought patterns that contribute to the distressing emotions and self-destructive behavior associated comorbid anxiety and SUD.
Exposure Therapy is a form of CBT used primarily for treating specific phobias. Therapists also use exposure therapy to treat Obsessive-Compulsive Disorder (OCD). This technique involves gradually increased exposure to the feared object or situation to help diminish the fear and anxiety associated with that object or situation.
Prolonged Exposure Therapy is a specific type of exposure therapy often used in the treatment of PTSD. It involves a combination of in vivo exposure and imaginal exposure to triggers and memories associated with trauma. It can help individuals realize they do not need to avoid thoughts and memories that no longer pose a real threat.
Eye Movement Desensitization and Reprocessing (EMDR) is a type of therapy originally used to treat emotional trauma. Developed in the 1980s, EMDR is now used in the treatment of a variety of psychiatric disorders. It’s used in some dual diagnosis treatment settings, particularly with patients who have comorbid PTSD and SUD.
Pharmacotherapy involves the use of medication to help alleviate troubling symptoms. It’s often used during detox to reduce withdrawal symptoms and can also play a critical role in the treatment of anxiety. There are two primary types of medications used to treat anxiety – SSRIs (selective serotonin reuptake inhibitors) and benzodiazepines. SSRIs include medications such as Paxil (paroxetine), Zoloft (sertraline), and Celexa (citalopram). Benzodiazepines include Ativan (lorazepam), Xanax (alprazolam), and Klonopin (clonazepam).
Using benzodiazepines in the treatment of comorbid anxiety and substance use disorder is risky, since they have a high potential for misuse. SSRIs are non-addictive, but after regular use they carry a risk of anti-depressant withdrawal, also known as anti-depressant discontinuation syndrome. This involves withdrawal-like symptoms – if the SSRI is discontinued suddenly rather than tapered slowly – and may occur in people who’ve been taking SSRIs for more than six weeks. Medications should always be prescribed and closely monitored by a psychiatrist who understands the complexities of dual diagnosis treatment.
Treatment for comorbid anxiety and alcohol/substance use disorder may also include mindfulness techniques, relaxation training, psychoeducation, and family therapy.
Treatment Goals for Comorbid Anxiety Disorders and SUD
Dual diagnosis treatment of comorbid anxiety disorders and SUD is designed to help individuals learn how to manage their anxiety symptoms, change unhealthy patterns of behavior, and eliminate and/or manage cravings effectively. When a treatment program can meet these goals, patients have the greatest chance of successful, sustained recovery.