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By: Rick Fannin
One of the behaviors seen in persons with addiction is a disproportionate struggle with anxiety. Decades of research have shown that anxiety and addiction co-occur at greater rates than would be expected. The relationship between anxiety and addiction is concerning and complex.
Both addictions, including alcohol and drugs, and anxiety disorders, are disease processes that affect human behavior, wellbeing, relationships, and quality of life. Anxiety increases the risk of substance abuse problems. Likewise, substance abuse increases the risk of developing an anxiety disorder. This gives these disorders a "causation" and "correlation" relationship. Meaning, the two disorders often coexist, and one disorder may cause the other disorder. But does anxiety cause addiction? Or does addiction cause anxiety?
An estimated 18 and 28 percent of people in the United States population have an anxiety disorder during any given year. Within this percentage of individuals with an anxiety disorder, there is a 33 to 48 percent occurrence rate for a coexisting substance use disorder.
A study from the journal Psychiatric Services found that in a sample of 326 patients with substance abuse disorder, a full 48 percent also had significant anxiety or anxiety mixed with depression. In studies of military veterans or others likely to have experienced traumatic events, the rates of anxiety co-occurring with addiction are even higher.
What Are Anxiety Disorders?
We all feel anxious or nervous in our daily lives, whether we're making an important decision, taking a test, or facing problems at work. These are normal feelings. However, anxiety disorders involve more than just occasional worry. People with these illnesses feel constant dread that doesn't simply disappear. It can get even worse over time, damaging relationships and overall quality of life. When you combine anxiety and addiction, you have co-occurring disorders that can send you into a downward spiral.
Examples of anxiety disorders include generalized anxiety disorder, social anxiety disorder (social phobia), panic disorder, specific phobias, and separation anxiety disorder. You can have more than one anxiety disorder. All forms of anxiety disorders recognized by the National Institutes of Mental Health) can reinforce or be reinforced by substance abuse.
Risk Factors for Developing an Anxiety Disorder
The causes of anxiety disorders aren't fully understood. Life experiences such as traumatic events appear to trigger anxiety disorders in people who are already prone to anxiety. The factors that may increase your risk of developing an anxiety disorder include:
- Trauma. Children who endured abuse or trauma or witnessed traumatic events are at higher risk of developing an anxiety disorder at some point in life. Adults who experience a traumatic event also can develop anxiety disorders.
- Having blood relatives with an anxiety disorder. Anxiety disorders can run in families.
- Other mental health disorders. People with other mental health disorders, such as depression, often also have an anxiety disorder.
- Stress due to an illness. Having a health condition or serious illness can cause significant worry about issues such as your treatment and your future.
- Stress buildup. A big event or a buildup of smaller stressful life situations may trigger excessive anxiety — for example, a death in the family, work stress, or ongoing worry about finances.
- Personality. People with certain personality types are more prone to anxiety disorders than others are.
- Drugs or alcohol. Drug or alcohol use or misuse or withdrawal can cause or worsen anxiety.
You may have noticed that many of the risk factors for developing anxiety are similar to the risk factors associated with developing a substance abuse problem. Trauma, stress, mental disorder, and genetics are common risk factors that may lead to the development of either, or both, anxiety or substance use disorders.
Complications From Anxiety Disorders
Having an anxiety disorder does more than make you worry. It can also lead to, or worsen, other mental and physical conditions, such as:
- Depression (which often occurs with an anxiety disorder) or other mental health disorders
- Substance misuse
- Social isolation
- Problems functioning at school or work
- Poor quality of life
- Trouble sleeping (insomnia)
- Digestive or bowel problems
- Headaches and chronic pain
Which Came First – The Chicken (Anxiety) or The Egg (Addiction)?
Do anxiety disorders cause addiction problems, or does addiction create anxiety disorders? The answer is both. Neurological changes from substance addiction can create anxiety within a person. In contrast, an anxious person will often self-medicate to calm themselves down in a pattern that leads to substance abuse. Substance addiction and anxiety commonly feed off each other, with anxiety leading to substance abuse and the effects of addiction creating anxiety disorders.
Individuals struggling with anxiety are at significant risk of developing an addiction to drugs or alcohol due to the symptoms of the mental illness. As unwanted symptoms develop, individuals who have anxiety may turn to substances to self-medicate and relax, putting the taxing symptoms on hold for a short time. People may use alcohol and drugs as an outlet to escape the reality of anxiety and produce a sense of happiness.
However, when someone becomes dependent on alcohol or drugs, they may experience severe anxiety when they are sober. This uncomfortable situation can lead an individual without prior anxiety to develop drug-induced or withdrawal-related anxiety symptoms. The continued abuse of drugs or alcohol can worsen anxiety and change the brain's electrical connections. An individual can create a substance-induced anxiety disorder.
Self-mediation with drugs and alcohol gives an individual temporary relief from anxiety. However, there is long-term damage done to the mechanisms that help relieve the symptoms of anxiety. This cycle of self-medication and rebound anxiety digs a deeper and deeper hole for the addicted person, making treatment and breaking this downward spiral harder and harder as time goes by.
Forming Bad Habits that Last a Lifetime
While different drugs work in distinct ways, all drugs commonly activate the brain's reward system via the dopamine system. This allows behaviors such as drinking, smoking, and abusing substances to be rewarded every time they occur, slowly changing the behavior into a habit.
According to the University of Utah, "As the brain continues to adapt to the presence of the drug, regions outside of the reward pathway are also affected. Over time, brain regions responsible for judgment, decision-making, learning, and memory begin to change, making certain behaviors "hard-wired physically."
Simply stated, the neurons that fire together wire together. This rewiring of the brain becomes the goal of integrated treatment of anxiety and co-occurring substance use disorders.
Treating Co-Occurring Addiction and Anxiety Disorders Together
As with all co-occurring disorders, substance use and anxiety can complicate each other. Treating substance abuse without treating the anxiety that causes it is a fruitless endeavor. If the underlying cause of anxiety is allowed to remain, the addict's reason to use may remain as well, and these motivations may drive the individual back into active addiction.
The coexistence of anxiety and addiction creates a unique treatment challenge. In fact, it is a challenge similar to most co-occurring disorders:
"treating substance abuse without treating the co-occurring disorder can lead to higher rates of relapse."
Let's take a look at the study in Psychiatric Services of 326 patients with substance abuse disorder. The study question was how do co-occurring disorders like anxiety and depression influence relapse. In this group, 73 percent of people without anxiety or depression remained substance-free six months after treatment. But for people with anxiety accompanying their addiction, only 40 percent remained abstinent at the six-month point.
Treating the anxiety that may underlie substance abuse can be anything but easy. In large part, the difficulty of treating co-occurring disorders is because addiction and addictive behaviors are literally worn into the brain's structure.
Over time, substance abuse creates neurobiological consequences, including loss of memory and impaired executive function. The brain's ability to adapt itself to its environment, known as neuroplasticity, means that the more you use specific brain pathways, the more accessible these pathways become in the future. Through neuroplasticity, the behaviors of substance abuse reinforce themselves, making these behaviors into brain-based behavioral patterns.
The more often you think certain kinds of thoughts or act certain ways, or feel certain feelings like anxiety, the more these patterns are built into the architecture of your brain. Effectively treating anxiety and co-occurring addiction disorders requires neuroplasticity in the opposite direction – some call this "rewiring your brain."
Evidence Based Treatment of Co-Occurring Anxiety and Substance Use Disorders
Treating anxiety in the context of substance abuse requires therapies that help the brain exist in non-anxious states long enough that the brain can build new neural pathways as alternatives to the pathways of addiction.
Behavioral therapies, such as motivational enhancement therapy, cognitive behavioral therapy, contingency management, and 12-step facilitation, are the standard of care for individuals with substance use disorder and are a key part of a treatment plan for individuals with co-occurring mental health disorders such as anxiety. The following evidence-based treatments help the brain build new wiring that counteracts patterns of anxiety and addiction.
Cognitive Behavioral Therapy (CBT)
CBT is typically considered a gold standard in anxiety treatment, as well as, substance use disorders. This kind of talk therapy aims to discover a solution to the problem that brings a person into treatment. This therapy aims to change the destructive behavioral pattern that may lead to anxiety or substance abuse.
Our thoughts, emotions, and behaviors are all connected. The way that we think influences the way that we feel and the things that we do. CBT does this by focusing on a person's attitudes, beliefs, thoughts, and images and examining the way these things relate to how they deal with emotional issues.
Mindfulness-based Cognitive Therapy (MBCT)
This therapy combines the principles of cognitive therapy with meditative practices to help patients practice mindfulness. According to research studies, people struggling with anxiety often recall negative thoughts and experiences from the past, which cause them to worry about their future, making them even more depressed and anxious.
Through mindfulness, patients can identify their thought and mood patterns. Mindfulness practice combined with cognitive therapy can also reverse the downward spiral most people with anxiety experience by teaching them to be present in the moment and have gratitude for the small things in life.
Dialectical Behavior Therapy
Dialectical Behavior Therapy (DBT) is a type of Cognitive Behavioral Therapy, but what makes it unique is its emphasis on mindfulness and dialectical thinking. Rather than only treating symptoms as problems to be solved, DBT places an equally important emphasis on acceptance of experiences as they are in this moment.
DBT focuses on dialectical thinking: dialectics refers to a philosophical stance in which two ideas or truths, seemingly opposed to one another, can both exist at the same time. For example, a person coming to therapy may need both acceptance of where they are right now and motivation to change. In other words, they need to recognize that everything is exactly as it should be, and at the same time, know that they must do better and try harder to create positive change.
DBT works through learning emotional and cognitive skills (acquisition), and subsequently applying those skills to your life (generalization). Generally, DBT tackles difficult and distressing emotions, and it can help you improve your capacity for emotional regulation, that is, your ability to control the feelings you have, when you have them, and how you experience and express them
Changing and influencing emotions is a central goal of DBT, but before you can get to this step, it is critical to understand and know where these emotions are coming from and why they arise. The "understanding and acknowledging" step of DBT is one of the main facets that separates it from regular CBT: this approach supports the mindful and non-judgmental observation and description of emotional experiences. This aspect makes DBT effective across a range of mental health problems, including anxiety disorders and substance use disorders. The skills you learn from DBT help you differentiate emotions from facts, allowing you to work with and manage emotions and behaviors effectively.
Smith, J. P., & Book, S. W. (2008). Anxiety and Substance Use Disorders: A Review. The Psychiatric Times, 25(10), 19–23.