“There’s a huge overlap between the two,” says Petros Levounis, MD, chair of the department of psychiatry at the Rutgers New Jersey Medical School and vice-chair of the American Psychiatric Association’s Council on Addiction Psychiatry.
An estimated 18% of American adults suffer from persistent and life-draining anxiety disorders, which are the nation’s most common mental illnesses. Common types include:
- Acute stress disorder
- Generalized anxiety disorder
- Panic disorder
- Obsessive-compulsive disorder
- Post-traumatic stress disorder
- Social anxiety disorder
- Specific phobias
Although anxiety disorders are highly treatable, only about one-third of people with these conditions ever receive medical treatment. Instead, they may choose to numb their anxiety to get through the day, and to try to get more or better sleep, by drinking alcohol, smoking and/or taking prescription and/or illicit drugs.
Overall, researchers estimate that 20% of people with an anxiety disorder also are addicted to alcohol or other drugs. But some studies suggest that the addiction rate may exceed 50% among some groups, including combat veterans, rape victims, and others who have experienced traumatic events.
Sadly, about one in every eight children has an anxiety disorder, too, which increases the likelihood of poor school performance, missed social opportunities and later substance abuse. Research shows that children with untreated anxiety disorders are far more likely than kids whose anxiety disorder is successfully addressed to develop an addiction in adolescence or young adulthood.
Which Comes First — the Anxiety or the Addiction?
“There are three major ways that anxiety and addiction can co-exist,” says Dr. Levounis. In the first scenario, people initially develop an anxiety disorder, start self-medicating with drugs of abuse and end up with a dual problem: anxiety and addiction.
In the second scenario, someone begins using a drug of abuse and then develops an anxiety disorder as a consequence of their addiction. “We see that mostly with alcoholics,” says Levounis. “They very often suffer from depression and anxiety secondary to their alcoholism.”In the third scenario, anxiety and addiction develop independently. “They just happen to co-occur in the same person,” he says.
Treatment For Anxiety and Addiction Is Most Effective
Until recently, someone with co-existing anxiety and addiction often received conflicting medical advice. If they first went to a psychiatrist, they were typically referred to a substance abuse counselor and told they had to get their addiction under control before they could be treated for anxiety. If they first went to a substance abuse counselor, they were usually referred to a psychiatrist and told that they had to get their anxiety under control before they could be treated for addiction. “Neither of these two approaches worked,” says Levounis.
Today, the consensus is that the anxiety and addiction must be treated simultaneously. Research shows that treating substance abuse without treating the underlying anxiety is associated with an increased risk of relapse. For example, a recent study of 326 patients who were treated just for substance use disorder found that 76% of those without co-occurring anxiety were sober six months after treatment. By contrast, only 40% of those who also had an anxiety disorder were abstinent six months after treatment.
According to Levounis, there has been a sea change in the treatment of anxiety disorders. For decades, tranquilizers such as benzodiazepines were the medications of choice. “We have thrown that out the window,” he says. “The new algorithm is for depression we give antidepressants, and for anxiety we also give antidepressants.”
The reason: Although depression can be characterized as a preoccupation with the past and anxiety can be thought of as a preoccupation with the future, both disorders involve the brain’s serotonin system and respond to the same medications. Today’s medications of choice for anxiety include SSRIs (selective serotonin reuptake inhibitors), SNRIs (selective norepinephrine reuptake inhibitors) and the older tricyclic antidepressants.
Of the most commonly prescribed antidepressants, the only one that’s unsuitable for such double duty (treating anxiety and/or depressions) is the atypical antidepressant bupropion. “It only works for depression and does not work for anxiety,” says Levounis.
Treating Anxiety and Addiction: Beyond Medication
Psychotherapy also can lead to a long-term reduction of anxiety. For example, cognitive behavioral therapy (CBT) can be useful in helping patients gain insight into the roots of their anxiety. The goal of CBT is to identify, understand and change harmful and negative thinking and behavior patterns.
Another form of psychotherapy, Eye Movement and Desensitization Reprocessing (EMDR), can desensitize patients to anxiety by teaching them how to defuse their anxiety triggers and cope with the onrushing feelings of anxiety.
Other strategies that can lessen anxiety include:
- Regular exercise
Levounis is a fan of self-help therapies, but only up to a point. “Taking care of yourself, exercising, getting a good night’s sleep will certainly improve your condition,” he says. “But very often, this isn’t enough. In general, people tend to underestimate the severity of their psychiatric problem and their substance abuse problem and think they can handle it themselves.”
People with a longstanding, co-existing anxiety disorder and substance use disorder need professional help. “Once an addiction takes strong hold in a person’s brain and the person’s life, then there’s a very good chance they’ll need addiction treatment in itself,” Levounis stresses.
Effective treatment for substance abuse depends on the type of addiction. If a person is addicted to certain substances – such as tobacco or opioids – prescription medications can speed the transition to abstinence. However, there are no such medications to counter an addiction to some substances, including cocaine and cannabis (marijuana).
Ultimately, conquering an addiction may require a combination of psychotherapy, counseling and 12-step work. “These are very powerful and effective,” believes Levounis. If people are reluctant to seek psychiatric care for an addiction, 12-step work alone can work wonders, he adds: “If they suffer from a significant alcohol use disorder, absolutely we should recommend them to try AA.”