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Both Barrels:
The Devastating Comorbidity of Anxiety Disorders and Substance Abuse

(Released May 2012)

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  by J. Erick Sinkhorn  


Key Citations




Chicken & Egg:
Self-Medication and Substance-Induced Anxiety


Sometimes comorbidity results from the attempt to mitigate the symptoms of an anxiety disorder with drugs or alcohol. This phenomenon is known as self-medication.

Often, the individual who self-medicates does not even realize he or she is suffering from a mental illness, only that the effects of the substance they use brings some degree of relief. The relief is short-lived, however, and the individual must increase in quantity and frequency their dosage to experience the desired result. This pattern will of course eventually lead to a drug or alcohol use disorder.

Recent research has shown self-medication with alcohol to be associated with an increased risk of substance use disorders in patients with anxiety-related symptoms (Robinson et al). These findings are consistent with the self-medication theory of addiction, which suggests that a person is drawn to different substances on the basis of his or her particular symptoms. Individuals who experience anxiety, for example, are more likely to seek substances that produce feelings of relaxation. Thus alcohol or other sedatives would be particularly attractive to them.

One study found that over 12% of individuals who met the criteria for an anxiety disorder and self-medicated with alcohol later developed an alcohol addiction. This result was more than twice the number (4.7%) of anxiety sufferers who did not self-medicate The study further revealed that among participants with a baseline alcohol use disorder, the prevalence of anxiety disorders ranged from 5.7 percent (panic disorder) to nearly 10 percent (specific phobia) for those who self-medicated with alcohol (Robinson et al).

Army soldiers attend a class on PTSD
Soldiers and civilians watch a presentation about Post Traumatic Stress Disorder December 15, 2009 at Fort Hamilton Army Garrison in Brooklyn, New York.

Self-medication may in particular explain the high rates of substance abuse among those with post-traumatic stress disorder. Approximately 31% of individuals with PTSD have abused or been dependent on drugs at some point in their lifetime. About 40% have also abused or been dependent on alcohol (Tull). This high rate of co-occurrence between PTSD and substance abuse has garnered the attention of researchers, who seek better understand this relationship so that treatments can be targeted more effectively.

Despite the prevalence of self-medicating behaviors, anxiety disorders do not always develop first. It is often the case that a mental health problem will spontaneously arise from a substance abuse issue. This may result directly from the substance's chemical impact on the brain, or may develop out of an extended period of intense distress associated with chemical abuse.
Chronic drug or alcohol use can create all manner of personal, legal and health problems. These problems and their consequences are very real, sometimes representing a threat to the individual's very life or freedom. While the anxiety experienced under such circumstances would generally be considered normal and appropriate, prolonged periods of extreme duress can actually alter the individual's brain chemistry and neural pathways. Eventually, the heightened state of anxiety to which one has become accustomed will persist, even if the addiction and its corresponding threats are removed.

In such instances, the individual may develop a substance-induced anxiety disorder. According to the DSM-IV-TR, this diagnosis is made when the anxiety symptoms are above and beyond what would be expected during intoxication or withdrawal and when psychotic symptoms are severe (American Psychiatric Association, DSM-IV-TR).

Substance-induced anxiety is very common. Chemicals in drugs like cocaine, marijuana, hallucinogens, and prescription pain relievers, as well as alcohol and even seemingly harmless substances like caffeine, can affect the way the brain functions and cause an array of anxiety symptoms. These include constant worry or nervousness, a feeling of impending disaster, panic, insomnia or other sleep problems, memory loss and the inability to concentrate.

Not only can these symptoms occur while using drugs, they may last for weeks after the drug use has stopped. This is a difficult cycle to break because the anxiety, depression, and other symptoms that people feel when the drug wears off just make them want to use it again. Thus, they begin "treating" the anxiety problems that result from substance abuse with more substance abuse.

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