Written By: Sarah Williams, PhD in Clinical Psychology
It is not uncommon for individuals who struggle with a substance abuse problem to also suffer from one or more psychiatric conditions. This is known as comorbidity, or dual diagnosis, which occurs when an individual develops two disorders or conditions, either sequentially or simultaneously.
When two conditions occur together, whether they are psychiatric or medical in nature, it is expected that the symptoms of both conditions interact in some way. Moreover, the interaction of symptoms can have an impact on the course of both conditions, as well as the outcome of each condition individually.
Substance abuse problems and anxiety disorders both are among the most commonly occurring psychiatric problems within the United States.
Individuals with a dual diagnosis of substance abuse and anxiety are expected to exhibit more functional impairments, which include negative impacts on both their occupational and social functioning. Moreover, dually diagnosed individuals pose unique treatment difficulties to professionals.
This guide will discuss the comorbidity of substance abuse disorders and anxiety disorders, as well as commonly used interventions for treating patients who present with substance abuse problems and co-occurring anxiety.
Anxiety Disorder SymptomsAnxiety and fear are a normal reaction to danger within the environment. In fact, some anxiety is necessary. Anxiety helps to motivate individuals to study for upcoming tests or even readies our body to escape dangerous situations as quickly as possible.
However, sometimes feelings of nervousness or being uncomfortable and afraid can have a detrimental impact on the individual’s ability to lead a normal life.
Anxiety disorders are a serious psychiatric condition. For individuals who suffer from an anxiety disorder, their feelings of nervousness, worry and fear have become so overwhelming that they are no longer able to do the things that they used to.
There are many types of recognized anxiety disorders and the symptoms of each will vary across disorders.
Common Symptoms of Anxiety
- Feelings of fear, worry, nervousness, panic, or uneasiness.
- Difficulty relaxing or sitting still.
- Difficulty falling asleep or staying asleep.
- Cold, clammy, or sweaty hands and/or feet.
- Excessive sweating.
- Shortness of breath.
- Numbness or tingling sensations in the hands and/or feet.
- Heart racing or heart palpitations
- Chest pain.
- Dry mouth.
- Nausea or vomiting.
- Muscle tension.
- Sore muscles.
- Racing thoughts or the feeling like you cannot control your worries.
Panic Disorder SymptomsPanic disorder is a specific type of anxiety disorder, which is characterized by the presence of panic attacks.
A panic attack is described as sudden feelings of intense fear or panic in situations in which there is no frightening or other discernible stimulus to explain the elicitation of this feeling.
Individuals who suffer from panic attacks frequently describe that they felt as though they were having a heart attack, which can be pretty frightening for most people.
While a small portion of individuals who have suffered from a panic attack may not have any concerns about the recurrence of these symptoms, it is not uncommon for individuals to become very nervous about future episodes of panic.
Further, these individuals may attempt to stay away from certain situations where they may have experienced a past panic attack or where they may feel trapped and unable to escape, should they experience a future panic attack.
Individuals who avoid certain places out of the fear that they may have symptoms of panic and are unable to escape are regarded as having agoraphobia.
Common Symptoms of a Panic Attack
- Racing or pounding heart beat.
- Shortness of breath.
- Chest pain or discomfort.
- Shakiness or trembling.
- Choking sensation.
- Excessive sweating.
- Nausea or stomach upset.
- Feeling faint or dizzy.
- Hot or cold flashes.
- Fears of dying.
- Fears of going crazy.
SOURCE: Anxiety and Depression Association of America, 2014
Direct Effects of Substance Abuse on Anxiety Symptoms
While symptoms of anxiety are believed to contribute to developing substance abuse problems by way of self-medication, the use of substances can also increase the risk of developing symptoms of an anxiety disorder or make pre-existing symptoms of anxiety worse.
The use of substances can increase the risk of developing anxiety disorder symptoms or make pre-existing symptoms worse.
Alcohol Abuse. Alcohol abuse can lead to symptoms of anxiety and has even been shown to contribute to the onset of panic attacks.
While alcohol and other central nervous system (CNS) depressants, including benzodiazepines—such as alprazolam (Xanax) and lorazepam (Ativan)—as well as barbiturates, may initially appear to have calming effects on an individual’s degree of stress, excessive use of these drugs can lead to impairments in an individual’s physical and mental functioning, which can be a major source of stress.
More commonly, though, withdrawal from alcohol and other CNS depressant drugs may trigger rebound anxiety and even panic attacks. Further, this can increase the individual’s risk for relapse.
Marijuana Use Marijuana use, on the other hand, may not directly contribute to the development of anxiety symptoms, though in some cases using marijuana can exacerbate pre-existing symptoms of anxiety.
For instance, marijuana use can lead to symptoms that mimic that of a panic attack, such as:
- A racing heart.
- Difficulty breathing.
- Feeling of being detached from oneself.
- Poor motor coordination.
In particular, individuals with a history of panic attacks are more likely to have these symptoms triggered with marijuana use.
Moreover, withdrawal after a long period of marijuana use is associated with the onset of temporary anxiety; however, with time these symptoms tend to subside, as the individual is able to successfully abstain from marijuana use during the withdrawal phase.
Stimulant Drug UseStimulant drugs are most commonly linked with both the onset and exacerbation of anxiety, as they lead to a rapid excitement of the neurotransmitters in the brain.
Excessive symptoms of anxiety and panic are among the most commonly reported side effects of using stimulant medications.
Withdrawal from stimulant medications is characterized by a sudden drop in neurotransmitter levels, which also leads to symptoms of anxiety.
Examples of Stimulant Drugs
- Amphetamines and similar drugs (e.g., Adderall, Ritalin)
- MDMA (street name: Ecstasy)
- Mephedrone or MDPV (street name: bath salts)
Brain Activity with Stimulant DrugsUsing stimulant drugs, such as Adderall, is likely to cause anxiety and panic.
Prevalence of Comorbid (Dual Diagnosis) Substance Abuse and AnxietyMany people will come home from work and have a drink in order to de-stress from the day. In fact, since alcohol works as a depressant, it can give the illusion that it is a highly effective stress reliever.
As such, individuals in highly stressful jobs or who regularly feel unable to relax because of anxiety are at risk for developing problems with alcohol. In most instances, the psychological need to have a drink whenever you feel a little stressed or uncomfortable is a clear warning sign that you may have a problem with alcohol.
Effects of Substance AbuseMost professionals will agree that a substance abuse problem is defined by the excessive use of substances, such as alcohol or drugs, which leads to clinically significant impairment on the individual’s ability to function on a day-to-day basis.
Catching and treating substance abuse problems early can reduce the risk of long- term negative impacts.
Substance abuse can have detrimental impacts on the individual’s ability to function at work, home, or school, and can even cause problems in terms of friendships.
It is typical for individuals who were functioning very well prior to the onset of their substance abuse to have exhibited a much more gradual course of onset— this can mask the condition somewhat, rendering it much more difficult to identify and treat early.
Indeed, it is well known that catching substance abuse problems early is the best.
Rates of Substance Abuse and AnxietyBoth substance abuse disorders and anxiety disorder are among the most commonly diagnosed psychiatric conditions in the United States.
In fact, the lifetime prevalence rate for a substance abuse disorder has been estimated to be around 14.6% and the lifetime prevalence rate for an anxiety disorder has been estimated to be about 28.8%.
In the U.S., 14.6% of the population have suffered from substance abuse and 28.8% have suffered from anxiety.
14.6%28.8%Further, findings from studies using samples drawn from both the community, as well as clinical populations, have indicated that being diagnosed with either a substance abuse disorder or an anxiety disorder places the individual at an augmented risk for developing problems with the other. 
Though nearly all of the anxiety disorders have been linked with substance abuse problems, panic disorder—with or without agoraphobia—is the second leading anxiety disorder related to substance abuse (odds ratios = 1.0-9.2). 
Common Treatments for ComorbiditiesIdeally, individuals who have a dual diagnosis of substance abuse problems and anxiety are able to receive comprehensive treatment, such that the interventions chosen target both presenting conditions. Indeed, there are several treatment options available for treating both substance abuse problems and anxiety.
Pharmaceuticals/MedicationsOne class of medications that has received support for its role in treating comorbid anxiety and alcohol abuse is selective serotonin reuptake inhibitors (SSRIs).
More specifically, both paroxetine (brand name: Paxil) and sertraline (brand name: Zoloft) have been explored among samples of individuals who have been diagnosed with alcohol abuse and anxiety. 
Findings from these studies, however, remain mixed with some finding support for reduced symptoms of both anxiety and alcohol dependence, while others do not. As such, more work is needed to explore the role of selective serotonin reuptake inhibitors on symptoms of comorbid substance abuse and anxiety.
One anti-anxiety medication, buspirone (brand name: BuSpar) has received support for its role in treating both alcohol abuse and symptoms of anxiety. Further, the anticonvulsant medication topiramate (brand name: Topamax) has demonstrated potentially positive results in treating individuals with cocaine dependence and symptoms of anxiety.
How Anti-Anxiety Medications Work
SSRIs block the reabsorption of serotonin in the brain, boosting your mood.
Behavioral TherapiesThe use of behavioral therapy, either alone or in conjunction with medication, is a critical component of the treatment for dually diagnosed substance abuse and anxiety problems.
In fact, behavioral therapy is often the preferred method of treatment, given that prescribing medication—particularly the benzodiazepine anti-anxiety medications, with their high propensity for dependency and abuse—is a major concern for many substance abuse professionals.
Cognitive Behavioral Therapy
The most commonly referred behavioral approach for individuals suffering from comorbid substance abuse problems and anxiety is cognitive behavioral therapy(CBT). The goal of this approach is to change an individual’s maladaptive beliefs and unhelpful behaviors.
Individuals who undergo cognitive behavioral therapy are taught:
- To recognize their thoughts, feelings and physiological responses to certain situations.
- Skills in relaxation practice that they then use during graded exposure exercises.
- Are clinician-guided.
- Encourage individuals to face feared situations in a stepwise fashion.
- Allow the individual to experience success and mastery, in order to face increasingly challenging situations.
Cognitive Behavioral TherapyCBT works by changing negative and unhelpful thoughts, behaviors, and emotions.
CBT, in particular, has received empirical support for its role in treating substance abuse, both among adult and pediatric populations, as well as anxiety problems.
CBT has received much support for its role in treating substance abuse and anxiety problems.
While most studies have supported the use of CBT for individuals with substance abuse and anxiety, other studies have actually shown that exposure—a specific intervention component of cognitive behavioral therapy—can have detrimental impacts on the individual’s progress with regard to their substance abuse problems.
Targeting Treatment for Co-occurring Conditions
The treatment of individuals with dually diagnosed, or co-occurring, substance abuse problems and anxiety brings about important considerations.
In most cases, professionals will attempt to treat both co-occurring conditions simultaneously; however, this may not actually be the most beneficial for individuals with substance abuse problems and anxiety. For instance, some individuals may be more ready to make changes with regard to one disorder over the other.
As such, it may actually be beneficial for these individuals to target treatment accordingly, rather than attempting to focus treatment on both.
Further, individuals undergoing behavioral treatment for anxiety may impede their progress by using alcohol to cope with feelings of distress that may come up as the result of undergoing treatment.
Thus, it is important for professionals treating these conditions to be mindful of the course of symptoms of the comorbid condition and to engage in continual monitoring of the individual’s progress in treatment.
Indeed, there is very little information regarding outcomes from treatment approached in this way. Thus, more work is necessary in order to clearly identify the ideal approach to targeting symptoms of co-occurring substance abuse problems and anxiety.
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