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Anxiety and Substance Abuse

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It can be difficult to manage an anxiety disorder or a substance use disorder, and it can be even more difficult to manage both disorders when they co-occur together. When a mental health disorder, such as an anxiety disorder, and a substance use disorder present at the same time, this is known as a co-occurring disorder. Anxiety disorders that co-occur with substance use disorders are quite common. Statistics for substance abuse and anxiety show that:

  • Anxiety disorders are the most frequently occurring mental health disorder in the United States, and nearly 20% of adults are diagnosed with some type of anxiety disorder.1
  • About 32% of American adults have both a mental illness and a substance use disorder (SUD) at some point in their lives.2
  • In 2020, more than 40 million Americans aged 12 and over had a substance use disorder within the last year, with over 28 million diagnosed with an alcohol use disorder.3

This page will discuss the following:

  • Substance abuse and anxiety.
  • Different types of anxiety disorders and symptoms associated with them.
  • The relationship between anxiety and substance abuse.
  • What dual diagnosis and co-occurring disorders mean and how to recognize them.
  • The reason it is important to receive treatment for substance abuse and anxiety disorders at the same time.
  • What to expect from treatment for substance abuse and anxiety.
  • How you can help a loved one who is struggling with anxiety and substance use disorders.

What is Anxiety?

Anxiety is a normal human emotion, and is intended to keep us aware and prepared to react in dangerous situations.1 Many situations can lead to feelings of anxiety, such as facing a difficult choice, having to speak in front of others, getting ready for an exam, or when facing imminent danger.1, 4 However, anxiety disorders occur when these emotions start to interfere with your ability to function in everyday life, affecting your relationships with others, your performance at school or work, or in some cases, your ability to leave the house.1, 4 There are many different types of anxiety disorders that include the following:1, 5, 6

  • Generalized Anxiety Disorder (GAD), which involves intense, chronic anxiety about various aspects of daily life, even if there isn’t anything specific that leads to this anxiety.
  • Social Anxiety Disorder, which involves severe anxiety surrounding socialization, commonly centering around fears of being being embarrassed. This can lead to avoidance of social interactions, or can be limited to only specific situations.
  • Panic Disorder, which involves the occurrence of sudden panic attacks, and the person may go out of their way to avoid situations that may cause or contribute to a panic attack.
  • Specific Phobias, which involve an overwhelming and irrational fear of a specific place or thing, and exposure to the trigger can cause extreme panic. The person will commonly do everything they can to avoid the trigger.
  • Separation Anxiety Disorder, which involves significant anxiety or fear surrounding being separated from loved ones beyond what is considered normal. It also involves ongoing worries about harm occurring to a loved one, or fears about loss of a loved one.
  • Agoraphobia, which involves anxiety surrounding several different situations, including being in crowded areas or waiting in a line, having to use mass transit, being in open areas, being in closed-in areas, or being out of the house alone. People with agoraphobia commonly worry about panicking in these situations and not being able to escape or get help, and often avoid these situations.

There are a variety of factors that contribute to the development of anxiety disorders. Some common factors include:

  • Gender. Women are twice as likely as men to develop anxiety disorders and are more likely to develop more severe symptoms.6, 7
  • Genetics. There is a genetic component to anxiety disorders, so if your close relatives have anxiety disorders, you are more likely to develop one.1, 6
  • Exposure to stress or trauma. If you experienced abuse, violence, death of someone close to you, divorce, or severe illness, the risk of developing an anxiety disorder is higher.1, 6
  • Personality. Some personality traits can make you more prone to developing an anxiety disorder, including being more sensitive to anxiety, increased focus on negative emotions, and being more inhibited.6

Signs and Symptoms of Anxiety

While the symptoms may vary depending on the specific disorder, they all feature excessive amounts of fear or worry that affect your functioning.1 Symptoms can manifest physically and emotionally and include:1, 8

  • Avoiding certain places, things, or social situations.
  • Being on edge or on constant alert.
  • Chest pain, racing heart, or palpitations.
  • Diarrhea.
  • Difficulty sleeping.
  • Dizziness.
  • Fatigue.
  • Feeling as though something terrible is about to happen.
  • Feeling restless or irritable.
  • Having difficulty focusing.
  • Headaches.
  • Nausea or stomach upset.
  • Shortness of breath.
  • Spending a lot of time worrying.
  • Sweating.
  • Tension or jumpiness.
  • Tremors.

Drug Abuse and Anxiety

There is a relationship between anxiety and addiction, and having one disorder makes you more likely to be diagnosed with the other.9 Substance use disorders (SUDs) are most likely to occur with generalized anxiety disorder (GAD), panic disorder, and agoraphobia.9, 10 People with anxiety and an SUD are more likely to have difficulty staying in treatment, drop out early, have worse symptoms, and experience worse outcomes.10, 11

Both marijuana and stimulants cause the heart rate to speed up, which can mimic physical symptoms of anxiety and potentially exacerbate anxious thoughts.12, 13 Stimulants such as cocaine or methamphetamine can also dramatically increase anxiety.6, 14 More than 25% of people who use methamphetamine are also diagnosed with anxiety disorders.14


Alcohol Abuse and Anxiety

A link between anxiety and alcohol use disorder has also been established, particularly for GAD, panic disorder, agoraphobia, social anxiety disorder.9, 15 People with an alcohol use disorder (AUD) and anxiety commonly have more severe symptoms associated with their alcohol use disorder, more severe alcohol withdrawal symptoms, increased risk of relapse after treatment, more severe anxiety symptoms, and are less likely to make progress in treatment.9, 15


What Comes First: Substance Abuse or the Mental Health Problem?

Whether the substance abuse or anxiety comes first can vary between individuals, and there are three distinct possibilities for the development of these issues. In some cases, the anxiety disorder can occur first, and substances may be misused to manage the symptoms. Using medications inappropriately or misusing substances to mask symptoms of anxiety is known as self-medicating.9, 10

In others, the substance use may occur first and the anxiety disorder can follow as a result of changes in how the brain works because of the substance.9, 10 Risk factors are similar for anxiety and SUDs, and they affect the same parts of the brain, increasing the likelihood of developing both a substance use disorder and an anxiety disorder.10, 15 Substance use can also lead to anxiety disorders in some cases, especially with chronic, high-dose use.15, 16


Recognizing Dual Diagnosis

When an individual has an SUD and another mental health disorder, such as anxiety, this is known as a co-occurring disorder or dual diagnosis.17, 18 Since these disorders can influence each other and affect progress; anxiety and addiction recovery treatment programs should ideally provide integrated treatment.9, 19 This means that both issues are addressed at the same time during treatment in order to help you more effectively.19, 20


Treating Anxiety and Co-Occurring Substance Use

Symptoms of an anxiety disorder can mimic symptoms of other health issues, and substance use can also make it hard to accurately diagnose anxiety.1 In order to receive an accurate diagnosis, you should receive a thorough exam from a physician to rule out underlying health issues, and then be evaluated by a mental health practitioner.1, 4 Since some substances can cause anxiety during intoxication or withdrawal, you may not be formally diagnosed until you have been off substances for a period of time.15 Once you are diagnosed with a co-occurring disorder, treatment typically involves a combination of psychotherapy and medication, and some addiction treatment centers also incorporate complementary therapies (yoga, pet therapy, meditation, etc.).1, 17

There are a variety of therapy types that can be used to treat anxiety disorders. Some of the most common include:1, 4, 10, 15, 21

  • Cognitive-behavioral therapy (CBT), which aims to change patterns of thought and behaviors to reduce anxiety.
  • Exposure therapy, designed to reduce the fear response experienced when exposed to triggers while practicing relaxation techniques to build healthy coping skills.
  • Seeking safety, designed to address anxiety issues resulting from trauma, while also treating SUDs.
  • Motivational interviewing (MI), designed to help you work through any ambivalence you may have about treatment and then overcome these ambivalent feelings.

Medication can be an important aspect of treatment for anxiety disorders and SUDs. There are medications available to help manage withdrawal symptoms and to reduce the likelihood of relapse of certain substances, including alcohol and opioids.10, 20

Antidepressants can balance chemical levels in your brain that play a role in your mood and stress levels.4 The most common antidepressants used to manage anxiety are Paxil (paroxetine), Zoloft (sertraline), Prozac (fluoxetine), and Celexa (citalopram).15, 22 Benzodiazepines, such as Xanax (alprazolam) or Valium (diazepam), can be used short-term to manage anxiety symptoms, but these have a high addiction potential and should be used cautiously in people with co-occurring disorders.1, 11

Complementary therapies can be incorporated into the treatment plan, and include a range of techniques that can increase the effectiveness of traditional treatment.1 These include:1, 4, 21, 23

  • Relaxation techniques. This can involve deep breathing, mindfulness, meditation, or yoga, which you can practice when feeling anxious.
  • Exercise. Incorporating exercise can be a good way to reduce anxiety and stress.
  • Pet therapy. Animals can help lower anxiety levels and be incorporated into therapy sessions. Dogs and horses are commonly used in therapy, and have been shown to be effective in sessions.
  • Vitamins and supplements. Taking omega-3 fatty acids and folate may help you respond better to treatment and prevent the development of future issues. However, it’s important to check with your doctor first, since they may interact with medications you currently take.

Treatment can be provided in different settings, depending on your needs. Detox offers a safe place for you to clear substances you have been taking from your body, where you are supervised by medical staff and medication can be offered to ease withdrawal symptoms.17 Afterwards, further treatment can be provided in two different settings.

Inpatient treatment requires you to stay at the facility for the duration of treatment, where staff is present 24/7 to monitor you and provide counseling during the day.17, 24 Outpatient treatment allows you to attend scheduled therapy appointments while living at home and following your daily routine with minimal interruption.17, 24


How to Help a Loved One With Co-Occurring Disorders

While you can’t make a loved one better, there are some things you can do to help them. Talking to them honestly about your concerns can make them more aware of what you see.25 It can be helpful for you to offer to visit the doctor with your loved one, since they can provide a more objective point of view.26 It’s also important for you to practice self-care, making time to take care of your own health and well-being.25

How to Talk to Someone With Anxiety and Addiction

When talking to someone with anxiety and addiction, there are some do’s and don’ts to keep in mind. These include:25, 27, 28, 29

  • Do speak directly about your concerns.
  • Do remain calm and stay patient.
  • Do listen without judgment and validate their feelings.
  • Do offer your help. This can include suggesting treatment options, or attending family therapy with them.
  • Do schedule a private time to talk to your loved one, when you won’t be interrupted.
  • Do set healthy boundaries with the person.
  • Do try to get them to participate in healthy behaviors with you.
  • Do learn more about Community Reinforcement and Family Training (CRAFT), which can help you and your loved one more effectively.
  • Don’t criticize or lecture.
  • Don’t become confrontational.
  • Don’t blame the person.
  • Don’t enable their behaviors.
  • Don’t have this talk when they’re under the influence.
  • Don’t give up, even if they refuse to go to treatment currently.

Find Help for Anxiety and Substance Abuse

The only way to determine which treatment options are best for you is to talk with your medical or mental health provider. Begin your path to recovery today by verifying your insurance to see what and how much will be covered.

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Kristen Fuller, MD, enjoys writing about evidence-based topics in the cutting-edge world of mental health and addiction medicine and contributes to medicine board education. Her passion lies in educating the public on the stigma associated with mental health. Dr. Fuller is also an outdoor activist, an avid photographer, and is the founder of an outdoor women's blog titled, GoldenStateofMinds. In her free time, she enjoys hiking, backpacking, skiing, camping, and paddle boarding with her dogs in Mammoth Lakes, California, where she calls home.
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