Alcoholism and Anxiety

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I used the term alcoholism in the title for clarity, but the new DSM-V term is Alcohol Use Disorder, AUD. When I write AUD, I’m referring to alcoholism. In a way I like the new term, AUD, because it removes the split between abuse and dependence and looks at the progression of alcoholism from early to middle to late stages. It forces caregivers to look more closely at signs and symptoms and perform a more comprehensive assessment.

Another area of debate regarding AUD treatment is the diagnosis of co-occurring anxiety. The question of which came first is largely unimportant, if the therapist understands both AUD and anxiety — however, it’s good to discuss anxiety and AUD, and look at the research, so that there is better understanding. It’s harmful for an alcoholic who claims to self-medicate her anxiety with alcohol to think she can treat her anxiety and return to normal drinking. This is one aspect of the anxiety/AUD issue — the idea that anxiety is the primary problem and some people self-medicate with alcohol, and because alcohol makes the anxiety worse, the vicious cycle creates a problem with alcohol. Here’s what Steven Balt, MD writes on the subject:

Alcoholism and anxiety go hand in hand. The extent of this comorbidity is clear from the numbers: as many as 45% of patients with alcohol disorders meet diagnostic criteria for a co-occurring anxiety disorder. And alcoholic patients with a comorbid anxiety disorder—particularly panic disorder or social phobia—are three to seven times more likely to relapse than those without concurrent anxiety (Kushner MG et al, Alcoholism: Clin Exp Res 2005;29:1432–1443).

It’s not clear why anxiety and alcoholism so commonly co-occur, but there are at least three potential, and not mutually exclusive, explanations for this phenomenon. First, anxiety may lead to alcohol abuse. According to this theory, patients use alcohol as a way to “self-medicate” their anxiety (Morris EP et al, Clin Psychol Rev 2005;25:734–760). Second, and conversely, excessive alcohol use may generate an anxiety disorder, via a “kindling” effect of repeated withdrawal cycles or disruptions to the stress response system. Finally, there may be no clear primary disorder, but rather a common underlying vulnerability to both anxiety and to alcohol abuse (Kushner MG et al, Current Psych 2007;6(8):55–64). This may be psychological, like high anxiety sensitivity, or biological, like GABA receptor dysfunction or a gene polymorphism.

The other question is how to treat co-occurring anxiety and AUD. There are different modalities, such as Cognitive Behavioral Therapy, but the greater concerns are method, timing and priority. Is it better to treat the alcohol problem first or the anxiety problem first? This is the sequential method. Another method would be to treat the two problems at the same time but not necessarily with the same services — in other words, an addiction specialist would treat the AUD, while another therapist who deals with anxiety would treat the anxiety. The third method is the integrated method, which entails one therapist or service treating both the anxiety and the AUD — this requires greater skills and understanding of both issues. The integrated method appears to be the most effective. There is also evidence that anxiety and AUD are not that distinct.