The Effects of Substance Abuse on Anxiety Disorders

Mental health and substance abuse are often bound in comorbidity, with particular prevalence in those 18 and older (ADAA, 2018). One pair of disorders that share frequent comorbidity are anxiety and substance abuse. Carra et al. (2015) suggests that anxiety suffers tend to self-medicate with alcohol or drugs (p. 391), while Blau (2017) adds that substances for self-medication are less difficult to obtain and less expensive to maintain than trying to receive psychiatric services and that street drugs are more potent than prescription medications (p. 2). For anxiety sufferers, cannabis and other depressants serve just as well as prescription Xanax or antihistamines. Because anxiety disorders are the most common mental health problem in the United States, it stands to reason the mental health community would have a handle on treatment. However, less than 37% of those with an anxiety disorder receive treatment despite seeking medical and psychiatric help five to six times more than people with other mental health disorders (ADAA, 2018). As anxiety disorders continue to plague the population of the United States, it is in the best interest of mental health and medical providers to analyze and appropriately address the contexts in which individuals employ the use of illicit substances as symptom management tools for their mental health disorders to document the mental and physical effects these substances have on those with anxiety disorders, particularly adolescents.

Anxiety Disorders Defined 

Anxiety is a normal and adaptive response to stress or fear. Feelings of anxiety are usually associated with increased watchfulness and muscle tension in preparation for a perceived threat (APA, 2012). These behaviors were vital to successful human evolution and are important for humans to learn natural fear responses. When anxiety extends beyond normal levels or lasts chronically, though, a professional may diagnose an individual with an anxiety disorder (APA, 2013). Anxiety disorders affect one-third of the population at some point over the course of a lifetime (Bandelow & Michaelis, 2015).  Anxiety disorders are characterized by undue fear, anxiety, and other disturbances in behavior and thinking (APA, 2013). When these symptoms are severe enough, an individual may experience significant distress and disruption in their ability to function (APA, 2013). The first step to a diagnosis of an anxiety disorder is determining an individual’s symptoms.  

Symptoms of anxiety differ depending on the specific disorder but may be either somatic or psychic. Somatic symptoms include heart tremor and palpitations, dizziness, nausea, and muscle tension (APA, 2013). Psychic symptoms include difficulty concentrating, nervousness, insomnia, and excessive worry (APA, 2013). Panic attacks are specific symptoms present within many anxiety disorders, but they are also features of other mental disorders (APA, 2013). Symptoms may manifest in response to a specific phobia or more generalized fears (APA, 2013). Somatic symptom disorders, major depression, and physical ailments are also characterized by feelings of anxiety (Bandelow, Michaelis, & Wedekind, 2017). Professionals must differentiate between anxious feelings due to one of the aforementioned conditions and those associated with an anxiety disorder before making a diagnosis (APA, 2013). After ruling out differential diagnoses, professionals can determine the specific type of anxiety disorder.

DSM-5 references 11 different types of anxiety disorders. These are “separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, panic disorder, agoraphobia, generalized anxiety disorder, substance or medication-induced anxiety disorder, anxiety disorder due to a medical condition, other specified anxiety disorder, and unspecified anxiety disorder” (APA, 2013, para. 16). Specific phobias are most common, followed by panic disorder without agoraphobia, social anxiety disorder, and generalized anxiety disorder (Bandelow et al., 2017). Anxiety disorders are often comorbid with each other as well as with major depression, somatic symptom disorders, personality disorders, and substance abuse disorders (APA, 2013). The Hamilton Anxiety Scale, the Panic and Agoraphobia Scale, and the Liebowitz Social Anxiety scale are used to determine the severity of a person’s anxiety (Bandelow et al., 2017). However, these scales are used to rate different anxiety disorders since each is unique in the thing(s) people feel anxious about.

Acute stress disorder begins or worsens after exposure to trauma. Intrusive symptoms include distressing memories of the event, recurring dreams, dissociative reactions such as flashbacks and body memories, prolonged psychological upset or intense physiological reactions to anything resembling traumatic event (APA, 2013). Individuals exhibit avoidance symptoms, negative mood, an altered sense of reality, and arousal symptoms including problems with sleep and concentration, hypervigilance, and aggression (APA, 2013). “Other specified anxiety disorder” involves enough symptoms to damage social or occupational function while still not meeting the full diagnostic criteria for any of the other disorders. Providers primarily use this diagnosis when individuals experience “limited-symptom attacks… [and] generalized anxiety not occurring more days than not” (APA, 2013, p. 233).

Separation anxiety presents as developmentally inappropriate emotions (fear, anxiety) regarding separation from a specific individual. It primarily affects children but can be seen in adults. The disorder is marked by thinking of or experiencing separation from specific people that causes distress, believing attachment figures will come to harm, refusal to leave home, nightmares about separation, and experiencing headaches and physical complaints when separation is expected (APA, 2013). Substance/medication-induced anxiety disorder consists of anxiety or panic caused by medications, alcohol, or drugs. An individual will experience extreme feelings of anxiety, paranoia or panic while medicated, drunk, or high so that functioning is further impaired, and enjoyment of substances is circumvented.

Obsessive-compulsive disorder includes recurrent and unwanted thoughts, urges, and images intruding on daily activities and causes anxiety or stress (APA, 2013). Individuals work to neutralize or ignore intrusive thoughts with directed actions or different thoughts. OCD also involves compulsions or repetitive behaviors individuals are compelled to act on in order to reduce anxiety about a perceived disastrous event (APA, 2013). Obsessions and compulsions mar daily functioning for at least one hour of every day. According to the DSM-5, panic disorder “refers to recurrent unexpected panic attacks” (APA, 2013, p. 209). A panic attack is a sudden and intense fear or intense anxiety that escalates for several minutes and contains four of the established 13 symptoms (APA, 2013). 

Social anxiety entails fear of social situations due to perceived feelings of judgment by others. Individuals fear they will act inappropriately and will be rejected. The anxiety and fear are not proportional to the feared situation and causes a significant upset in social, occupational, or other areas of functioning. PTSD involves exposure to trauma either directly, as a witness, discovering traumatic events happened to family or close friends (APA, 2013). Symptoms occur after trauma and are intrusive. They include involuntary memories, nightmares, dissociation, physiological reactions, and intense psychological distress (APA, 2013). Individuals perform avoidant behaviors to associations of the traumatic event. PTSD can cause memory lapses and distortions and depressive symptoms. PTSD sufferers are typically hypervigilant, startle easily, and have issues with concentration and sleep (APA, 2013). 

People with GAD will experience abnormal amounts of worry and anxiety about events and activities. Symptoms include feeling on edge, fatigue, brain fog, agitation, tense muscles, and difficulty sleeping (APA, 2013). Disturbances to social and occupational functions are significant. Anxiety due to another medical condition is diagnosed when the medical ailment induces anxiety and was documented before the onset of anxiety (APA, 2013). An example of this would be hyperthyroidism, which can dramatically increase the heart rate. Or, irritable bowel syndrome, which causes anxiety about bowel attacks in public.  

Selective mutism often afflicts children with social phobias or social anxiety and adults with post-traumatic stress disorder. Sufferers do not initiate speech in social interactions or respond when spoken to. Selective mutism also involves acute shyness, social anxiety, isolation and withdrawal with mild oppositional behavior. Phobias include fear or anxiety about an object or situation that provokes individuals to avoid the object or situation (APA, 2013). Fear and anxiety are not appropriate to any actual danger or to sociocultural context and cause significant loss of daily social or occupational functions. An example of specific phobia is agoraphobia; the fear of leaving the home or open/closed spaces, public transportation, crowds or queues, and social situations (APA, 2013). Panic attacks may occur when patients encounter feared situations or objects. There is also unspecified anxiety disorder, but the DSM-5 notes this diagnosis is only given when an individual does not meet the full criteria or there is insufficient information to make a diagnosis of another specific anxiety disorder (APA, 2013). 

Short-term disorders can last from a few days (as with acute stress disorder) up to six months with the exception of substance-induced anxiety, which ends when the individual discontinues using the substance. Long-term disorders are pervasive, lasting at least six months. Some anxiety disorders are well known through media representation. However, much of this media has portrayed anxiety disorders inaccurately by sensationalizing, hyperbolizing, and confusing symptoms. The prevalence of this has led to the general public believing these disorders present in those ways. This may play a role in self-diagnosis and self-medication of a perceived anxiety disorder. 

Inaccurate representation plays a role in some of the properties of anxiety disorder patient care such as determining causes for disorders, psychotherapeutic and medicinal treatments, and comorbidity with other psychiatric disorders like substance abuse. According to Cox, Norton, Swinson, and Endler (1990), the connection between anxiety disorders and substance abuse can be divided into two parts: “the incidence of anxiety disorders in substance abuse patients and the incidence of substance abuse in patients with panic-related anxiety disorders” (p. 385). Cox et al. (1990) note 10-40% of alcohol abusers have been diagnosed with an anxiety disorder, while 10-20% of anxiety-disordered individuals abuse alcohol or other drugs (p. 385). Despite its prevalence for comorbidity, these two disorders do not have considerable research explaining why they present together so frequently. Treatment and intervention outcomes suffer due to a lack of understanding of the relationship between anxiety and substance abuse (Baillie et al., 2010). 

Substance Use as a Cause of Anxiety Disorder

It has been documented that favored prescription medications and several substances of choice used to invoke relaxation, bolster confidence, or eliminate social reservations actually instigate social anxiety or produce substance-induced anxiety disorders. Some even trigger panic attacks. Smith and Book (2008) note that substance-induced anxiety disorders only occur in .2% of comorbidities, making the disorder quite rare (p. 2). They also found supporting evidence that in 75% of cases, the anxiety disorder precedes substance use, indicating the latter was a form of self-medication, especially in the African American population (Smith & Book, 2008). The Alcohol and Drug Abuse Institute’s research consultant Susan Stoner (2017) conducted a national survey in 2015 that found 22.2 million people age 12 and older self-medicated with drugs – specifically marijuana. In another study conducted in June 2017, Stoner surveyed 1,746 patients to determine the reason for their marijuana usage. It was reported that 37% used it to combat anxiety, 16.9% partook to relieve panic attacks, and over 55% stated they used marijuana to increase relaxation (p. 3). Several studies have documented marijuana use to cope with the symptoms of various anxiety disorders (Lee, Neighbors, & Woods, 2007; Ruehle, Rey, Remmers, & Lutz, 2012; Crippa et al., 2009). 

Exacerbation

The chemistry involved in marijuana use, however, says something a little different. Stoner’s survey also notes that THC – the psychotropic chemical in marijuana – was found to decrease anxiety at lower doses but the effect is reversed at higher doses (Stoner, 2017). However, CBD, the non-psychotropic chemical in the drug – was found to decrease anxiety at low and high doses, implying that the two may cancel each other out at a certain point, causing anxiety reduction to wane. Other substances have been recognized in research as having contradictory effects. For instance, according to a study by Brady, Haynes, Hartwell, and Killeen (2013), alcohol is often used to stave panic symptoms, but withdrawal can generate panic attack within the first few weeks of staying sober (p. 7). The study also suggests “smoking, and nicotine, in particular, can alleviate anxiety, but other studies indicate that nicotine use and withdrawal can cause anxiety” (Brady et al., 2013, p. 11). Incidentally, 40% of people diagnosed with an anxiety disorder are nicotine users. Similarly, Wyman, Hons, & Castle (2006) found that amphetamines, cocaine, and opiates (which are known for reducing perceived anxiety and in some cases sedating individuals) also had high instances of exacerbated anxiety when used in certain situations or during withdrawal (p. 106). 

Treatment Options and Future Considerations

Smith and Randall (2012) advise to modify and combine evidence-based treatment strategies and balanced interventions to “to accommodate the unique needs of people who have both disorders” (p. 414). They suggest diagnosis and treatment include considerations for comorbidity pathways and integration. Smith and Book (2008) offer several recommendations for the treatment of dual disorders involving psychotherapy and psychopharmacology as primary approaches (p. 2). Researchers have observed SSRI medications to be effective for social anxiety disorder and excessive alcohol use if the disorders present simultaneously. Smith and Book (2008) also believe that psychotherapy should play an important role in treatment planning while still taking into consideration that some individuals with anxiety disorders tend to shy away from therapies that utilize program principles akin to Alcoholics Anonymous’ “12 Steps” (p. 3).

A Biblical Perspective

The book Modern Psychopathologies: A Comprehensive Christian Appraisal (2005) reviews the ways in which the church seeks to understand and reconcile where faith and spirituality integrate with the scientific pathology used to describe, process, and treat mental illness. Reviewer Rodney L. Bassett (2006) explained how the book moves from historical views of pastoral work and soul care, which has been integral to the church for millennia, to voicing concerns about spiritual exclusions (including the notion of sin) from mental health and mental illness topics. By removing the spiritual element, the authors believe dialogues and ideologies about mental illness are incomplete. Pastor Brad Hambrick (2015) of The Summit Church agrees that the church can add to the mental illness conversation. He states that emerging Christian literature, classes, and events about mental illness can be equally therapeutic. Open dialogues about the comorbidity of anxiety disorders and substance use help the church to be an unbiased safe place for discussions about all aspects of mental health as well as teach others how these subjects are pertinent parts of living a Christian life.

References

ADAA. (2018). Facts & statistics. Retrieved from https://adaa.org/about-adaa/press-room/facts-statistics

American Psychiatric Association [APA]. (2013). Diagnostic and statistical manual of mental disorders (5th Ed). 

Baillie, A. J., Stapinski, L., Crome, E., Morley, K., Sannibale, C., Haber, P., & Teesson, M. (2010). Some new directions for research on psychological interventions for comorbid anxiety and substance use disorders. Drug and Alcohol Review, 29(5), 518-524. doi:10.1111/j.1465-3362.2010.00206.x

Bandelow, B., & Michaelis, S. (2015). Epidemiology of anxiety disorders in the 21st century. Dialogues in Clinical Neuroscience, 17(3), 327-335. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610617/pdf/DialoguesClinNeurosci-17-327.pdf

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of Anxiety Disorders. Dialogues in Clinical Neuroscience, 19(2), 93-107. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573566/pdf/DialoguesClinNeurosci-19-

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Blau, M. (2017, June 27). STAT forecast: Opioids could kill nearly 500,000 Americans in the next decade. Retrieved from https://www.statnews.com/2017/06/27/opioid-deaths-forecast/

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Cox, B. J., Norton, G. R., Swinson, R. P., & Endler, N. S. (1990). Substance abuse and panic-related anxiety: A critical review. Behaviour Research and Therapy, 28(5), 385-393. doi:10.1016/0005-7967(90)90157-e

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Hambrick, B. (2015, February). Towards a Christian perspective on mental illness. Retrieved from http://www.mentalhealthministries.net/resources/articles/christian_perspective/Towards-a-Christian-Perspective-on-Mental-Illness.pdf

Lee, C.M., Neighbors C., & Woods B.A. (2007). Marijuana motives: Young adults' reasons for using marijuana. Addictive Behaviors, 32(7), 1384-94.

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Smith, J. P., & Randall, C. L. (2012). Anxiety and alcohol use disorders: Comorbidity and treatment considerations. Alcohol Research: Current Reviews, 34(4), 414-31.

Stoner, S. A. (2017, 6). Effects of marijuana on mental health: Anxiety disorders. Retrieved from http://adai.uw.edu/pubs/pdf/2017mjanxiety.pdf

Wyman, K., Hons, B.A., & Castle, D. J. (2006). Anxiety and substance use disorder comorbidity: Prevalence, explanatory models and treatment implications. Journal of Dual Diagnosis, 2(4), 93–119. Doi:10.1300/J374v02n04