The distinction between anxiety and fear differentiates anxiety as a rather vague inner state of uneasiness that is not linked to a specific threat, whereas fear is an inner state of uneasiness that is linked to a specific tangible threat. However, over time, the two terms have become closer in meeting. Anxiety is often now considered to be a less intense manifestation of fear as opposed to being an inner state associated with no real tangible menace.
Anxiety is often described as an inner state comprised of the feelings of nervousness, worry, jitteriness, increased heart rate, rapid breathing, sweating, etc. The distinction between anxiety as a temporary feeling that varies in intensity between individuals and a major symptom of a category of psychological disorders deserves consideration:
- State anxiety: State anxiety refers to the experience of an unpleasant inner state when a person is faced with some type of environmental threat. When the environmental threat is removed, the anxiety dissipates. For example, suppose you are walking down the street and suddenly confronted with a large, snarling dog. You may feel a bit anxious. When the dog leaves, your anxiety should dissipate.
- Trait anxiety: Trait anxiety refers to the individual differences in the experience of the intensity of anxiety that people perceive when confronted with the same anxiety-provoking stimulus. For example, in the above dog scenario, some people may become wildly hysterical when confronted with such a dog, whereas others may only feel mild nervousness.
- Anxiety disorders: Experiencing anxiety is a normal life function as anxiety acts as a protective factor to help an individual acknowledge or avoid potentially dangerous situations. In addition, anxiety has a functional aspect to it as moderate levels of anxiety can increase an individual’s performance in many situations. However, an individual with an anxiety disorder does not experience the typical dissipation of anxiety that other people experience in response to certain situations (state anxiety), and their level of anxiety (trait anxiety) is often significantly out of proportion to the actual threat involved. Their experience of anxiety interferes with their ability to function normally. There are several different anxiety disorders, including generalized anxiety disorder, panic disorder, specific phobias, and social anxiety disorder. Individuals who experience these disorders are at risk to develop a number of other issues associated with their experience of anxiety, including a higher potential to engage in substance abuse than individuals who do not have a diagnosis of an anxiety disorder.
The Relationship between Anxiety and Substance Abuse
Individuals who experience the normal manifestations of anxiety do not have an increased potential to develop a substance use disorder. Individuals who experience anxiety in association with the parameters typically observed in individuals with anxiety disorders do experience an increased risk to develop a substance use disorder. For instance, one of the largest research studies investigating relationships between different psychological disorders found that 17.7 percent of the respondents who had a substance use disorder also met the diagnostic criteria for an anxiety disorder (compared to 6-8 percent of other individuals). Information from this same study revealed that for all the major types of anxiety disorders listed above, the odds of having an anxiety disorder with a co-occurring substance use disorder were significantly higher than the odds of having an anxiety disorder without a co-occurring substance use disorder. This finding indicates that there is a significant relationship between having a dysfunctional experience of anxiety and the development of a potential substance abuse problem.
Is important to understand that this relationship does not imply that everyone who experiences dysfunctional levels of anxiety will develop a substance use disorder. It instead implies that people who have dysfunctional levels of anxiety (to the point of qualifying for an anxiety disorder) are at a significantly higher risk to engage in substance abuse.
Of course, any drug of abuse can be associated with having an anxiety disorder; however, most often, abuse of alcohol, narcotic pain medications, and anti-anxiety medications are associated with having an anxiety disorder. There are three major potential explanations for the relationship between the two disorders:
- The self-medication hypothesis proposes that the development of a substance use disorder is an attempt by the individual to self-treat a specific psychological disturbance (in this case, anxiety). By definition, the anxiety disorder would have to precede the substance use disorder. This remains a popular explanation in lay circles and in some clinical circles.
- Having a substance use disorder results in experiencing symptoms that would also qualify an individual to be diagnosed with certain psychological disorders. For example, individuals with severe alcohol use disorders will experience dysfunctional levels of anxiety during periods of withdrawal or even short periods of abstinence of a few days or a few hours. In this case, the substance use disorder would have to predate the psychological symptoms of anxiety.
- The third potential explanation is a shared liability hypothesis that proposes that people who develop substance use disorders and other psychological disorders share a number of similar risk factors. They have experiences of extreme stress or trauma; these disorders share similar neurobiological vulnerabilities/pathways; and these disorders appear to have similar genetic associations. Because of these similar risk factors, individuals who develop one type of psychological disorder are automatically at risk to develop a similar psychological disorder, such as a substance use issue. In this case, either disorder could appear first or the disorders could appear at similar time intervals in a person’s life.
There is research that has indicated that the symptoms of anxiety disorders often precede the development of a substance use disorder in people who develop both; however, this does not confirm the self-medication hypothesis, as the shared risk factors hypothesis predicts that this possibility would occur as well. In addition, research has not consistently supported the self-medication hypothesis. When an individual develops a chronic substance abuse problem, the person’s substance abuse can actually produce symptoms of anxiety as opposed to dissipating them. In general, it is believed that a number of factors interact to produce these disorders, including environmental factors and inherent factors. Thus, the best overall explanation for the development of co-occurring anxiety and substance use disorders appears to be a shared factor type model that includes some consideration that individuals may at times attempt to self-medicate and that chronic substance abuse also produces symptoms of anxiety.
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When any individual is diagnosed with two different psychological disorders at the same time, both disorders need to be treated concurrently in order to ensure the best chance at a successful treatment process. Just focusing on one disorder and waiting to treat the other one is almost a guarantee for failure in recovery from either disorder.
Individuals who have anxiety disorders and substance use disorders need a comprehensive treatment program, implemented by a multidisciplinary team that includes physicians, psychologists, social workers, and other mental health workers to intervene in a comprehensive manner. Treatment must be based on sound empirically validated principles (treatment principles that have been confirmed as being effective by research) and at the same time, be tailored to fit the specific needs of the individual.
Treatment options include all potential empirically validated treatment protocols that fit the particular case at hand. For example:
- Some individuals will require medical detox depending on the substance use disorder, whereas others may not require medical detox.
- Some individuals may require inpatient treatment initially due to complicated substance use issues (e.g., withdrawal issues), serious manifestations of an anxiety disorder, or other environmental factors that are not conducive to recovery and treatment (e.g., being homeless or having abusive family members).
- Some individuals may require placement services like vocational counseling, whereas others may not.
- Some individuals may require medication-assisted treatment programs for either their anxiety or substance use disorder, whereas others may not.
- All individuals will require some form of comprehensive group and/or individual counseling that addresses their specific issues, both with anxiety and with the substance use disorder. Most often, these therapy interventions will consist of some form of Cognitive Behavioral Therapy.
- Some individuals may require family therapy to deal with certain family dynamics that contribute to both disorders.
- Individuals have the option of attending social support groups, including 12-Step groups for both their anxiety disorder and substance use disorder.
- All individuals will require a long-term aftercare program that prepares them for the inevitable challenges they will face once the treatment protocols have run their course.
Having an anxiety disorder increases the risk for an individual to also be diagnosed with a co-occurring substance use disorder. Having a substance use disorder is also associated with a higher risk for the development of an anxiety disorder. The relationship between these disorders is complex, and there is no definitive cause-and-effect explanation that can describe how having one particular disorder may lead to having the other. Nonetheless, treatment considerations must include treating both disorders concurrently in order for treatment for either disorder to be successful. A comprehensive treatment program that includes strong social support and a solid long-term aftercare plan will have the best chance of being successful.
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