Anxiety is a sensation that is brought on by emotion and fear. It presents itself in physical symptoms. Anxiety is often characterized by feelings of tension, apprehension, worry, irrational or excessive fear, and stress and can produce physical symptoms such as increased blood pressure, sweating, trembling, dizziness, rapid heartbeat, nausea, vomiting, diarrhea, muscle tension, headaches, trouble concentrating, insomnia and irritability.1
Most importantly, anxiety is a strong physical reaction to anxious thoughts, predictions, beliefs, and fears, that are usually irrational or excessive. Anxiety is not simply the stress that individuals naturally feel in difficult circumstances, such as before public speaking, or when writing an exam; anxiety presents itself irrationally and therefore, can be very difficult to understand and control.
Behavioral symptoms of anxiety include anxious thoughts, anxious predictions, anxious beliefs, avoiding feared situations, avoiding activities that previously caused anxiety, safety behaviors, and excessive physical reactions to the situation at hand.
Substance Use Disorder (SUD) is a disease that is characterized by the dependence and negative effects of harmful substances such as alcohol or drugs. SUD’s are a disease that affects the brain and behavior, making it incredibly difficult to stop. Prolonged substance use leads to dependence and cravings, meaning that the body becomes dependent on a substance to function.
Substances activate the brain’s reward systems, producing feelings of pleasure, relaxation, and euphoria. Because of this, substance abuse to achieve those feelings will continue; despite negative outcomes, they might be experiencing as a result of substance use.
Once your body becomes dependent on a substance, stoppings its use may cause some unpleasant withdrawal symptoms. This creates a cycle whereby it becomes extremely difficult to stop using when the easy fix for negative withdrawal symptoms is the use of the drug that created the problem in the first place.
The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) outlines 11 criteria that are used to identify the presence of a substance use disorder. The number of criteria that apply to a patient will determine the severity of their disorder. The 11 criteria outlined by the DSM-5 are:2
The relationship between anxiety and substance use disorders is multifaceted. In recent years, researchers have begun to understand that anxiety and substance use disorders commonly co-occur, and people who suffer from one of the disorders are more likely to suffer from the other as well. This is because substances can function as a temporary fix and relief for anxiety symptoms. People who suffer from anxiety may turn to substances to try to soothe their symptoms, which over time can lead to dependence on those substances.
On the other hand, anxiety can be one of the side effects of substance use, and prolonged substance use can often result in feelings of anxiety and depression. A study published in 2020 found that anxiety and depression are the most common problems reported by people who are seeking treatment for substance abuse.3
Anxiety is often a major symptom of withdrawal from both alcohol and drugs, and can last for up to two years after recovery and withdrawal.3 Because of the prolonged use of substances changes the way that your brain functions and changes your brain’s reward system, you become more likely to experience negative mental health effects.
In 2004, A National Epidemiological Survey on Alcohol and Related Conditions was conducted with 43,000 adults.5 About 17.7% of these adults with a SUD in the past 12 months also met the criteria for having an anxiety disorder.5 15% of those who had an anxiety disorder in the past 12 months had at least one co-occurring SUD.5
Based on criteria from the DSM, the relationship between anxiety disorders and drug use disorders is stronger than the relationship between anxiety and alcohol use disorders. Amongst those with anxiety disorders, the most prevalent co-occurring drug use disorders were marijuana use (15.1%), cocaine use (5.4%), amphetamine use (4.8%), hallucinogen use (3.7%), and sedative use (2.6%).5
Reports published in the Journal of American Medical Association showed that approximately 50% of individuals with severe mental health disorders also suffer from substance use disorders.3 37% of people with alcohol use disorder and 53% of people with drug use disorders also have at least one serious mental illness. From the sample of all people with a mental health disorder, 29% abuse either alcohol or drugs.3 This shows that the relationship between anxiety disorders and substance use disorders is strong, and having either disorder increases your chances of also having or developing the other disorder.
One of the tricky aspects of treating co-occurring disorders such as anxiety and substance abuse is that certain anxiety medications may pose risks for addiction. Two popular medications used to treat anxiety disorders are Gabapentin (an anticonvulsant) and Xanax (a benzodiazepine).
Gabapentin is an anticonvulsant prescription medication originally intended for use against seizures and the pain following an episode of shingles. While there have not been many medical studies looking into the effect of gabapentin for the treatment of anxiety disorders, it is sometimes used off-brand to treat anxiety when other medications have not worked.
Due to its ability to be used for multiple issues, in 2020, Gabapentin was the sixth most prescribed medication in the U.S.6 Unfortunately, gabapentin can also have negative consequences, as it carries the potential for addiction and can also cause suicidal thoughts, mood swings, and other physical symptoms.
This can be problematic because in trying to treat an anxiety disorder, gabapentin can also cause a substance use disorder. Essentially, you would be replacing an anxiety disorder with a substance abuse disorder, or end up with both co-occurring disorders. This makes it more difficult to treat both the anxiety disorder and the substance use disorder, and treatment will have to reflect the complexity of co-occurring disorders.
Xanax, which is the brand name for alprazolam, belongs to a group of drugs called benzodiazepines and is the most prescribed psychiatric medication in the U.S. Xanax acts on the brain and central nervous system, decreasing the levels of abnormal excitement in the brain and producing feelings of calmness. It reduces nervous tensions and anxiety that are caused by an unbalance of brain chemicals by boosting a natural chemical called gamma-aminobutyric acid.
Even more so than Gabapentin, Xanax is highly addictive and can have negative side effects as well, including suicidal thoughts and mania. Long-term abuse of Xanax can be associated with depression, psychotic experiences, and aggressive or impulsive behaviors. Therefore, the use of Xanax to treat anxiety disorders can also easily lead to the abuse of the substance, and consequently a substance use disorder.
Treatment for co-occurring disorders, otherwise known as a dual diagnosis, requires an integrated approach where both the anxiety disorder and substance use disorder are treated simultaneously. Because anxiety and drug abuse affect each other, it is impossible to treat one disorder without treating the other.
Treatment options for co-occurring disorders include treatment programs that specialize in dual diagnosis. Treatment can be inpatient treatment where patients live at a facility and receive 24-hour care or outpatient treatment where individuals live at home and visit the hospital or clinic to receive their treatment, whether that is medication, counseling, or other types of treatments. Some of the treatment options for co-occurring anxiety and substance use disorders are:
The first step to any type of substance use treatment is detoxification. When you stop using substances after a prolonged period of use, you can experience unpleasant withdrawal symptoms such as sweating, nausea, vomiting, anxiety, insomnia, muscle pain, fatigue, restlessness, tremors, difficulty sleeping, and more.
When experiencing withdrawal symptoms, it may be tempting to use the substance that your body developed the dependence on. This is why it is advisable to seek out medical detoxification where your body can detox under medical supervision, and with medication if necessary. This will make you more likely to succeed in detoxification, and avoid relapse. Stopping the use of substances is important for the treatment of anxiety disorders; because it is important to not use substances in a misguided attempt to self-medicate from anxiety.
CBT is a form of counseling that focuses on teaching skills and strategies that are used to reduce problematic behaviors and challenge negative patterns of thinking.7 When using CBT for substance abuse, you would identify negative patterns of behavior associated with substance use and implement strategies to be able to avoid triggers and fight against cravings.7
When using CTB for anxiety disorders, there would be a focus on changing patterns of thinking to decrease the feelings and emotions associated with problematic thinking. This involves cognitive therapy which focuses on how our negative thoughts contribute to our anxiety and behavior therapy which focuses on how we behave and react in situations that trigger anxiety.7 CBT on its own or in combination with medications or other forms of therapy is very useful for treating co-occurring disorders.
Transcranial Magnetic Stimulation is a noninvasive procedure that involves placing an electromagnet against your head and having small magnetic bursts released to stimulate the part of the brain responsible for mood. TMS is typically used to treat depression but has also been effective in the treatment of anxiety and substance use disorders.
TMS is also used to treat the withdrawal symptoms that occur when stopping the use of substances after prolonged used and to help fight drug cravings. Because TMS is non-invasive, it is a good option for people who do not want to take medications to treat their co-occurring disorders, as many medications pose a risk of abuse.
Neurofeedback refers to the training of the brain function and re-training it to function more efficiently. Neurofeedback is a process that takes place over a longer period and starts with observing the brain, the way that it acts, and the way that it responds to anxiety. The brain is then rewarded when it changes its activity to more appropriate patterns.
This happens by showing the person something in particular and then measuring the brain function. Over time, the brain will become trained to respond to different scenarios differently. Neurofeedback is useful for anxiety disorders and substance use disorders in retraining the way that the brain functions and responds to different triggers.
Clonidine is in a class of medications called central alpha-agonists. It is a prescription medication used to treat attention-deficit hyperactivity disorder and high blood pressure. Clonidine has also been used in the treatment of anxiety disorders and is believed to decrease anxiety attacks and ‘psychic’ symptoms. Clonidine is also prescribed to help with opioid withdrawal symptoms and with the detoxification process. This makes it a multi-functioning medication since it can be used for anxiety disorders and substance use disorders.
Propranolol belongs to a class of medications called beta-blockers and is used to treat heart problems, anxiety, and migraines. Propranolol works by slowing down your heart rate so it is easier for your heart to pump blood around your body. It helps reduce physical symptoms of anxiety such as sweating and shaking and also helps you feel calm and relaxed. Propranolol is also sometimes used for the treatment of severe cocaine withdrawal symptoms, such as anxiety and cravings.
Herbal remedies may be used in addition to or as an alternative to prescription medication since they are less likely to have unwanted side effects. The following herbs may help alleviate anxiety:
Cannabidiol is a type of cannabinoid which is a chemical found naturally in cannabis plants. Research has shown that taking CBD oil consistently can help alleviate anxiety symptoms.
Magnesium, vitamin D, calcium, zin, iron, and B vitamins can help to reduce anxiety.
Consistent meditation (the act of sitting quietly with our thoughts) can help to reprogram neural pathways in the brain and improve our ability to regulate emotions and reduce anxiety.
Yoga helps to reduce anxiety and stress by helping to focus on your breath and being present in the moment and not letting the anxiety take over our thoughts.
Mindfulness is a mental state in which we are aware of ourselves in the present moment, we accept our feelings, thoughts, and bodily sensations, and observe them. Mindfulness helps us to control our thoughts, and focus on the reality around us which can reduce anxiety.
Caffeine is known to increase symptoms of anxiety by stimulating the body’s fight or flight response. Avoiding caffeine can help to maintain a state of calm throughout the day.
The following foods can help to reduce anxiety: brazil nuts, fatty fish such as salmon, eggs, pumpkin seeds, dark chocolate, turmeric, yogurt, and green tea. Maintaining a healthy diet can help to reduce anxiety symptoms.