For some people, a glass of wine after a long day at work is used to help "take the edge off," or a drink at a party to help "loosen up." For many of these individuals, alcohol use in moderation is not of concern. However, for people with anxiety disorders, using alcohol or other substances can make anxiety symptoms worse and can even trigger panic attacks. Moreover, the risk and occurrence of alcohol abuse is high in people with anxiety disorders. This makes alcohol use an important issue to consider for people with anxiety disorders.

According to a major study released in 2004 on co-occurring alcohol abuse and mental health disorders (called the National Epidemiologic Survey on Alcohol and Related Conditions and conducted by the National Institute on Alcohol Abuse and Alcoholism), about 20 percent of Americans with a current anxiety or mood disorder (such as depression) also have a current alcohol or other substance abuse disorder, and about 20 percent of those with a current alcohol/substance abuse disorder also have a current anxiety or mood disorder. Other studies have put these numbers even higher. While having co-occurring alcohol abuse and anxiety disorders can make an individual's situation more complex, the good news is that these disorders are treatable - separately and together. Read on to learn more about the co-occurrence of anxiety disorders and alcohol abuse, and how they can be treated.

Are people with anxiety disorders more likely to suffer from alcohol abuse than the general population and vice versa?

People with anxiety disorders are two to three times more likely to have an alcohol or other substance abuse disorder at some point in their lives than the general population, and vice versa. However, as explained in more detail later in this piece, the risk and prevalence of alcohol abuse is more common among people with certain anxiety disorders than others.

Which occurs first in people with co-occurring disorders - the anxiety disorder or alcohol abuse?

There is a lot of variability in how people experience these conditions together. Possible courses of the co-occurring conditions include:

• The alcohol abuse and anxiety disorders are independent of one another, meaning that one does not cause the development of the other. However, the symptoms of one can make the symptoms of the other worse.
  
• An anxiety disorder leads an individual to use alcohol or other substances to "self-medicate," or attempt to alleviate their anxiety symptoms on their own (which does not help, and only exacerbates, their anxiety).
  
• An alcohol abuse problem causes heightened anxiety during certain specific periods of abuse, such as during the actual time of drinking and/or withdrawal states (some studies have shown the withdrawal from alcohol may activate the same neural pathways as anxiety). These anxiety symptoms may go away during other times and usually are eliminated completely after the problem drinking stops.
  
• An alcohol or other substance abuse problem leads to development of a substance-induced anxiety disorder in which a person's substance abuse causes anxiety to exist all or close to all the time during a period of alcohol or other substance abuse in one's life. This may happen because some substances change the way brain cells communicate with each other, including affecting the amount of neurotransmitters (or chemical messengers) in an individual's nervous system. Thus, substance abuse can damage parts of the brain that keep anxiety in check. This type of anxiety disorder will last during the period of substance abuse, and sometimes for a short period of time after the substance abuse has stopped.

In the past, there was a general consensus that among people who abuse alcohol, those who also had an anxiety and/or mood disorder were usually substance-induced and the disorder would disappear once the substance abuse was treated. However, according to the earlier-mentioned National Epidemiologic Survey on Alcohol and Related Conditions, the vast majority of people with both alcohol/substance abuse and anxiety disorders experience them independently, with none or only some of anxiety episodes being induced by alcohol or drugs. This is important point for both patients and therapists, who should not assume that treating substance abuse will solve an anxiety disorder on its own. Treating both disorders together is often necessary.

What added difficulties can arise from having both alcohol abuse and anxiety disorders?

Having both an anxiety disorder and alcohol abuse disorder can have a "vicious cycle" effect. For example, someone with an anxiety disorder may use alcohol to alleviate their anxiety symptoms, causing them to experience more anxiety as a side effect of using these substances, which then leads them to drink more alcohol. Other complications may include:

• People with the co-occurring disorders are at high risk for many additional problems such as hospitalizations, financial problems, family problems and medical illnesses.
  
• People with both disorders may have lower treatment compliance than people with just one disorder.
  
• People with both an anxiety disorder and alcohol abuse have an increased risk of relapse into alcohol abuse than people who have an alcohol problem without anxiety.
  
• People with both disorders may be at an increased risk for experiencing dangerous interactions between prescription medication and alcohol (in the event that they relapse into alcohol abuse) than people with an anxiety disorder alone.
  
• People with an anxiety disorder may have more pronounced alcohol withdrawal symptoms than alcohol abusers without anxiety.

This makes it of the utmost importance to treat both disorders. The above points should all be discussed with a doctor when determining an individual treatment plan.

Are there specific anxiety disorders that are more often associated with alcohol abuse? How does the relationship between anxiety and alcohol differ based on a person's specific anxiety disorder?

While individuals with any anxiety disorder can also have an alcohol abuse problem, research has found this co-occurrence is more common in people with certain anxiety disorders, including social anxiety disorder (SAD) and posttraumatic stress disorder (PTSD). Moreover, some research has shown the order in which the disorders develop often varies based on the type of anxiety disorder (although, as noted earlier, any order of development is possible as every person is different). For example, alcohol abuse in people with SAD and agoraphobia usually develops after the onset of the anxiety disorder (with people reporting they are using the alcohol in an attempt to control anxiety, i.e., "self medication"). On the other hand, alcohol abuse commonly begins before or at the same time as anxiety symptoms in people with generalized anxiety disorder (GAD) and panic disorder. Again, this is not always the case.

Some disorders also have noteworthy considerations/circumstances when co-occurring with alcohol abuse. These include:

Panic Disorder - Panic attacks can often be caused by use of alcohol or drugs, worsening the course of a person's disorder (or even inducing it). Panic disorder has also been singled out in research as a risk factor for a major substance abuse relapse among people with both disorders.

Posttraumatic Stress Disorder (PTSD) - PTSD and alcohol abuse may commonly occur together for a variety of reasons, including alcohol abuse may increase the likelihood of being exposed to trauma (and thus developing PTSD), or individuals with PTSD may use alcohol to "self medicate" in an attempt to ease their symptoms. Many characteristics of substance abuse can exacerbate symptoms of PTSD, including sleep disturbance and irritability. While professionals in the past often treated substance abuse before treating co-occurring PTSD, many now treat them together because symptoms of PTSD (such as intrusive thoughts and sleep disturbance) can drive relapse to substance abuse.

Social Anxiety Disorder (SAD) - Often, people with social anxiety report that alcohol helps lessen their social anxiety, which is likely why alcohol abuse is so common in this population. However, in reality, substance use often makes anxiety worse. There are also special treatment considerations for people with co-occurring substance abuse and social anxiety. Certain treatment approaches commonly used for substance abuse, such as group therapy or 12-step programs (used by Alcoholics Anonymous or Narcotics Anonymous) may be difficult for a socially anxious person. Thus, a more individualized treatment strategy may be necessary for people with co-occurring SAD and substance abuse.

Can an anxiety disorder and substance abuse be treated at the same time and by the same professional?

Many professionals will suggest treating these conditions at the same time to offer the best chance for successful recovery and lessen the chance of relapse, particularly when one disorder is not causing the other. (For a substance-induced anxiety disorder, the substance abuse would be addressed first because the anxiety should improve after abuse terminates). Many professionals or treatment teams can treat these disorders together. Ask your doctor if he or she can treat both conditions by him/herself, or in conjunction with another professional as part of a treatment team.

What treatments are available for people suffering from both?

Researchers are still exploring how to best treat people with both conditions. Many therapists will attempt to use non-medication treatments for people with both anxiety and substance abuse disorders because of the increased risk for abuse of medication among substance users. When prescription medications are used, therapists aim to use ones that have low abuse potential and that are safe if taken with abused substances should a person relapse into alcohol or drug use. (Note that even when considered "safe" by an interaction standpoint, medications that treat anxiety and/or substance abuse are less effective when used with alcohol or drugs.) While medications that effectively treat both anxiety disorders and substance abuse are still being explored, many doctors will suggest using an SSRI, a group of antidepressants commonly used in the treatment of anxiety disorders that include Prozac (fluoxetine), Zoloft (sertraline), Luvox (fluvoxamine), Paxil (paroxetine), Celexa (citalopram) and Lexapro (escitalopram), often in conjunction with therapy. Many doctors will avoid prescribing people with both disorders benzodiazepines, another group of medications also used to treat anxiety disorders, because they can carry an increased risk of abuse, tolerance and physical dependence and thus may not be the best option for someone with current or past substance abuse.

The choice of medication should be discussed carefully between doctor and patient and will always depend on individual circumstances. This choice will also depend on the specific anxiety disorder a person suffers from (i.e., panic disorder, obsessive-compulsive disorder, etc.), as some medications will be more effective than others for an individual disorder.

Other treatment options for both anxiety disorders and substance abuse, which can be used alone or in combination with medication, include:

• Cognitive-behavioral therapy (CBT) - Individuals learn to identify, challenge and gain control over unwanted behaviors. These therapies have been demonstrated effective in both anxiety and substance abuse disorders.
• Individual psychotherapy - Individuals explore areas of emotional and social conflict. This is used for both disorders.
• Group psychotherapy - Individuals gather in a group to discuss shared and individual experiences. This is also used for both disorders.
• Self-help/other treatment groups - Individuals with similar needs or experiences meet, and meetings are facilitated by a consumer, layperson or survivor. Self-help groups for anxiety disorders can be found on ADAA's website here. You can also contact Alcoholics Anonymous or Narcotics Anonymous for meetings in your area.

For more information on treatment options, click here.

How can I find help in my area?

ADAA offers a searchable listing of mental health professionals nationwide. Click here to find a therapist. You can also search for addiction professionals by state on the NAADAC, the Association for Addiction Professionals, website here.

References and Resources

About.Com: "Anxiety Disorders Can Prompt Alcoholic Relapse"

Alcoholics Anonymous

Alcohol Research & Health: "Social Anxiety Disorder and Alcohol Use" (Vol. 26, No. 2, 2002)

American Journal of Psychiatry: "Alcohol Use and Anxiety: Diagnostic and Management Issues" (164:2, February 2007)

Narcotics Anonymous

National Drug Intelligence Center (Department of Justice)

National Institute on Alcohol Abuse and Alcoholism

National Institute of Mental Health

Psychiatric Times

Substance Abuse and Mental Health Services Administration

The International Society for Traumatic Stress Studies

WebMD: "Anxiety Disorders Linked with Alcoholism Relapse"