The current conceptualization of anxiety has significantly been altered compared to classic interpretations of anxiety by pioneers in psychopathology, such as Sigmund Freud. Freud and his contemporaries viewed anxiety as an inner feeling of nervousness that could not be attributed to any specific concrete threatening situation. Fear was considered feelings of uneasiness or nervousness associated with a specific threatening situation that could be identified.

Today, the two different definitions have merged, and anxiety is considered by most clinicians to be a less intense manifestation of fear to either a real, tangible threatening stimulus or situation, or vague feelings of nervousness that cannot be associated with any specific type of hazard. Other clinicians differentiate fear as being an emotional response to an impending threatening situation, whereas anxiety is an emotional response that results as an anticipation of a future threatening event. Thus, anxiety becomes fear when the future threat becomes current, according to this notion.

Researchers and clinicians still refer to differences in how anxiety is expressed or experienced. In this context, individuals can express different manifestations of trait or state anxiety.

  • Trait anxiety refers to individual differences in subjective feelings of anxiety. Certain people may experience feelings of anxiety as far more intense or discomforting than other individuals.
  • State anxiety refers to the anxiety that occurs as a result of a specific situation or condition. Once the situation or condition is no longer present, the anxiety dissipates (or it should dissipate).

Nearly everyone will experience some anxiety at some point in their lives. A person who truly never experiences anxiety under any circumstances most likely has some form of brain damage. Certain situations, such as public speaking, are well known to elicit feelings of anxiety in many individuals. Other individuals may have very specific triggers that elicit feelings of anxiety, whereas others may not experience internal feelings of uneasiness as a result of these situations.

The normal experience of anxiety is not considered to be a potential risk factor for the development of a substance use disorder, such as an alcohol use disorder. Individuals who experience normal variations in mood and levels of anxiety typically do not turn to drugs or alcohol as coping mechanisms. Individuals who experience extreme forms of anxiety, such as very intense periods of anxiety or extremely prolonged periods of anxiety, are often diagnosed with an anxiety disorder. Having an anxiety disorder is associated with the potential increased risk to develop a substance use disorder, such as an alcohol use disorder.

What Are Anxiety Disorders?

Anxiety has a functional component to it that allows individuals to recognize and deal with potentially harmful situations. Anxiety is considered to be the product of an evolutionary process that has allowed humans to adapt and survive in harsh environments.

The experience of anxiety can trigger the famous fight-or-flight response that occurs due to the person’s cognitive appraisal of the situation interacting with the functioning of the central and peripheral nervous system. For instance, a person walking down an alley who comes in contact with a snarling dog will most likely experience extreme anxiety that will trigger a flight response. Once the person has escaped the situation, their level of anxiety will normally dissipate.

In addition, stress and anxiety can improve an individual’s performance on specific types of tasks. Performance on many types of tasks is at its optimum level when individuals experience moderate levels of anxiety. When individuals experience extremely low or extremely high levels of anxiety, their performance can often suffer (the Yerkes Dodson Law).

Individuals who suffer from anxiety disorders experience chronic dysfunctional levels of anxiety that are either out of proportion to any tangible or perceived threat and/or continue to experience high levels of anxiety even when a perceived threatening situation has long resolved. These individuals often experience significant distress and dysfunction as a result of their anxiety, and this anxiety interferes with normal functioning. When individuals have issues that lead to very intense or prolonged feelings of anxiety that result in significant distress, they are also at a greater risk to develop other issues, including issues with substance abuse.

According to the American Psychiatric Association (APA), the anxiety that occurs in anxiety disorders is either:

  • Significantly more intense than would occur in most individuals in the same situation
  • Significantly longer in duration compared to the experience of most other individuals under the same conditions
  • Inappropriate for the specific situation

According to the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5), there are 10 categories of anxiety disorders. These anxiety disorders are diagnosed by the use of behavioral diagnostic criteria. There are no medical tests, brain scans, etc., that can diagnose an anxiety disorder in anyone.

The major anxiety disorders are briefly outlined below.

  • Panic disorder occurs when individuals who have experienced panic attacks begin to develop dysfunctional behaviors as a result of anticipating future panic attacks. Just having occasional panic attacks is not sufficient for a diagnosis of panic disorder.
  • Specific phobias are anxiety disorders that occur as a result of extreme anxiety or fear of specific types of objects, living things, or situations. The anxiety that the person experiences is considered to be out of proportion to the actual threat these situations present.
  • Social anxiety disorder occurs when individuals have excessive feelings of anxiety when they think they are going to be exposed to social situations where they believe they will be harshly evaluated by other people.
  • Generalized anxiety disorder occurs when individuals have long periods of ongoing anxiety for a period of at least two months that is associated with numerous situations and conditions.
  • Agoraphobia is a disorder that brings extreme anxiety when individuals are in situations where they believe they cannot escape. In order for a formal diagnosis of agoraphobia to be made, the individual must have this extreme fear or anxiety associated with two different situations. The DSM-5 lists the specific types of situations that can result in the diagnosis.
  • Substance/medication-induced anxiety disorder occurs when an individual experiences anxiety as a result of certain types of medications or drugs.
  • Anxiety disorder due to a medical condition occurs when a person has a specific medical condition, such as hyperthyroidism, that results in them experiencing extreme and/or dysfunctional levels of anxiety.
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People who experience normal manifestations of anxiety will sometimes experience extreme and even dysfunctional levels of anxiety; however, their anxiety will dissipate once the threatening situation has resolved. Normal variations in anxiety are not stressful enough to result in an individual using alcohol or other drugs as a form of self-medication; although, it should be understood that the self-medication hypothesis is not the only explanation for the relationship between dysfunctional anxiety and substance abuse.

An often cited research study, the National Epidemiological Survey on Alcohol and Related Conditions, determined that individuals who experience normal manifestations of anxiety are not at risk to develop substance abuse problems like alcohol abuse. The study also found that individuals who had co-occurring diagnoses of an anxiety disorder and a substance use disorder, such as an alcohol use disorder, were far more common than individuals who simply had a singular diagnosis of an anxiety disorder. Thus, there appears to be a significant relationship between having an anxiety disorder and a substance abuse issue.

Research studies have identified interesting relationships between anxiety disorders and substance use disorders, such as alcohol use disorders. As mentioned above, the self-medication hypothesis, where an individual who has a pre-existing anxiety disorder uses alcohol to deaden their feelings of anxiety (to self-medicate their anxiety), is one of these explanations. However, the self-medication hypothesis is not sufficient to explain the relationship between a great number of individuals who have co-occurring alcohol abuse and anxiety disorders.

According to APA and numerous research studies cited in the Textbook of Anxiety Disorders:

  • A large number of individuals who have a co-occurring anxiety disorder and alcohol use disorder report that they had issues with substance and/or alcohol abuse prior to developing issues with anxiety.
  • Research on individuals diagnosed with panic disorder has indicated that many individuals develop alcohol abuse issues before their panic disorder is recognized.
  • At one time, post-traumatic stress disorder (PTSD) was categorized by APA as an anxiety disorder. Even though it is no longer categorized as an anxiety disorder, individuals with PTSD still experience significant levels of anxiety. Research has indicated that having a previous alcohol use disorder or other substance abuse issue is a risk factor for developing PTSD.
  • Individuals with social anxiety disorder often also have significant alcohol use and abuse issues. Even though these individuals report that their use of alcohol helps to reduce their level of anxiety, studies actually find that alcohol use worsens their anxiety. Nonetheless, people diagnosed with social anxiety disorder still continue to use alcohol despite alcohol making their anxiety worse.

Currently, most researchers and clinicians believe that the relationship between anxiety and alcohol abuse is multifaceted and consists of a number of variables that interact with one another to produce specific presentations in different people. One of the most common explanations of the relationship between anxiety disorders and substance abuse is a shared liability model that conceptualizes most mental health disorders as being related. According to this model, individuals who develop one type of mental health disorder (e.g., an anxiety disorder) are at an increased risk to develop any number of other mental health disorders as well (e.g., a substance use disorder, such as an alcohol use disorder).

The factors that interact to produce this vulnerability include genetic and environmental factors, such that different interacting factors are more like to produce different comorbid issues (co-occurring disorders). Thus, a simple explanation would be that simply having either a diagnosis of an anxiety disorder or a diagnosis of an alcohol use disorder could cause the other disorder to occur.

Treating an Individual with Co-Occurring Anxiety and Alcohol Use Disorders

When a person has a comorbid diagnosis of a specific mental health disorder and a substance use disorder, the situation is often referred to as a dual diagnosis or co-occurring disorders. Individuals who have dual diagnoses present unique challenges in treatment because it is ineffective to treat one of the disorders and ignore the other. Thus, individuals with dual diagnoses need to have both issues addressed at the same time. Whenever an individual has an anxiety disorder and a co-occurring alcohol use disorder, they must receive treatment for both of these issues concurrently, or the treatment for either issue will be ineffective.

When a person is treated for a substance use disorder and a comorbid mental health disorder, such as an anxiety disorder, an integrated treatment approach is preferred.

  • A team of treatment professionals addresses the individual’s situation.
  • A multidisciplinary team consists of different mental health professionals and other treatment providers who each address a specific issue.
  • Treatment providers often consist of physicians (e.g., psychiatrists, addiction medicine physicians, and other specialists), therapists (e.g., psychologists, counselors, social workers, etc.), and other treatment professionals that address the specific needs of the client (e.g., speech therapists, occupational therapists, vocational rehab specialists, case managers, etc.).
  • Each treatment professional works with the client to reach specific identified goals. Treatment can occur in individual sessions, group sessions, or even in sessions where different treatment providers work together.
  • The team meets periodically to discuss the progress of the individual and address specific issues.
  • The individual also attends other interventions, such as 12-Step meetings, community mental health groups, occupational counseling, etc., as needed in the individual case.
  • Treatment is aimed that meeting long-term success by helping the individual to achieve short-term goals.
  • Treatment is ongoing, even after many of the goals have been reached.
  • Like any form of intervention, more time spent in treatment-related activities is strongly associated with positive outcomes.
  • Treatment for the anxiety disorder will vary depending on the type of anxiety disorder the individual has been diagnosed with.
  • Treatment for the alcohol use disorder will follow the standard overall protocol for alcohol abuse treatment and be individualized for the needs of the client.

Integrated treatment programs are highly successful and help individuals with co-occurring anxiety disorders and alcohol use disorders to recover from their issues and lead productive lives.