Anxiety and addiction treatment, with both understood together.

Self-medicating

Why do people with anxiety drink or use to cope?

People with anxiety often drink or use because it works at first: the substance quiets the worry quickly. The trouble is what happens after, when the relief wears off and the anxiety returns stronger.

Alcohol is easy to get, so it is commonly used to cope with anxiety. It may seem to relieve anxiety in the short term, but over time heavy drinking and repeated withdrawal can push both the anxiety and the drinking higher. Genes and surroundings play a part in the pairing too.

The numbers show how often it happens. Anxiety disorders are the most common psychiatric disorders in the United States, and among people treated for an anxiety disorder, 20% to 40% also have alcohol use disorder, NIAAA reports. In the national survey NIMH cites, from the early 2000s, 19.1% of American adults had an anxiety disorder in the past year.

The three anxiety disorders seen most with drinking

Generalized anxiety disorder brings constant, wide-ranging worry, poor sleep, tiredness and trouble relaxing. Social anxiety disorder is an intense fear of being watched, judged or embarrassed. Panic disorder involves repeated attacks of intense fear lasting minutes to an hour, often followed by avoiding the places where they struck.

Telling them apart

Is it anxiety, or is it the substance?

Anxiety in someone who drinks or uses heavily can come from the substance itself, from an anxiety disorder of its own, or from both. Telling which takes time and a careful history, not a single conversation.

Clinicians are advised to build a timeline with the person. The aim is to learn whether anxiety is present during stretches without alcohol, which points toward an independent anxiety disorder, or fades when drinking stops, which points toward anxiety caused by the alcohol. The answer helps set expectations and shapes the plan.

The same overlap is why assessment matters. Overlapping symptoms make co-occurring conditions harder to diagnose, and people with both often have symptoms that are more persistent and severe than either alone. Clinicians experienced in both substance use and mental health can reduce the chance of a missed diagnosis.

The same holds for panic disorder: before it is diagnosed, other medical problems are checked, and substance-related disorders are considered because their symptoms can look like panic attacks.

Before the call, it helps to note whether the anxiety is worse the morning after or between uses, any panic attacks and where they struck, and every prescription being taken, especially any benzodiazepine or other sedative.

Panic

What should you know about panic attacks and substance use?

A panic attack is a sudden wave of intense fear with physical symptoms, and drinking, stimulants and withdrawal can all set one off. It feels dangerous, and the fear of the next one can shape a whole life.

A panic attack starts suddenly and most often peaks within 10 to 20 minutes, with some symptoms lasting an hour or more. A pounding heart, chest discomfort, shortness of breath and dizziness are common. Panic attacks are not life-threatening in themselves, NIMH notes, but they can feel like a heart attack, and many people with panic disorder first seek care in an emergency room for that reason.

Alcohol and stimulants, caffeine and cocaine among them, may trigger or worsen panic. Panic disorder is commonly associated with alcohol and substance misuse, and people with it often change their lives to avoid another attack. For some, a drink or a pill becomes the way to face a crowded room, a drive or a flight.

Treatment for panic

The gold standard, in NIMH’s words, is cognitive behavioral therapy. One technique, interoceptive exposure, practices facing the body sensations of panic, such as a racing heart, until they lose their power to set off an attack. Medication can help too; antidepressants may take several weeks to work, and benzodiazepines, though fast, can lead to tolerance and dependence.

If you are not sure whether it is panic or a heart problem, treat it as an emergency and call 911.

Treatment

How are anxiety and addiction treated together?

Anxiety and addiction are treated together through one coordinated plan that addresses both conditions at the same time. Integrated treatment leads to better results than separate, disconnected care, as NIDA and NIAAA both report.

Anyone entering treatment for one condition should be screened for the other. Integrated care means mental health and substance use treatment combined, so the person gets coordinated care in one place, using behavioral therapies, medicines, care management or a mix.

Talk therapy

For generalized anxiety, panic and social anxiety, the gold standard psychotherapy is cognitive behavioral therapy, with exposure therapy as a common method and acceptance and commitment therapy as an option for social anxiety. On the substance side, standard care for alcohol use disorder includes motivational enhancement therapy, CBT, contingency management and twelve-step facilitation. An integrated plan might include CBT for both, with skills for each in alternating sessions or, increasingly, taught together.

Medicines, and the questions they raise

Combining an antidepressant with a medicine for alcohol use disorder can treat both, and clinicians need not wait for sobriety to start an antidepressant when there is a clear need, while checking for interactions with alcohol. NIAAA also advises avoiding as-needed medicines with misuse or overdose potential, such as benzodiazepines for anxiety, in people with alcohol use disorder. SAMHSA adds that combining medicines for substance use disorders with benzodiazepines can have serious adverse effects. Every one of these is a decision for a prescriber who knows the whole picture.

For people whose anxiety was being treated with a benzodiazepine, what replaces it is covered in the plan for anxiety once a benzodiazepine is reduced.