Evidence-Based Reviews

Which to treat first: Comorbid anxiety or alcohol disorder?

Current Psychiatry. 2007 August;6(8):55-64

References

1. National Institute on Alcohol Abuse and Alcoholism. Alcohol use and alcohol use disorders in the United States: main findings from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Bethesda, MD; National Institutes of Health; 2006. NIH Publication No. 05-5737.

2. Kushner, Sher KJ, Beitman BD. The relation between alcohol problems and the anxiety disorders. Am J Psychiatry 1990;147:685-95.

3. Kushner MG, Abrams K, Thuras P, et al. Follow-up study of anxiety disorder and alcohol dependence in comorbid alcoholism treatment patients. Alcohol Clin Exp Res 2005;29:1432-43.

4. Kushner MG, Abrams K, Borchardt C. Anxiety disorders co-occurring with alcohol or drug use disorders: a review of major perspectives and findings. Clin Psychol Rev 2000;20:149-71.

5. Randall CL, Thomas S, Thevos AK. Concurrent alcoholism and social anxiety disorder: a first step toward developing effective treatments. Alcohol Clin Exp Res 2001;25:210-20.

6. Thomas SE, Thevos AK, Randall CL. Alcoholics with and without social phobia: a comparison of substance use and psychiatric variables. J Stud Alcohol 1999;60(4):472-9.

7. Conger JJ. Reinforcement theory and the dynamics of alcoholism. Q J Stud Alcohol 1956;17:296-305.

8. Sher KG, Levenson RW. Risk for alcoholism and individual differences in the stress-response dampening effect of alcohol. J Abnorm Psychol 1982;91:350-68.

9. Carrigan MH, Randall CL. Self-medication in social phobia: a review of the alcohol literature. Addict Behav 2003;28(2):269-84.

10. Schuckit MA, Hesselbrock V. Alcohol dependence and anxiety disorders: what is the relationship? Am J Psychiatry 1994;151:1723-34.

11. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders. Arch Gen Psychiatry 2004;61:807-16.

12. Thomas SE, Randall CL, Carrigan MH. Drinking to cope in socially anxious individuals: a controlled study. Alcohol Clin Exp Res 2003;27(12):1937-43.

13. Merikangas KR, Metha RL, Molnar BE, et al. Comorbidity of substance use disorders with mood and anxiety disorders: results of the International Consortium in Psychiatry Epidemiology. Addict Behav 1996;23(6):893-907.

14. Kushner MG, Sher KJ, Erickson DJ. Prospective analysis of the relation between DSM-III anxiety disorders and alcohol use disorders. Am J Psychiatry 1990;156:723-32.

15. Book SW, Thomas SE, Randall PK, Randall CL. Paroxetine reduces social anxiety in individuals with a co-occurring alcohol use disorder. J Anxiety Disord. In press.

16. Kadden RM, Kranzler HR, Rounsaville BJ. Validity of the distinction between “substance-induced” and “independent” depression and anxiety disorders. Am J Addict 1995;4:107-17.

17. Kushner MG, Donahue C, Sletten S. Cognitive behavioral treatment of comorbid anxiety disorder in alcoholism treatment patients: presentation of a prototype program and future directions. J Mental Health 2006;15:697-708.

When implementing a serial treatment, it is not always clear which disorder to treat first. Distinguishing comorbid disorders as “primary” or “secondary” often is done inconsistently and imprecisely, so treatment decisions based on these terms can be erroneous. Using the order of disorder onset also is an unreliable guide to which disorder is in priority need of treatment.^7,16

Based on our experience and research, where and why the comorbid patient presents for treatment should be factored heavily in these treatment decisions. For example, individuals seeking anxiety treatment who have a comorbid alcohol use disorder typically possess little insight into their drinking problem and a frank resistance to clinician-driven attempts to modify their drinking behavior. We would expect a similar reaction from patients presenting for alcohol disorder treatment who are told they must first obtain psychiatric treatment for anxiety symptoms. The serial approach often necessitates that patients be treated initially for the problem for which they present and then referred afterward for the comorbid condition as needed.

In an open-label pilot treatment study of 5 subjects with social anxiety disorder and a co-occurring alcohol use disorder (C.L.R., S.W.B., unpublished data, 2007), we first treated the anxiety disorder with the selective serotonin reuptake inhibitor paroxetine, up to 60 mg/d. After 6 weeks, we addressed the comorbid alcohol problem using a brief alcohol intervention. This approach met with little or no resistance to reduce drinking—all 5 subjects successfully decreased their alcohol consumption, and none dropped out of treatment. A controlled follow-up trial is planned to provide empiric support for serial treatment of anxiety and alcohol use disorders in mental health treatment settings.

Box

What is substance-induced anxiety disorder?

DSM-IV-TR describes an anxiety disorder as independent from a coexisting substance use disorder only if the anxiety disorder:

began distinctly before the substance use disorder
or persisted during periods of extended abstinence (>1 month) from substance use/abuse.

Otherwise, substance abuse is presumed to have induced the anxiety disorder. This perspective implies that no specific treatment beyond drug/alcohol abstinence is required to resolve a substance-induced anxiety disorder.

In a large community-based sample, Grant et al¹¹ found that <0.5% of individuals with comorbid anxiety and substance abuse met the strictly defined DSM-IV-TR criteria for a substance-induced anxiety disorder. Cases in which a comorbid anxiety disorder resolved during periods of substance abuse abstinence were especially rare. This observation suggests that substance-induced anxiety syndrome as defined by DSM-IV-TR is very rare in clinical practice.

DSM-IV-TR diagnostic criteria do not recognize an “anxiety-induced substance use disorder,” in which pathologic anxiety might induce a substance use disorder. Conceptually, however, this idea is as reasonable as substance-induced anxiety disorder and fits within the self-medication model.¹²

Parallel treatments, which can mitigate some disadvantages of the serial approach, increasingly are being used in chemical dependency treatment settings, where it is common to have psychiatric consultations. Based on our experience, however, this approach is far less common in psychiatric treatment settings, where clinicians do not routinely treat (or sometimes even assess for) comorbid alcohol or drug disorder in anxious and depressed patients. Also, the parallel approach often requires coordinating the times, locations, and strategies of treatments systems and clinicians, which can lead to problems:

Substance use disorder treatment expertise is not always available for patients in mental health treatment.
Clinicians from disparate systems may not fully understand the impact of the comorbid disorder and the culture of the parallel treatment system.
Practitioners (or patients) might see medications or cognitive-behavioral therapy (CBT) exercises for anxiety as contradicting core tenants of the parallel treatment approach.
It is not certain that standard treatments validated in non-comorbid patients would have the same therapeutic benefits when administered in a parallel treatment.⁵

Clinical Point

Our CBT-based integrated treatment approach includes psychoeducation, cognitive restructuring, and cue exposure

Integrated treatments seek to address both comorbid disorders in a single treatment program. Our group has found, for example, that a CBT program aimed at treating comorbid anxiety could be successfully integrated with a standard alcohol disorder treatment.¹⁷

Several factors limit the use of integrated treatments, however:

Few such programs exist.
Treatment providers in mental health and addiction settings typically are not cross-trained.
Personnel and other institutional supports are often lacking for integrated treatment programs.

Integrated treatment plan

Our CBT-based integrated approach to alcoholism treatment in patients with a comorbid anxiety disorder incorporates 3 components:

psychoeducation
cognitive restructuring
cue exposure.

Psychoeducation. The goal of psychoeducation is to explain the biopsychosocial model of anxiety disorder, alcohol disorders, and their interactions. This information is the general platform on which the specific treatment program is established in the next phase of the treatment.