In addition to providing basic epidemiologic facts, we use simple language and graphics to emphasize the vicious cycle that can emerge between drinking and anxiety, wherein the more one uses alcohol to manage anxiety in the short run the more anxiety there is to manage in the long run.
We introduce the role of cognitions, thoughts, beliefs, and expectations in how individuals react to situations to produce anxiety and drinking urges. Finally, we teach patients a standard paced diaphragmatic breathing exercise designed to minimize hyperventilation commonly identified among individuals with anxiety disorders.
Cognitive restructuring. We teach patients about thinking patterns that contribute to initiating and maintaining anxiety and panic. We also teach patients how to recognize and restructure cognitions that promote alcohol use as a means of coping with anxiety, such as focusing on alcohol’s short-term calming effects instead of its longer-term anxiogenic effects. This phase requires clinical expertise in CBT skills; a wide range of resource materials is available to walk the patient (and clinician) through cognitive restructuring exercises (see Related Resources).
Cue exposure involves systematic therapist-guided exposure to fear-provoking situations and sensations with the goal of decoupling them from anxiety-inducing thoughts about catastrophic outcomes.
Exposures are used:
- for reality testing
- to allow patients to practice new anxiety management skills
- to increase patients’ sense that they can successfully cope in feared situations (“self-efficacy”).
We expand this approach to include alcohol-relevant cues associated with anxiety states. Exposures—imaginal and in vivo—incorporate this information to help patients decouple anxiety feelings from drinking urges and to practice alternate coping strategies.
Pilot data for integrated Tx
After 4 months of participating in an integrated CBT program, 32 alcoholism treatment patients with panic disorder were significantly less likely to meet criteria for panic disorder, compared with 17 patients who received standard chemical dependency treatment without the CBT program (M.G.K., C.D., B.F., unpublished data, 2007). Before treatment, both groups averaged approximately 2.5 panic attacks per week. At follow-up the group that received CBT averaged <0.5 panic attacks per week, whereas the control group averaged approximately 2 panic attacks per week.
Overall, there was a positive effect for CBT treatment in terms of relapse to full alcohol dependence—10% in the treatment group met this criteria vs 35% in the control group. Integrated CBT treatment was more effective in reducing relapse risk among patients who reported the strongest baseline expectations that alcohol consumption helps to control their anxiety symptoms: 0% in the treatment group relapsed to full alcohol dependence vs. 57% in the control group. For comorbid cases that had the weakest anxiety-reduction expectancies, 21% in the CBT group met the relapse criterion compared with about 20% in the control group.
In summary, an integrated CBT program for comorbid panic disorder appears to provide the greatest added value to standard alcoholism treatment among patients who expect alcohol to relieve their anxiety symptoms.
Treatment in a psychiatric setting
Our group is in the process of generating a database upon which to make empirically based treatment recommendations. Until then, we can offer treatment recommendations based upon experience and the limited data available.
When planning psychiatric treatment for a patient with an anxiety disorder, start by assessing the patient’s alcohol use (Figure 2). The National Institute on Alcohol Abuse and Alcoholism (NIAAA) offers assessment tools (see Related Resources) to help you judge whether a patient’s alcohol use exceeds recommended limits (for example, 7 drinks per week for women and 14 per week for men).
Teach individuals whose drinking is excessive and/or regular (especially deliberate drinking aimed at coping with anxiety) about the risk associated with alcohol use and potential interference of alcohol/drugs with successful anxiety treatment. Suggest that patients reduce their drinking, and solicit their input into what would be a reasonable goal, such as those suggested in the NIAAA clinical guidelines (see Related Resources). Also advise patients to refrain from drinking/using before or during anxiety exposures so they can obtain the maximum benefits of treatment.
Individuals who are severely alcohol dependent or fail to meet their reduced drinking goals may require additional treatment. Options include:
- referral to a specialized addiction treatment setting
- pharmacotherapy with FDA-approved medications for treating alcohol dependence, such as naltrexone, acamprosate, or disulfiram.