Evidence-Based Reviews

Which to treat first: Comorbid anxiety or alcohol disorder?

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Therapies that target just one problem are in sufficient for patients who have both.


 

References

Men and women with anxiety disorders are at three times the general population’s risk of being alcohol-dependent (Table),1 and those who seek treatment for an anxiety disorder are at even higher risk of alcohol disorder.2,3 This comorbidity can complicate treatment attempts if either disorder remains unaddressed, leading to increased relapse risk and multiple treatment episodes.

Based on our research and clinical work in helping patients with comorbid alcohol dependence and anxiety disorders,2,4-6 this article describes:

  • potential relationships between anxiety disorders and alcohol disorder
  • pros and cons of 3 approaches to treating this comorbidity
  • how to identify and address alcohol disorder in patients with anxiety disorders, depending on available resources.

Table

Comorbidity rates of anxiety disorders and alcohol dependence*

Anxiety disorderOdds ratio for having alcohol dependence
MenWomen
Any3.23.3
Panic disorder3.83.7
Social phobia2.63.6
Generalized anxiety disorder3.63.4
Specific phobia2.82.9
* Numbers indicate odds of having alcohol dependence when the anxiety disorder is present vs absent.
Source: 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), reference 1

3 comorbidity models

The most common understanding of this comorbidity (Figure 1) is that having an anxiety disorder predisposes one to develop an alcohol or substance use disorder via self-medication—using alcohol or drugs to modulate anxiety and negative affect.7-9 However, substance use disorder experts have argued that the social, occupational, and physiologic effects of substance use can generate new anxiety symptoms in vulnerable individuals.10 In other words, physiologic and/or environmental disruptions from chronic alcohol or substance use could promote conditions and circumstances in which anxiety symptoms are more likely to emerge or worsen.

Although DSM-IV-TR does not delve into the causes of mental disorders, it states that substance use can cause or “induce” an anxiety syndrome with symptoms that resemble or are identical to those of the various anxiety syndromes that are not related to substance disorder (Box).11,12

Alternatively, the idea that a third factor can serve as a common cause for both conditions fits with the view that substance use disorder and anxiety disorder can be phenotypic expressions of a common underlying genetic/physiologic liability.13

Finally, these models are not mutually exclusive. Anxiety symptoms or substance use could cause or aggravate the other.

Figure 1
Hypothetical models of comorbidity


Which comes first?

Anxiety disorder typically begins before a substance use disorder in comorbid cases, although some studies have reported the opposite pattern or roughly simultaneous onset of both disorders.2

Using a prospective method in college students, we found that the risk of developing alcohol dependence for the first time as a junior or senior more than tripled among students who had an anxiety diagnosis as a freshman.14 We also found, however, that students who were alcohol dependent as freshman were 4 times more likely than other freshman to develop an anxiety disorder for the first time within the next 6 years.

In short, having either an anxiety or alcohol disorder earlier in life appears to increase the probability of developing the other later. This finding supports the idea that the types of associations that link pathologic anxiety and substance use vary among individuals and, perhaps, within individuals over time.

3 treatment approaches

Treating 1 of the comorbid conditions—anxiety or alcohol disorder—does not tend to resolve the other.3,15 This suggests that therapies aimed at treating a single disorder are not satisfactory for treating comorbid cases. Possible multi-focused approaches include:

  • serial (or sequential) approach—treating comorbid disorders one at a time
  • parallel approach—providing simultaneous but separate treatments for each comorbidity
  • integrated approach—providing one treatment that focuses on both comorbid disorders, especially as they interact with one another.

Each has strengths and weaknesses, and the approach you choose for your patient may depend on clinical circumstances and available resources.

Serial treatment has the structure to empirically evaluate whether the initially untreated comorbid condition is resolved by treating the other condition. For example, you could treat an anxiety disorder as usual and refer the patient for alcohol disorder treatment only if drinking remains an active problem following anxiety treatment. This approach also allows you to use well-established treatment systems, programs, and specialists as usual.

One disadvantage to the serial approach, however, is that the initially untreated comorbid disorder could undermine the resolution of the treated disorder. We found, for example, that treating either the anxiety or the alcohol disorder alone fails to resolve the comorbid condition and might leave a patient vulnerable to relapse before serial treatment can be completed.3,15

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