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Introduction
Comorbidity describes a situation where a patient exhibits two or more illnesses or disorders. The term could be used to mean any co-occurrence of psychiatric and medical disorders. On the other hand, co-occurring disorders describe people who suffer from mental illnesses and substance abuse disorders. According to Smith and Randall (2012), anxiety disorder and alcohol use disorder (AUDs) are often diagnosed concurrently. The trend is blamed on the complex clinical presentations between these two disorders. Smith and Randall (2012) further report that co-occurring anxiety disorders and AUDs are relatively common since approximately 2.4% of Americans have reported struggling with their comorbidity. These authors explain that the high comorbidity prevalence between the two is caused by complex clinical factors and symptoms, which attract substantial societal costs. In addition, they note that both environmental and genetic factors can explain why anxiety disorders and alcohol related disorders often occur together. Guided by this background, this paper describes the risk factors and how the anxiety disorder and alcohol-related disorders interrelate. Besides, it reports on assessment, diagnosis, and treatment options.
Assessing Co-occurring Disorders based on DSM-5
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) refers to an updated taxonomic tool provided by the American Psychiatric Association (APA) as a principal authority for analyzing psychiatric conditions (Regier, Kuhl & Kupfer, 2013). The tool highlights symptoms, descriptions and all the criteria essential in diagnosing and treating mental health disorders as well as statistics on the extent of the effect of psychiatric conditions. This includes data on common treatment approaches, age of onset, effects of the treatment and the effect of the illness in terms of differences in gender. The DSM-5 tool is divided into five axes. Axis 1 outlines clinical syndromes for substance use disorders and mental health disorders that potentially cause impairments (Hasin et al. 2013). The disorders were grouped into categories such as anxiety disorder, eating disorder, and mood disorder. Axis II highlights mental retardation and personality disorders. Axis III details general medical conditions that exacerbate Axis II and Axis I disorders, such as brain injuries and HIV/AIDs. Axis IV is composed of environmental and psychosocial problems while Axis V details global assessment of functioning.
According to Axis I of the DSM-5 tool, anxiety disorders and alcohol related disorders are classified as co-occurring disorders. This implies that alcohol use and anxiety are connected. For instance, people tend to drink to relax their minds and reduce anxiety. On the other hand, chronic intake of alcohol could lead to anxiety. Given the high prevalence of both anxiety and alcohol use in the USA, it is not surprising that the two disorders occur concomitantly. According to Watkins (2019), alcohol is the most consumed drug in the USA. A 2012 survey study by the Substance Abuse and Mental Health Services Administration (SAMHSA) disclosed that 2/3 of teenagers in America were likely to become alcoholic which contravenes government’s legal drinking age which is 21 years. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) notes that in normal conditions, it takes 10 minutes for a person to become intoxicated (Watkins, 2019). This happens when the body’s blood to alcohol content (BAC) rises significantly. A continued rise in BAC impairs the person’s judgement, in a process known as intoxication. Over-indulgence in alcohol consumption could be catastrophic to the user. In addition, overly depending on alcohol leads to alcohol use disorder. NIAAA reports that 6.2% of the adults in the USA suffer from AUD (Watkins, 2019). The severity of this disorder is varied. Nonetheless, the common symptoms include drinking longer than is socially acceptable, having difficulties resisting the urge to drink, drinking to the point of becoming dependent, alcohol interfering with other activities, high tolerance to alcohol, and persistent drinking even after the onset of anxiety or depression.
Temporary anxiety is a normal part of life. However, some people feel anxious for prolonged periods of times, resulting into anxiety disorders. Such experiences have a negative impact on the quality of life of the person. It reduces their ability to focus on meaningful life activities such as work and relationships. One of the main forms of anxiety is the generalized anxiety disorder (GAD). Common symptoms of anxiety include consistent restlessness, fatigue, irritability, erratic sleep patterns, tense muscles, and having trouble with concentration (Marsh et al. 2019). GAD could be accompanied by panic disorders which are usually intense and severe levels of anxiety. Another anxiety disorder is the social anxiety disorder which is normally triggered by an intense fear of social situations. This disorder is symptomized by difficulties engaging other people, fearing judgement, being highly self-conscious, trembling around others, nausea when attending social gatherings, and excessive worrying when invited to a social event.
Some people recourse to using alcohol to fight off the anxiety since it is both a sedative and a depressant. As their BAC rises, their bodies relax, thus easing their anxiety. Others use alcohol to reduce their stress levels. As much as this is the case, DeMartini and Carey, (2011) caution that using alcohol to treat anxiety often backfires. In fact, SAMHSA cautions that prolonged alcoholism could in return cause or worsen the initial anxiety disorder. The Anxiety Depression Association of America (ADAA) backs these findings by citing that 20% of patients with anxiety disorder are either addicted or dependent on alcohol. Smith and Book (2018) explain that alcohol can rewire the brain, making it susceptible to developing anxiety problems. In worst case scenarios, alcohol could trigger post-traumatic stress disorders. Marsh et al. (2019) explain that anxiety disorders could equally be caused by withdrawal symptoms. This author cautions that as much as anxiety and alcohol are co-occurring, the former should not be used as a self-medication as its long-term disadvantages outweigh the short-term advantages. In addition, it is noted that treating alcohol related disorders will not address the concurrent anxiety disorder. As a result, it is prudent to treat both conditions independently. Treating one and forfeiting the other increases chances of relapse to the concurrent condition. For instance, given that the symptoms for co-occurring disorders often trigger another disorder as in the case of anxiety and alcohol related disorders, then treating alcoholism alone will inevitably force the person to abuse alcohol as a self-medication against anxiety. To avoid such occurrences, these disorders can be effectively managed by combining therapies and medication.
Development of Co-morbidity and Co-occurring Disorders
As illustrated in the DSM-5, the most common co-morbidity and co-occurring disorders are anxiety and AUDs. Given their co-occurring condition, DSM-5 emphasizes the need for dual-diagnosis. Prior to understanding how to conduct the dual-diagnosis, it is important to understand the development of comorbid anxiety and alcohol use disorders. According to Smith and Randall (2012), the question on the coalescence of these two disorders has intrigued clinicians and investigators for decades. Nonetheless, there are three primary pathways for understanding how comorbidity develops. The common-factor model explains the first instance noting that there are three variables that explain co-occurrence of comorbid AUDs and anxiety (Smith & Randall, 2012). The second pathway is known as the self-medication model which hypothesizes that people use alcohol as a coping mechanism against anxiety but in the process, it leads to co-occurrence of AUDs (Carvalho et al. 2019). The third pathway is known as substance-induced pathway where AUD triggers anxiety and makes the person vulnerable to re-occurrence of anxiety disorders.
The common factor model argues that there is no direct causal connection or relationship between anxiety and AUDs. Instead, three variables could be used to explain their joint presence in human beings. The first variable is that early presence of anxiety could predict the possibility of developing alcohol dependence at later stage. The second variable fails to provide a direct explanation on the link between anxiety disorder and AUDs, instead, it highlights how comorbidity is caused by other variables. The third variable dictates that co-occurrence of the two disorders is a result of genetic factors such as anxiety sensitivity and personality traits (Smith & Randall, 2012). The self-medication model has attracted the most attention over the past three decades. This model posits that patients with anxiety disorders use alcohol to alleviate or cope with the symptom of anxiety. In the process, it leads to AUDs. This model is shared across other alcoholism models namely; stress response dampening model and tension reduction model. Querying people with comorbid anxiety and AUDs exposes that they engaged in targeted drinking as a coping mechanism for their anxiety. Third, the substance induced anxiety model explains the comorbidity of AUDs and anxiety. This model argues that anxiety is caused by prolonged consumption of alcohol. Carvalho et al. (2019) explain that alcoholism could lead to biopsychosocial problems which changes the functioning of the nervous system. Acute alcohol intake stimulates brain activities as it triggers the anxiolytic effect, thus producing more aminobutyric brain chemicals and neurotransmitters (Smith & Randall, 2012). Withdrawal could also change the brain chemicals, thus causing anxiety. Repeated withdrawal results into progressive neural adaptation known medically as kindling. The process makes the alcoholic susceptible to stress-induced anxiety.
Diagnosing and Treating Primary and Secondary Co-morbidity and Co-occurring AUDs and Anxiety Disorders
It is important to establish the best diagnostic procedures for dual-diagnosing comorbid anxiety and AUDs. Smith and Randall (2012) express concerns over the inherent difficulty of discerning whether the AUDs or anxiety is substance or genetically induced. Reliance on self-reported diagnosis data is likely to impair the precision of diagnosis, especially in cases where the patient suffers recall bias. Such biases are very possible for people with acute anxiety. Careful diagnosis of comorbid anxiety and AUDs therefore requires gathering of detailed data guided by retrospective timeline. In addition, the clinician could subject the collateral informants to interviews while also observing symptoms arising from prolonged abstinence from alcohol use. The clinician could further review medical records, their current state of being, and laboratory data of the patients to establish their performance. The duration of abstinence required to establish anxiety disorder tends to vary depending on the disorder. For instance, anxiety arising from alcohol withdrawal, generalized anxiety disorder or panic anxiety disorder requires a prolonged period of abstinence for the diagnosis to show. It contrasts anxiety disorders that exhibit less overlap in symptoms such as obsessive-compulsive disorder. Because of these dynamics, a wise diagnostician has to wait several weeks before determining the possible source of symptoms and discern that they are not as a result of withdrawal. Secondly, Gimeno et al. (2017) propose the use of a comprehensive diagnostic algorithm to establish differential diagnosis. The main shortcoming of these two approaches is that some patients are not able to abstain for a prolonged period. A prospective functional analysis is often introduced to differentiate anxiety symptoms from substance-induced syndromes. This approach is helpful since it identifies antecedents and consequences of alcohol use and anxiety.
After gathering diverse information on the symptoms of comorbid anxiety and AUDs, the physician can then make an accurate diagnosis. These results will be appropriate in informing the selection of a suitable treatment approach. Capron, Bauer, Madson and Schmidt (2018) retort that after discovering that the anxiety disorder is substance-induced, it is important to treat both anxiety and AUDs. Failure to follow these guidelines would potentially lead to subsequent remission and relapse. The identification of a suitable treatment approach should further be informed by consideration of unique factors associated with the comorbidity of anxiety and AUD (Capron et al. 2018). As a result, a range of psychotherapy and pharmacotherapy approaches can be used to address AUDs and anxiety disorders. Likewise, there are a range of alternative evidence-based treatments for each of the two disorders. Nevertheless, there are times when psychotherapists need to modify their approach to treatment for comorbid individuals since the standards for treating such disorders could potentially cause negative impacts on the patients.
Figure 1 below summarizes pharmacotherapy and psychotherapy treatments approved by Food and Drug Administration (FDA).
Figure 1: FDA approved treatments for comorbid disorders (Smith & Randall, 2012)
As evident in figure 1, medication-based treatments for anxieties entail using an assortment of agents derived from different classes of medication. This comprises serotonergic-based medications, tricyclic antidepressant drugs (TCAs), monoamine oxidase inhibitors, serotonin-norepinephrine reuptake inhibitors, and benzodiazepines (Smith & Randall, 2012). These drugs have proven effective as justified by randomized clinical trials done under well-controlled conditions. Benzodiazepines are effective and safe agents used to manage short term anxiety disorders. Serotonergic-based medicines suppress the signaling system of the human brain branded as neuro-transmitter serotonin. It is a safe drug, thus used widely in treating anxiety disorders. Apart from the pharmacotherapies, psychotherapy is used to treat anxiety disorders. In most cases, cognitive-behavioral therapies (CBTs) are used as standard practices for mediating anxiety. Meta-analysis of these therapies has shown positive efficacy. According to Gimeno et al (2017), the CBT approach uses two strategies to derive the most effective outcome; exposure to stimuli and application of procedures used in managing anxiety, for instance, coping skills training, cognitive restructuring, and applied relaxation.
In addition to the treatment of anxiety disorders, there are pharmacotherapy and psychotherapy treatment for alcohol use disorders. Kushner et al. (2011) elaborate that there are three FDA approved medications for alcoholism. These are disulfiram, naltrexone, and acamprosate. Disulfiram is medication purposed to inhibit breakdown of ethanol. These reactions occur when the person drinks alcohol. It therefore acts as a way of deterring a drunkard from drinking. Naltrexone suppresses receptors that create a sensation of fulfilment and reward after intake of alcohol, therefore reducing the craving for alcohol. Acamprosate agent acts on the Gamma-aminobutyric acid (GABA) receptors which counter the effect of alcohol in the human system. Apart from these FDA approved medications, anticonvulsant topiramate has received widespread acknowledgement as a potential treatment for comorbid anxiety and AUD (Shinn & Greenfield, 2011). An alternative to medication is to subject the alcoholic person to psychotherapies, such as behavioral couples therapy, cognitive therapies, community reinforcement approaches, motivational interviewing, social skills training, 12-step facilitation, and relapse prevention therapy.
Effecting the Treatment
It is vital for clinicians using the normal pharmacotherapy psychotherapy protocols for comorbid condition treatment to apply them in a manner that optimizes outcome. To realize this goal, it is important to conduct case conceptualizations to classify either of the two disorders as primary and secondary. The classification could be based on the history of the patient such as their self-medication processes. The clinician should be objective and avoid the temptation of treating on the primary disorder. As noted under the mutual-maintenance model of comorbidity, ignoring the secondary disorder could result into a relapse of both disorders. Some of the models directing clinicians on how best to administer the treatment to prevent instances of relapse are—integrated, parallel, and sequential models (Milosevic et al. 2017). The sequential model involves treating the primary disorder and then the secondary disorder. Simultaneous or parallel model entails administering specific treatment for primary and secondary disorders at the same time but not by the same treatment facility or clinician, while integrated model entails treating comorbid disorders at the same time by the same treatment clinician.
Other strategies for avoiding relapse to either of the disorders include constant monitoring of the behavior of the patient to address issues such as obsessive-compulsive disorder and avoidance of social gatherings. The person should also be engaged in exposure exercises by being encouraged to engage in activities that stimulate the feared stimuli. The stimuli can be introduced using protracted techniques, namely graded exposure and imaginal exposure. Altering the stimuli allows therapists to accurately calibrate doses of exposure to enhance its effectiveness. Furthermore, it reduces the risks associated with overexposure.
Conclusion
This paper acknowledges the challenges of handling, understanding, and treating patients with anxiety disorders and alcohol related disorders. These two conditions are considered to be comorbid as they have a high potential of co-occurrence. For instance, an alcoholic is likely to have anxiety disorder while a person with anxiety is prone to becoming an alcoholic. Because of the coexistence of these conditions, it is certain that psychiatrists need to introduce psychotherapy and pharmacotherapy approaches to medicate the patients. As much as medication is helpful, it is important to consider the precautions and adopt the most suitable comorbidity treatment model. For instance, a clinician could use sequential, parallel, or integrated models of treatment to prevent instances of relapse. Alternatively, other strategies such as controlled exposure to the feared stimuli can be adopted to reduce instances of relapse.