Since the time of Sigmund Freud, the notion of anxiety has played a very significant role in the understanding of psychopathology and in the diagnosis of different types of psychiatric and psychological disorders. The concept of anxiety today is different than it was in Freud’s time. The conceptualization of anxiety versus fear in Freud’s day was such that anxiety was characterized as an inner feeling of uneasiness and nervousness that was not attributable to any specific tangible threat, whereas fear was a reaction to an actual tangible threatening situation. Over the years, the two terms have become basically interchangeable in the diagnosis of psychopathology, and anxiety is considered to be a less intense manifestation of fear that can occur to real, imagined, or unidentified threatening situations.
One designation that remains relevant to the understanding of anxiety is a differentiation between trait and state anxiety. Trait anxiety refers to the subjective differences that different individuals experience when they are anxious or fearful. Some individuals have more severe subjective feelings of anxiety than others even when exposed to the same anxiety-provoking stimulus. State anxiety refers to a temporary feeling of uneasiness, jitteriness, nervousness, etc., that is triggered by a specific stimulus or condition and resolves once that threatening condition is removed.
As mentioned above, everyone experiences some level of anxiety related to a number of different situations. The normal experience of anxiety is not considered to be problematic or to lead to the development of a mental health disorder, including substance abuse. Some individuals experience prolonged levels of anxiety as a result of certain stressors, and others experience anxiety that is considered to be far beyond what would normally be experienced when associated with the same circumstances. These individuals may develop anxiety disorders.
Anxiety is considered to be an evolutionary development that protects the individual from approaching potentially dangerous situations. For instance, suppose you are walking in the woods and suddenly come across a mountain lion. Most everyone will experience some level of anxiety at this encounter. Some individuals will experience very high levels of anxiety, whereas others with more experience in dealing with animals may experience lower levels of anxiety (trait anxiety). Anxiety often elicits the fight-or-flight mechanism, and most individuals in this case would take the flight option. Once the mountain lion is avoided, the anxiety will dissipate (state anxiety).
People with anxiety disorders experience anxiety that is out of proportion to the perceived threat (trait anxiety), and/or when the potential threatening situation is no longer salient, they continue to experience higher than normal levels of anxiety (state anxiety). This dysfunctional experience of anxiety interferes with the person’s ability to function in their everyday routine. Individuals who have dysfunctional levels of anxiety that do not dissipate are prone to developing substance use disorders.
The American Psychiatric Association lists over 10 different categories of potential anxiety disorders. The most relevant ones to substance use disorders are discussed briefly below. The descriptions provided are very cursory descriptions of each anxiety disorder.
- Specific phobia: Phobias represent a number of unrealistic expressions of fear or anxiety to specific types of situations, living entities, or objects. The fear or anxiety expressed by the phobic individual is almost always well out of proportion to the actual danger that the target of the phobia represents. The majority of phobic objects do represent potentially threatening or dangerous objects, such as snakes, flying, being in enclosed places, and so forth. It is rare to see individuals who have phobias to rather harmless objects, such as pencils, although these do occur. Individuals with specific phobias are at an increased risk to develop substance use disorders, particularly alcohol use disorders.
- Social anxiety disorder: Individuals diagnosed with social anxiety disorder have an excessive amount of anxiety about at least one social situation where they believe they will be observed and evaluated by others. These social situations can include things like performing in front of people (e.g., speaking in public), meeting people for the first time, eating in public, etc. The anxiety that the individual experiences is well out of proportion to the actual threat associated with the situation, and most individuals would view the reaction as being quite extreme. For example, being asked to give a talk in front of others is often an anxiety-provoking situation for many people; however, individuals with social anxiety disorder experience far greater levels of trait anxiety associated with this event and often go to extremes to avoid being in such a situation.
- Panic disorder: People who have panic disorder experience recurrent unexpected panic attacks and also display at least one month of excessive worry about panic attacks or perform very extreme and maladaptive actions to avoid having future panic attacks. These extreme actions are often avoidance behaviors associated with the situations that the individual believes induce their panic attacks. These individuals are also at increased risk to develop co-occurring substance use disorders.
- Agoraphobia: Agoraphobia is extreme fear or anxiety that is concerned with being in at least two places where the individual feels they cannot escape. There are a total of five of these situations listed by APA that include the fear of being in open spaces, the fear of being in a crowd, the fear of being in some form of public transportation, the fear of being in an enclosed place like a store or movie theater, and the fear of being outside one’s home alone. When individuals are in one of these anxiety-provoking situations, they experience symptoms that are similar to being in a panic attack and may even experience these symptoms when thinking about being in these situations.
- Generalized anxiety disorder (GAD): GAD is an anxiety disorder that must occur most of the time for a period of at least six months and is composed of anxiety about many different types of events. Individuals with GAD are often viewed as neurotic or “worrywarts” by others, and they often have constant feelings of restlessness, difficulty concentrating, fatigue, muscle tension, irritability, and issues with sleeping. Being consistently anxious about numerous situations puts one at risk for the development of substance abuse.
Two other categories of anxiety disorders, anxiety disorder due to a medical condition and substance/medication–induced anxiety disorder are also worth mentioning. In the former condition, an individual has some type of a medical condition (e.g., hyperthyroidism) that results in the experience of anxiety, and in the latter condition, the individual’s anxiety is induced by drugs, such as amphetamines, caffeine, alcohol, etc. Individuals who experience chronic anxiety associated with these conditions are obviously at risk to develop substance use disorders as well.
How Are Anxiety Disorders and Substance Use Disorders Related?
Most individuals experience transient anxiety that typically dissipates over time. The normal experience of anxiety is not sufficient enough to dispose an individual to develop a substance use disorder. People who experience normal, transient, everyday periods of anxiety are not at an increased risk to develop a substance use disorder. Individuals with anxiety disorders are at increased risk to develop co-occurring substance use disorders. For example, an extensive study known as the National Epidemiologic Survey on Alcohol and Related Conditions found that having co-occurring diagnoses of a substance use disorder and an anxiety disorder was more common than simply being diagnosed with an anxiety disorder by itself.
The strong relationship between anxiety disorders and substance use disorders is complicated and cannot be explained in simple terms. For instance, many sites use the self-medication explanation of this relationship, which basically states that individuals with anxiety disorders attempt to control their symptoms by using alcohol and drugs. While this certainly does happen in some cases, it by no means explains the relationship between substance use disorders and anxiety disorders in all individuals who express both disorders.
- Not all individuals with a dual diagnosis of an anxiety disorder and substance use disorder report having symptoms of their anxiety disorder before they developed issues with substance abuse.
- Alcohol use is prevalent among individuals with the diagnosis of social anxiety disorder, and these people often report using alcohol to lessen their anxiety, but many actually find that alcohol makes their anxiety worse. Even so, they still continue to drink.
- Research has indicated that individuals who have co-occurring substance use disorders and panic disorder often develop a substance use disorder before their panic disorder has been recognized or nearly at the same time.
- Even though a good percentage of people diagnosed with post-traumatic stress disorder (PTSD) develop substance use disorders, a risk factor for the development of PTSD (a disorder that is associated with the experience of severe and dysfunctional levels of anxiety) is having an earlier substance abuse problem.
Thus, the explanation that individuals with anxiety disorders use drugs or alcohol to self-medicate is not always consistent with a good deal of the data, although it may partially explain the relationship in some cases. The relationship between anxiety disorders and substance abuse is very complex and consists of a number of interacting variables that work in different ways in different individuals. It is generally accepted that the relationship between different mental health disorders and the observation that individuals are often diagnosed with more than one of these disorders, including an anxiety disorder and a substance use disorder, is that these disorders share a number of risk factors, such as similar genetic associations, shared neurobiological pathways, and shared environmental experiences, such as abuse or the experience of some other traumatic event.
An individual who is at risk to develop one mental health disorder is also at an increased risk to develop a number of other mental health disorders, including substance use disorders.