Q&A: Bridging disciplinary 'silos' to address co-occurring anxiety, alcohol misuse

Matt Kushner

The association between the chronic misuse of alcohol and anxiety is well-documented within the field of psychiatry, according to a review published in Alcohol Research: Current Reviews. Researchers noted that a substantial number of people with alcohol use disorder, or AUD, have also met diagnostic criteria for one or more anxiety and mood disorders, and multiple disciplines have developed theories to explain this association in order to devise treatment plans.

Review author Matt Kushner, PhD, of the department of psychiatry at University of Minnesota, spoke with Healio Psychiatry about the association between alcohol use disorder and anxiety as viewed through the lenses of psychiatry, psychology and neurobiology, as well as how clinicians can better treat these patients. – by Kate Burba

Question: Can you provide some background on the association between alcohol use disorder and anxiety?

Answer: Hippocrates was the first known medical scholar to describe a relationship between anxiety and the use of alcohol; he prescribed the latter to treat the former. Dating back as far as the 18th century, dozens of independent efforts to describe subtypes of alcohol abusers consistently identified an “Apollonian” subtype that included anxious-depressed and shy individuals who drink primarily to relieve feelings of negative affect.

This was contrasted with a “Dionysian” subtype that included outgoing and unafraid individuals who drink primarily as a part of a larger pattern of thrill-seeking and rule breaking. These typologies remain evident today but have been largely supplanted by the medical diagnostics of psychiatry.

This approach considers anxiety and depression problems not as long-standing traits associated with heavy drinking but as the symptoms of distinct psychiatric disorders that frequently co-occur with alcohol problems.

In the field of alcohol disorder treatment, the term “dual diagnosis” is used to describe addicted individuals with a co-occurring psychiatric disorder. This psychiatric comorbidity/dual diagnosis viewpoint lends itself to epidemiological studies in which disorders can be counted as present or absent. Such studies routinely show a doubling to tripling of risk for alcohol dependence when an anxiety or depression disorder is present. Some estimates suggest that up to half of individuals being treated for an alcohol-related problem also experience an anxiety and/or depression disorder, and these cases have been shown to have notably worse outcomes following treatment for alcohol-related problems.

Q: What main psychiatric take-aways did you find in this review?

A: The psychiatric comorbidity/dual diagnosis viewpoint casts specific diagnostic dyads (eg, alcohol use disorder with co-occurring social anxiety disorder, alcohol use disorder with major depression disorder, etc.) as the essential unit of study and intervention. However, research we reviewed indicates that the overall quantity of negative affect is a much stronger correlate of alcohol problems than is the presence of one particular psychiatric diagnosis or another. The review also suggested that psychological distress that may not qualify for a specific diagnosis of anxiety or depression disorder can become linked to problematic alcohol use.

Q: What main psychological take-aways did you find in this review?

A: Although earlier lab-based experiments did not consistently demonstrate an anxiolytic effect from alcohol, a large percentage of people consistently report that they believe alcohol to be stress relieving and that they drank to obtain this effect.

Subsequent research showed that the habit of drinking to cope with negative emotions provides a bridge between anxiety symptoms and alcohol use. Why some anxious people drink to cope with negative affect but others don’t is not known. However, this is likely a function of general alcohol-related enculturation, as well as individual differences in one’s physiological response to alcohol.

Q: What main neuroscientific take-aways did you find in this review?

A: Research reviewed showed that severe and/or chronic stress in early life dysregulates the brain’s responses to stress more or less permanently and that these changes correlate with later risk for anxiety and/or alcohol disorders. Further, heavy chronic alcohol use also seemed to act as an insult to the brain’s stress-response system, much like early life stress; however, the permanence of the resulting brain dysregulations remains uncertain.

We concluded from this that prolonged chronic anxiety and/or alcohol use can be both the result and cause of dysregulated neurobiological stress regulation. The “neurobiological opponent process” model developed by George Koob and colleagues describes how the brain’s mood and stress systems become increasingly dysregulated over the course of repeated bouts of intoxication and sobriety until the primary motive for drinking switches from increasing pleasure (“impulsive” drinking) to decreasing discomfort (“compulsive” drinking). This describes a “vicious cycle” in which ongoing use and relapse in late-stage addiction is motivated by the need to reduce the psychological discomfort resulting, in part, from the neurobiological consequence of chronic alcohol use itself. The opponent process model identifies negative affect as central in addiction whether or not criteria for a specific comorbid psychiatric anxiety disorder are met.

Q: Can you elaborate on the “underlying, mutually exacerbating, and neurobiological processes” between these conditions?

A: The review of psychiatric, psychological and neurobiological perspectives suggests that dysregulation in the brain’s stress and mood response systems are both a cause and effect of drinking-related problems and anxiety symptoms. Brain systems implicated included the central amygdala, which serves as hub for neuro-circuits implicated in both anxiety symptoms and addiction. This suggests that having either condition marks a neurobiological vulnerability to developing the other. We have conducted studies that support this supposition by showing that having an anxiety disorder leads to more rapid (“telescoped”) development of addiction related to both alcohol and nicotine.

Another implication of this view is that a worsening of either anxiety or addiction is likely to be accompanied by a worsening of the other condition since they share an underlying neuro-pathophysiology. For those motivated to drink as a means of coping, this relationship becomes a self-perpetuating “vicious cycle” in which more drinking leads to more anxiety, which, in turn, leads to more drinking.

Q: How will this information inform clinician practice and treatment?

A: There is a short list of “dos” and “don’ts” for clinical practice that emerge from this review. On the “do” side is to ask patients with anxiety and mood problems not just how much they drink but also whether they drink explicitly for the purpose of relieving anxiety symptoms or elevating their mood. The answer to this question carries substantially more predictive value for addiction risk than any other single question in this population. Clinicians should also communicate to their anxiety disordered patients that they may be neurobiologically prone to develop addictions. Because of this, the recommended “safe” level of alcohol use (no more than one drink per day for women and two for men) should probably be lower for those with anxiety disorders. Another “do” is to treat anxiety disorders regardless of whether they began before or after a co-occurring addiction. Too many clinicians remain committed to the dubious distinction between primary vs. secondary anxiety disorders, leading to the under-treatment of anxiety in those who are also abusing alcohol.

On the “don’t” side are clinical decisions resulting from the demonstrably false assumptions that: a) treating an anxiety disorder effectively will automatically translate into improvement of a co-occurring addiction; and, b) abstinence alone will automatically translate into remission of anxiety disorder symptoms. The standard of care at this time (although not universally applied) includes parallel treatment of both comorbid conditions; however, evidence suggests that anxiety symptoms and alcohol problems become interdigitated into a single hybrid condition that would ideally be addressed as such in treatment.

“Integrated” treatments educate patients about how anxiety is both a cause and a consequence of chronic alcohol use and teach patients healthy cognitive and behavioral coping strategies to use in negative affect situations that historically have precipitated their use of alcohol to cope. Such programs are typically supplemental to standard care.

Q: What further research, if any, would help provide more information or disorder correlation in order to refine treatment?

A: The review points to the conclusion that dysregulated stress responses may serve as a common cause and effect of anxiety and alcohol use disorders. Research aimed at testing the implications of this speculative conclusion is important, including questions such as the degree to which indices of stress dysregulation can serve to predict alcohol treatment outcomes and whether interventions directly targeting stress regulation can improve alcoholism treatment outcomes. Another important area that is understudied is the course of and factors affecting the re-regulation of the brain’s stress response systems in early sobriety. It may be, for example, that key information about successful recovery, need for additional treatment and risk for relapse is found in the degree to which dysregulated stress responses normalize in early abstinence.

Finally, the review suggests that future research should focus more on the overall load of negative emotionality than on the presence vs. absence of particular psychiatric diagnoses in addiction. This approach expands the relevant anxiety-alcohol nexus from the subgroup of addicted people who have a co-occurring anxiety disorder diagnosis to virtually all individuals struggling with advanced addiction.

Q: Is there anything else you’d like to add?

A: Like the parable of three blind people each touching a different part of an elephant, psychiatry, psychology and neuroscience have typically studied co-occurring anxiety and alcohol problems in disciplinary silos with little communication or integration between them. We wrote this review in an attempt to promote integration and cross-fertilization of these rich research disciplines to better characterize and treat alcohol use disorders.

Reference: Anker JJ, Kushner MG. Alcohol Res. 2020;doi:10.35946/arcr.v40.1.03.

Disclosures: The authors report no relevant financial disclosures.