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Both Barrels:
The Devastating Comorbidity of Anxiety Disorders and Substance Abuse

(Released May 2012)

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  by J. Erick Sinkhorn  


Key Citations




Overview of Anxiety Disorders


Anxiety itself is not necessarily unhealthy. It is a normal human emotion and a typical response to a perceived stressor. Evolutionarily, anxiety developed as a means to effectively prepare for and cope with threats to the individual. It lies at the heart of the fight-or-flight mechanism. The increased blood pressure, heightened sensitivity to sensory input, and release of adrenaline resulting from a state of anxiety all work to brace the body and mind for danger.

Anxiety disorders, however, are deleterious. They can produce a level of distress that interferes with a person's ability to lead a normal life. The emotions experienced by someone with this type of condition range in intensity from simple nervousness to debilitating terror (Barker).

Every year, about 40 million American adults age 18 years and older — about 18% of the adult population — suffer from an anxiety disorder (Kessler et al, "Prevalence, Severity, and Comorbidity"). Taken collectively, these conditions constitute the most common cause of workplace disability in the United States (Ballenger et al).

Anxiety disorders are divided into generalized anxiety disorder, panic disorder, and phobic disorders. Each has its own characteristics and symptoms, and each requires a different approach to treatment (Gelder, Mayou, and Geddes).

Generalized anxiety disorder

Generalized anxiety disorder (GAD) is a chronic condition characterized by an uncontrollable, disproportionately strong sense of fear or dread. These feelings are not rooted in a single issue or event, but may associate with any common concern (e.g.: finances, relationships, health, etc.) (Kessler et al, "Lifetime and 12-Month Prevalence"). Approximately 3.1% of American adults suffer from this disorder ("Anxiety Disorders,” NIH).

The primary symptom of GAD is the near constant presence of worry or tension, even when there may appear to be little or no apparent cause. The individual may startle easily and experience fatigue and irritability. A person may find he or she has problems making daily decisions or remembering commitments as a result of a lack of concentration or preoccupation with worry (Passer and Smith). Someone who suffers from GAD may experience problems falling or staying asleep, or he or she may experience sleep that is restless and unsatisfying. A diagnosis of GAD is made when a person experiences these symptoms for six months or more (Barker).

Panic disorder

Individuals with panic disorder suffer brief attacks of intense terror and apprehension, often marked by trembling, confusion, dizziness, nausea, and difficulty breathing. These episodes strike suddenly and repeatedly with no warning ("Anxiety Disorders," NIH).

Panic disorder around the world
Age-standardized disability-adjusted life year rates from panic disorder by country (per 100,000 inhabitants)

During a panic attack, an individual may flush or feel chilled. His hands may tingle or feel numb. She may experience chest pain or smothering sensations. Panic attacks usually produce a sense of unreality, a feeling of impending doom or a fear of losing control (Frisch and Frisch). Though an attack generally peaks within ten minutes, it can last for several hours.

In addition to recurrent unexpected panic attacks, a diagnosis of panic disorder requires that these events produce chronic consequences—either worry over the attacks' potential implications, persistent fear of future attacks, or significant changes in behavior as a result of the attacks (American Psychiatric Association, DSM-IV-TR). Panic disorder affects 2.7% of American adults ("Anxiety Disorders," NIH).

Phobic disorders

The largest category of anxiety disorders is phobic disorders, which represent all cases in which the individual’s fear and anxiety are triggered by a specific stimulus or situation. Between 5% and 12% of the population worldwide suffer from phobic disorders (Barker). The following are the three most common subtypes of this condition.

Social anxiety disorder

Social anxiety disorder (SAD), also known as social phobia, involves an intense fear and avoidance of negative attention, public humiliation, or social interaction. This feeling may be specific to particular social situations or, as is more often the case, experienced in most or all such interactions. The overwhelming worry and self-consciousness the individual experiences centers on a fear of being judged or of behaving in a manner that might result in embarrassment or ridicule.

Symptoms of social anxiety disorder include blushing, sweating, and difficulty speaking. As with all phobic disorders, those who suffer from social anxiety will often attempt to avoid the source of their fear. This tendency can be particularly problematic, and, in severe cases, can lead to complete social isolation.

Social anxiety disorder is the most common anxiety disorder, affecting 6.8% of the adult population in the United States ("Anxiety Disorders," NIH).

Obsessive–compulsive disorder (OCD)

Obsessive–compulsive disorder (OCD) is primarily characterized by distressing, persistent, and intrusive thoughts accompanied by urges to perform specific acts or rituals. The disturbing thoughts are called obsessions; the rituals are called compulsions. The condition affects roughly 3% of the world population (Barker) and approximately 1%—2.2 million—of American adults (Kessler et al, "Prevalence, Severity, and Comorbidity") ("Anxiety Disorders," NIH).

compulsive handwashing
Repetitive handwashing is a common OCD symptom

A person with OCD embraces a belief in a causative relationship in situations where one does not exist. Often the resulting process is entirely illogical. For example, the compulsion of walking in a certain pattern may be used to alleviate an obsession of impending harm. Performing these rituals is not pleasurable for the individual, and, at best, produces only temporary relief from the anxiety caused by obsessive thoughts.

Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a condition that results from a traumatic experience. PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such as mugging, rape, torture, kidnapping, abuse, or violence. It can also stem from long-term exposure to a severe stressor (Veterans Affairs Canada). It affects about 7.7 million American adults (Kessler et al, "Prevalence, Severity, and Comorbidity").

Common symptoms of PTSD include hypervigilance, flashbacks, avoidant behaviors, anxiety, anger and depression (Veterans Affairs Canada). Individuals with this disorder often have lasting thoughts and memories of the event associated with the onset of their condition. PTSD is frequently accompanied by substance abuse or one or more of the other anxiety disorders (Regier, Rae, Narrow, et al).

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