By Ronnit Nazarian, Psy. D
A common theme that I have found while speaking with patients who overdrink has been that they also experience an underlying anxiety disorder. Moreover, they have mentioned having difficulty finding something that helps them disconnect from their stress and anxiety that works as well as having a drink. To most people looking in from the outside, a person who experiences anxiety and a person who experiences drinking problems are often viewed as two separate individuals. Contrary to common belief, however, research shows that approximately 50% of individuals who experience alcohol problems also meet the criteria for one or more anxiety disorders.1 Alcohol use and anxiety are strongly linked and often called co-morbid disorders that interact with each other. One of the major contributors to an increased alcohol intake is a person’s level of anxiety.4
At Fifth Avenue Psychiatry, we recognize that many people who have an increased alcohol use will drink in order to cope with their anxiety (e.g., work stress, social stress, etc.). While alcohol may be used to help cope with anxiety, it can also have long-term consequences in increasing a person’s level of anxiety in the long term. In this blog, we discuss the ways anxiety and alcohol are linked, the consequences of using alcohol as a coping mechanism, alcohol-induced anxiety, and treatment approaches for dual diagnosis of anxiety and alcoholism.
Using Alcohol as a Coping Mechanism (Self-Medication Model)
A mild amount of anxiety is typical for anyone to experience as a reaction to a stressful situation. When someone suffers from an anxiety disorder, their reactions to stress can impact their daily functioning, relationships, sleep cycle, and work production. Those who struggle to cope may turn to the use of alcohol and drugs, engaging in compulsions, and avoiding events to decrease the anxious feelings.
Below are some of the ways people use alcohol to cope with anxiety:
- Drinking at a party to feel confident, less shy, and to socialize
- Drinking at the end of the week to destress
- Drinking to numb negative thoughts and emotions
- Drinking to feel included and connected to others
- Drinking to relax
- Drinking to forget bad memories
- Drinking to feel happy
- Drinking to no longer feel in control
- Drinking to no longer make decisions
- Drinking to take a break from reality
- Drinking to fall asleep
What drinking starts as “liquid courage” or a “way to let loose” for a person, it easily becomes a way of self-medicating as it becomes a means of coping. Research shows that most individuals who experience drinking problems and self-medicate with alcohol also experience a generalized anxiety disorder, social phobia, and panic disorder.4 More specifically, it appears that alcohol problems begin after the onset of anxiety disorders. Many individuals who experience social phobia and agoraphobia have reported initially using alcohol as an attempt to control anxiety. Active alcohol use can exacerbate symptoms of anxiety, which plays a significant role in the difficulty of diagnosing anxiety disorders in the face of active alcohol use. The lines blur with distinguishing between symptoms of alcohol withdrawal versus anxiety disorders when symptoms of withdrawal appear like symptoms of anxiety. 3
Over time, as individuals continue to self-medicate with alcohol as a coping strategy, they may require increasingly higher doses of alcohol. Consequently, this can result in an individual developing an independent substance use disorder. Individuals who self-medicate with alcohol are at risk of increased psychiatric co-morbidity, suicidal behavior, levels of stress and dysfunction, and lower health-related quality of life.5
How Alcohol Increases Anxiety Levels (Substance-Induced Anxiety Model)
Using alcohol to cope with anxiety can in turn significantly increase anxiety levels. While alcohol can diminish feelings of anxiety and provide short-term relief, it can lead to increased anxiety. Specifically, alcohol can act as an “Anxiogenic,” which creates feelings of anxiety and panic attacks when withdrawing from alcohol. This feeling can lead someone to continue to drink alcohol to decrease those uncomfortable feelings. This leads to a vicious cycle in which alcohol and anxiety play off each other and makes it no longer clear which disorder (anxiety or alcoholism) is the operating cause.2
Treatment for Co-Occurring Anxiety Disorders and Alcohol Use Disorders
There are many treatment models available to assist individuals with co-occurring disorders. The selection of treatment approach depends on the way in which, and the reasons why a person uses alcohol to cope. For individuals who use alcohol to cope with social anxiety, a combination of Cognitive Behavior Therapy (CBT) and Exposure Therapy can be helpful to challenge thoughts and behaviors surrounding events that cause anxiety. Individuals who use alcohol to cope with stress or intense emotions would benefit from Dialectical Behavior Therapy to learn how to regulate their emotions and tolerate distress. At the root of all treatment models, it would be critical for patients to develop new healthy coping strategies to replace their unhealthy behaviors, such as drinking alcohol. Alongside engaging in therapy, it may be beneficial for the individual to receive pharmacological treatment to decrease the feelings of anxiety that drive a person to drink.
When developing a treatment plan, it is important for the clinician to understand the individual’s presenting problems and determine which of the problems should be the primary focus of treatment. A majority of treatment typically begins with the elimination of alcohol use first. With alcohol out of the way, one can gain a better understanding of the primary reasons that drive a person to drink. Sometimes with the reduction of alcohol use, many symptoms such as anxiety and depression are actually reduced. Ultimately though, in many cases, challenging and treating anxiety symptoms that resulted in overdrinking is the ultimate goal.
- Anker, J. J., & Kushner, M. G. (2019). Co-Occurring Alcohol Use Disorder and Anxiety: Bridging Psychiatric, Psychological, and Neurobiological Perspectives. Alcohol research: current reviews, 40(1). https://doi.org/10.35946/arcr.v40.1.03
- Brady, K., Tolliver, B., & Verduin, M. (2007). Alcohol use and anxiety: diagnostic and management issues. The American journal of psychiatry, 164 2, 217-21; quiz 372 .
- Kushner, M. G., Sher, K. J., & Beitman, B. D. (1990). The relation between alcohol problems and the anxiety disorders. The American Journal of Psychiatry, 147(6), 685–695. https://doi.org/10.1176/ajp.147.6.685
- Smith, J. P., & Randall, C. L. (2012). Anxiety and alcohol use disorders: comorbidity and treatment considerations. Alcohol research: current reviews, 34(4), 414–431.
- Turner, S., Mota, N., Bolton, J., & Sareen, J. (2018). Self-medication with alcohol or drugs for mood and anxiety disorders: A narrative review of the epidemiological literature. Depression and anxiety, 35(9), 851–860. https://doi.org/10.1002/da.22771