Introduction
The co-occurrence of substance abuse and mental disorders is a common and growing problem among Americans that should be given attention as it impairs the life of those affected. One of these is the co-occurrence of substance abuse disorder and generalized anxiety disorder. In this regard, this paper provides an overview of this co-occurring disease in terms of its criteria for diagnosis, its incidence, causes, treatment, and the considerations for assessment.
DSM-IV Criteria for Generalized Anxiety
“Generalized anxiety disorder is a chronic and impairing disorder, independent of its substantial comorbidity with other mental disorders” (Andrews et al., 2010, p. 134). According to DSM- IV (Andrews et al., 2010), the following are the criteria for generalized anxiety disorder:
- Excessive anxiety and worry (apprehensive expectation), occurring more days than
not and for at least 6 months, about a number of events or activities (such as work or school performance)
B. The person finds it difficult to control the worry
C. The anxiety and worry are associated with three (or more) of the following six
symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: only one item is required in children
(1) restlessness or feeling keyed up or on edge
(2) being easily fatigued
(3) difficulty concentrating or mind going blank
(4) irritability
(5) muscle tension
(6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying
sleep)
D. The focus of the anxiety and worry is not confined to features of an Axis I disorder. E.g., the anxiety or worry is not about having a panic attack (as in panic disorder), being embarrassed in public (as in social phobia), being contaminated (as in obsessive compulsive disorder), being away from home or close relatives (as in separation anxiety disorder), gaining weight (as in anorexia nervosa), having multiple physical complaints (as in somatization disorder), or having serious illness (as in hypochondriasis), and the anxiety and worry do not occur exclusively during posttraumatic stress disorder
E. The anxiety, worry, or physical symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
F. The disturbance is not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or general medical condition (e.g., hyperthyroidism) and
does not occur exclusively during a mood disorder, a psychotic disorder or a pervasive
developmental disorder (Andrews et al., 2010, p. 135)
For DSM-V, Andrews et al. (2010) propose changing the label of the disorder to “generalized worry disorder,” “major worry disorder,” or “pathological worry disorder” (Andrews et al., 2010). They claim that this relabeling of the disorder would indicate that worry is the defining feature of the basic process of anxiety (Andrews et al., 2010). In this case, GAD can be considered the basic anxiety disorder that is distinguished by worry, which is a component of anxiety, and which can be generalized to various future activities or events. In this regard, Andrews et al. (2010) propose the following for the DSM-V GAD criteria:
A: The person experiences excessive anxiety and worry (apprehensive expectation):
- about two (or more) domains of activities or events (for example, domains like
family, health, finances, and school/work difficulties)
(b) which occurs on more days than not
(c) for 3 months (or more)
B. The anxiety and worry are associated with one (or more) of the following symptoms:
(a) restlessness or feeling keyed up or on edge
(b) muscle tension
C. The anxiety and worry lead to changes in behavior shown by one (or more) of the
following:
(a) marked avoidance of potentially negative events or activities
(b) marked time and effort preparing for possible negative outcomes of events or
activities
(c) marked procrastination in behavior or decision- making due to worries
(d) repeatedly seeking reassurance due to worries. (Andrews et al., 2010, p. 144).
Incidence of the Disorder
According to the National Institute of Mental Health (NIMH, n.d.), 6.8 million Americans have GAD, with its incidence being twice higher in women than in men (NIMH, n.d.). It can begin in adulthood but it often strikes children and adolescents.
On the other hand, NESARC (National Epidemiologic Survey on Alcohol and Related Conditions), reported that 9.4 percent (19.4 million persons) of American adults had substance abuse disorder, either drug or alcohol use disorder or both, between 2001 and 2002 (National Institute of Health, 2004). Of these, about 20% of those who had substance abuse disorder at the time of the study or within a year prior also experienced an anxiety or mood disorder (National Institute of Health, 2004). Similarly, around 20% of those who experienced anxiety or mood disorders also experienced a current substance use disorder (National Health Institute, 2004).
Causes of the Disorder’s Development and Co-occurrence with Substance Abuse
According to the Anxiety Disorders Association of America (n.d.), the cause of GAD is not known, although some scientists posit that it is caused by family background and biological factors (Anxiety Disorders Association of America, n.d.). Some studies also indicated that it may be inherited due to the findings that showed the presence of abnormalities in the GABAergic and noradrenergic activity (“Generalized Anxiety Disorder,” n.d.). In addition, it can possibly be caused by life situations and stress (Anxiety Disorders Association of America, n.d.).
On the other hand, although GAD and substance use disorder are independent disorders, they often co-occur where either disorder can come first. For people with GAD, substance use disorder can develop because of the person’s desire to self-medicate their anxiety symptoms (Medscape Education, 2013) while for people with substance use disorder, GAD symptoms may manifest during the withdrawal states (Medscape Education, 2013).
People with GAD tend to worry about everything even when there’s nothing to worry about, which makes them always feel irritable, on edge, and restless (Anxiety Disorders Association of America, n.d.). They often expect the worst and this constant worrying interferes with their daily living. When they use substances, such as alcohol or drugs, to alleviate their anxiety symptoms, they end up being unable to have satisfying relationships, develop coping skills, or feel comfortable with themselves (“What are Co-occurring Disorders,” 2013).
Evidence-based Treatment
Both medication and cognitive-behavioral therapy are used to treat a co-occurrence of GAD and substance abuse disorder. Medication is intended to treat the symptoms of GAD, and these medications include SSRIs (Selective Serotonin Reuptake Inhibitors), such as Prozac and Zoloft; SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors), such as Cymbalta and Effexor; Benzodiazepines, such as Xanax and Valium; and Tricyclic Antidepressants, such as Trypitzol and Tofranil (Anxiety and Depression Association of America, n.d.).
On the other hand, cognitive-behavioral therapy intends to identify, understand, and change the behavior and thinking patterns of the patient where the benefits are often seen within twelve to sixteen weeks (Anxiety and Depression Association of America, n.d.). Moreover, an integrated approach to the treatment should be employed where every single treatment session addresses both disorders (Hazelden Foundation, 2010).
Considerations for the Assessment and Treatment of the Disorder
When assessing a co-occurring diagnosis, the counselor should have considerations for what the client wants; what the treatment contract is; what the patient’s immediate needs are; what the multiaxial DSM-IV diagnoses are; what the multidimensional severity/level of the functioning profile is; which treatment dimensions are most severe; what the priority is for each medium/severe dimension; what specific services are needed to address the priorities; what intensity or dose of service is needed; where these services can be provided in the least intensive, but safe, level of care; how the outcomes will be measured; and what the treatment plan and placement of decision is (Center for Abuse Treatment, 2005). In addition, the counselor should be sensitive to the patient’s sexual, gender, and cultural orientation, as well as to trauma that has been experienced or is being experienced by the patient.
Conclusion
This paper provided an overview of the co-occurrence of substance abuse disorder and generalized anxiety disorder. Its diagnosis, incidence, causes, treatment, and the considerations for assessment were discussed, and given the high incidence and seriousness of this problem, more attention should be given to addressing this problem and to providing the care that people need.
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