Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse
Treatment Improvement Protocol (TIP) Series 9

Definitions and Diagnoses

The anxiety disorders are the most common group of psychiatric disorders. The term anxiety refers to the sensations of nervousness, tension, apprehension, and fear that emanate from the anticipation of danger, which may be internal or external. Anxiety disorders describe different clusters of signs and symptoms of anxiety, panic, and phobias.

A panic attack is a distinct period of intense fear or discomfort that develops abruptly, usually reaching a crescendo within a few minutes or less. Physical symptoms may include hyperventilation, palpitations, trembling, sweating, dizziness, hot flashes or chills, numbness or tingling, and the sensation or fear of nausea or choking. Psychologic symptoms may include depersonalization and derealization and fear of fainting, dying, doing something uncontrolled, or losing one's mind. A panic disorder consists of episodes of panic attacks followed by a period of persistent fear of the recurrence of more panic attacks.

When the focus of anxiety is an activity, person, or situation that is dreaded, feared, and probably avoided, the anxiety disorder is called a phobia. Phobia-inspired avoidance behavior as well as travel and activity restrictions may become intense and incapacitating. The phobias include agoraphobia, social phobia, and simple or specific phobia; panic attacks and panic disorders are often but not necessarily involved.

Specific phobia, also called single or simple phobia, describes the onset of intense, excessive, or unreasonable fear, stimulated by the presence or anticipation of a specific object or situation. The causes may be naturally occurring (for example, animals, insects, thunder, water), situational (such as heights or riding in elevators), or related to receiving injections or giving blood. Social phobia describes the persistent and recognizably irrational fear of embarrassment and humiliation in social situations. The social phobia may be quite specific (for example, public speaking) or may become generalized to all social situations. Agoraphobia is the fear of being caught in a situation from which a graceful and speedy escape would be impossible, difficult, or embarrassing. Examples of feared situations include attendance in an auditorium, being stuck in traffic, and being outside the house.

In generalized anxiety disorder, there is no specific focus to the anxiety; symptoms are free-floating. Generalized anxiety disorder involves excessive anxiety, worry, and apprehensive expectations focused on many life circumstances, more days than not, for a period of at least 6 months. The intensity, duration, and frequency of symptoms are out of proportion to the probability or consequences of the feared event. Somatic symptom clusters often involve: 1) motor tension (such as trembling, restlessness, and fatigue), 2) autonomic hyperactivity (for example, shortness of breath, palpitations, sweating, dry mouth, dizziness, and abdominal distress), and 3) hyperarousal (such as exaggerated startle response, irritability, insomnia, and poor concentration).

Obsessive-compulsive disorder (OCD) is an anxiety disorder involving obsessions or compulsive rituals or both. Obsessions are repetitive and intrusive thoughts, impulses, or images that cause marked anxiety. They often involve transgressing social norms, harming others, and becoming contaminated, but they are more intense than excessive worries about real problems. Compulsions are repetitive rituals and acts that people are driven to perform and which they perform reluctantly to prevent or reduce distress. The frequency and duration of their repetition make them inconvenient and often incapacitating. Examples include ritualistic behaviors (such as hand-washing and rechecking) and mental acts (for example, counting and repeating words silently); they are time-consuming and interfere significantly with daily functioning.

Post-traumatic stress disorder (PTSD) involves an individual's experiencing a psychologically traumatic stressor such as witnessing death, being threatened with death or injury, or being sexually abused. At the time of the stressor event, the individual experiences intense fear, helplessness, or horror. PTSD entails a persistent reexperiencing of the trauma in the form of recurrent and intrusive images and thoughts, or recurrent dreams, or experiencing episodes during which the trauma is relived (perhaps with hallucinations). People with PTSD experience persistent symptoms of increased arousal such as insomnia, irritability, hypervigilance, and exaggerated startle response. They persistently avoid stimuli related to the trauma such as activities, feelings, and thoughts associated with the traumatic event.

Interest in the role of sexual abuse and incest in PTSD and other psychiatric and AOD disorders has increased. Clinicians note that long-term responses to childhood and adult sexual abuse often include symptoms associated with PTSD and other psychiatric problems, including an increased risk for AOD disorders. Many such problems are addressed in treatment efforts popular in adult children of alcoholic (ACOA) programs, some of which are controversial and unsubstantiated by research or long-term observation. Such treatment approaches may exacerbate AOD use and psychiatric disorders and should be cautiously undertaken. Amnesic periods have to be carefully evaluated both as blackout phenomena and as possible dissociated states. Such differentiation can be extremely complicated. While a clinician's immediate response may be to identify these patients as being intoxicated, they may be experiencing independent psychiatric phenomena.

Prevalence

Prevalence rates for anxiety disorders in the general population can be estimated from the Epidemiologic Catchment Area (ECA) studies. According to the ECA studies, anxiety disorders affect more than 7 percent of adults (Regier et al., 1988). (In the general population, the lifetime prevalence rate of anxiety disorders is 14.6 percent.) Women, individuals under age 45, those who are separated or divorced, and those in low socioeconomic groups all have a higher rate of anxiety disorders than individuals in other groups.

The ECA studies indicate that in the general population:

• The 1-month prevalence rate for any anxiety disorder is 7.3 percent (4.7 percent for males and 9.7 percent for females), and the 6-month rate is 8.9 percent.
• The 1-month prevalence rate for phobia is about 6.2 percent (3.8 percent for males and 8.4 percent for females).
• The 1-month prevalence rate for panic disorder is about 0.5 percent (0.3 percent for males and 0.7 percent for females).
• The 1-month prevalence rate for obsessive-compulsive disorder is 1.3 percent (1.1 percent for males and 1.5 percent for females).
• Lifetime prevalence of post-traumatic stress syndrome in the general population is estimated to be less than 1 percent. The prevalence among individuals who have experienced a psychologically traumatic stressor and then developed psychiatric symptoms is poorly understood.

Among patients with AOD problems, there is a significant likelihood for having a coexisting anxiety disorder. One study noted that more than 60 percent of patients being treated for AOD disorders had a lifetime diagnosis of an anxiety disorder, and about 45 percent experienced an anxiety disorder within the past month (Ross et al., 1988). Other studies have demonstrated that most anxiety disorders among patients in addiction treatment are AOD induced (Anthenelli and Schuckit, 1993).

Differential Diagnosis

Anxiety sometimes has value as a signal of danger. In the same way that being sad is an appropriate response to some situations, experiencing anxiety can be an appropriate response. When manifestations of anxiety occur without apparent triggers or are out of proportion to the situation, they can be considered anxiety symptoms. If the symptoms are persisting, maladaptive, and meet certain diagnostic criteria, then the symptoms can be described as a syndrome. Further, if specific criteria are met in terms of consistency, repetitiveness, and duration, then the symptoms can be considered an anxiety disorder.

Anxiety symptoms are the most common psychiatric symptoms seen in AOD abusers. AOD-induced or withdrawal-related anxiety symptoms usually resolve within a few days or weeks. Most anxiety symptoms seen in AOD abusers resolve with AOD treatment; such conditions would be diagnosed according to the DSM-IV draft as substance-induced anxiety disorders. However, some people with AOD disorders have coexisting anxiety disorders that can be mildly to seriously debilitating.

Medical problems that may produce symptoms of anxiety include those affecting the cardiovascular and respiratory symptoms; neurological, hematological, and immunological disorders; and endocrine dysfunction. Several disease states can resemble generalized anxiety or panic, including acute cardiac disorders, cardiac arrhythmia, hyperthyroid conditions, brain disease, and HIV infection and AIDS. However, the most frequent imitator is addiction.

Medications that can cause anxiety symptoms include antispasmodics, cold medicines, thyroid supplements, digitalis, prescribed or over-the-counter diet medications, antidepressant medications, and, paradoxically, some antianxiety drugs such as benzodiazepines. Methylphenidate (Ritalin) and neuroleptic drugs can also cause anxiety. Withdrawal from depressants, opioids, and stimulants invariably includes potent anxiety symptoms. Steroids can make people hyperactive and anxious. Idiosyncratic reactions to medications, caffeine use, and nicotine withdrawal all can cause states similar to panic. Similarly, some medications cause acathisia, which is a feeling of restlessness and the urgent need to move about. Acathisia can be confused with anxiety.

The differential diagnosis of agoraphobia and social phobia includes avoidance behaviors that occur as a part of depression, schizophrenia, paranoia, other anxiety disorders, and some organic mental disorders. Many features of OCD can emerge as secondary complications of major depression, and obsessions may appear in the context of either depression or schizophrenia; distinctions between delusions and obsessions can be difficult to make. Like PTSD, adjustment disorder is a maladaptive reaction to a psychosocial stressor but involves a broader range of less extreme experiences. Adjustment disorder may result in a few of the symptoms seen in PTSD, but intense reexperiencing is less common.

PTSD and dissociative disorders such as multiple personality disorder (MPD) are often diagnosed among individuals with AOD disorders. Although the relationship has not been systematically examined, it is one to consider in differential diagnosis. MPD is receiving renewed attention and may occur frequently with AOD use disorders. Addiction treatment personnel should be trained that patients in a blackout or altered state may appear to be sober, and may in fact be sober. Recent studies indicate evidence of overdiagnosis of MPD. It is not necessary to assess all AOD patients for this disorder. Rather, training clinical staff to be alert for the signs and symptoms of MPD is a worthwhile goal. Mental health staff who treat patients with MPD should be alert for the signs and symptoms of AOD use disorders.

Many of these individuals need treatment provided by professionals who have specialized training in trauma resolution. Such patients need stability in their primary therapeutic relationship; hence, this work should not be undertaken in settings with high staff turnover. In most settings, the AOD abuse counselor should not try to treat patients who have experienced trauma.

Traditional long-term psychotherapy can cause patients anxiety, especially patients who were traumatized during some part of their lives. During acute treatment it may be best to teach patients the skills to express conflicts in socially appropriate ways, such as in self-help and therapeutic groups. Later, psychotherapy can help patients to resolve the underlying conflicts.

Acute Assessment Issues

The medical management of withdrawal is driven by the drug(s) to which a patient has developed tolerance; it does not vary significantly if the patient is anxious or depressed. Whatever the drug involved, the management of withdrawal-related anxiety involves issues similar to those associated with depression. Psychiatric support, confinement, and medication may all be needed.

People with simple anxiety are less likely to need to be hospitalized involuntarily. Since coexisting anxiety and depression constitute a greater risk factor for suicidal behaviors than depression alone, individuals with combined anxiety, depression, acute AOD use, and suicidal thoughts should be assessed for possible hospitalization, including involuntary commitment. Similarly, people who have uncontrollable agitation or who experience depersonalization may need to be confined. However, if tension is the main manifestation, there is less need for protection.

If the patient describes acute anxiety secondary to hallucinogen or marijuana use, the first line of treatment is "talking the patient down." If this does not calm down the patient, pharmacologic treatments can be used in some situations where the anxiety symptoms remain overwhelming and dangerous. Benzodiazepines may be indicated over the short term. Sedating antidepressants may be used during the subacute phase.

Phencyclidine-induced states can be extremely variable; they can be brief and mild or long-lasting and associated with significant danger and seizures. PCP can induce vertical nystagmus (involuntary motion of the eyeball), which is otherwise rare. Glutethimide causes agitated intoxication alternating with severe sleepiness and depression.

Agitated patients who do not have parasites (scabies, lice, and crabs) but complain of the sensation of insects crawling on or under their skin have probably used stimulants. Tactile hallucinations are hallucinations that involve the sense of touch. Formications are a type of tactile hallucination that involves the sensation of something creeping or crawling on or under the skin. Formication is seen in patients with alcohol withdrawal delirium and during the withdrawal phase of stimulant intoxication. Bilateral (affecting both sides of the body) and symmetrical symptoms (itching, scratching, and redness) are indicative of formications rather than of parasites. Manifestations of parasite infestations are not symmetrical but have asymmetrical patterns on each side of the body.

Subacute Assessment Issues

While danger to self and others is not a hallmark of anxiety disorders, people in dissociated states may put themselves in great danger and require involuntary commitment. The relationship between anxiety, depression, and suicide has been noted. Thus the potential for harm to self and others should be considered. The possibility of medical disturbance and psychological and AOD issues must be considered. Consider the example of a patient who is treated in the emergency room for a panic attack. Once the patient is transferred to treatment in an outpatient mental health clinic, a plan should be developed that includes assessing AOD use, functional level (liabilities and strengths), and physical status, including cardiac and endocrine tests as indicated. Specifically, patients should be assessed for hyperthyroidism; this is especially true for women, who are four times as likely as men to have this disorder. Anxious people should also be evaluated for early stages of HIV infection and transient ischemic attacks. Neurological status should be carefully evaluated.

A psychosocial assessment is needed. If AOD use has been ruled out, it should be determined if an overwhelming stressor has provoked the anxiety response, such as grief or psychosocial stressors. For example, confusion about sexual orientation can be a potent source of stress that can lead to anxiety symptoms. Anxiety can also have cultural influences. For example, there is a subgroup of addicted people who have lost the majority of their friends to AIDS. When an individual has a pervasive anxiety disorder, develops AOD problems, and lives in a dismal social situation, a thorough biopsychosocial assessment is needed.

Grounding people in the here and now is most important. This should be accompanied by providing education about addiction to the patient and family. There are several self-help and support groups for people with anxiety and phobias. People with phobias are often treated in specialized treatment programs that utilize desensitization techniques, biofeedback, and behavioral and cognitive therapies. These specialized treatment strategies have been shown to be effective by empirical research.

Long-Term Assessment Issues

In long-term treatment, dissociative states may occasionally emerge in patients, and counselors should have the skills for handling these patients. In people who appear to be in a glassy-eyed dissociative state, the interviewer should evaluate AOD use, and if this is ruled out, consider dissociation. If the patient appears to be in a dissociative state, the clinician should ground the patient in time and place, and focus on here-and-now issues. Focusing on external events and processes rather than the patient's internal processes or history is helpful. These methods will be effective whether the patient proves to be in a drug-induced state or is manifesting a frank dissociative disorder. Both AOD and mental health counselors need to evaluate these patients.

Some people who experience anxiety are in fact experiencing an anxious depression, but the diagnosis must be reevaluated over a 30-day period. This is sufficient time for observation except in the case of subacute withdrawal from benzodiazepines. After 30 days, all traces of AODs will be gone, most neurochemical disturbances will disappear, and acute withdrawal symptoms should be over. By this time, a depression can be seen with some clarity.

Once patients have established and somewhat consolidated abstinence in their lives, they should be provided with educational and vocational testing and given support to help plan short-term and long-term goals. Patients with dual disorders may experience setbacks during overall periods of improvement. Thus, concrete planning efforts for future goals often occur over a long period of time. Although generalized anxiety disorder may severely restrict day-to-day functioning of some patients, most respond well to treatment.

Acute Treatment Strategies

Some very anxious patients misinterpret their symptoms of chronic anxiety as symptoms of an acute anxiety episode. Their misinterpretation may prompt the therapist to make the same misinterpretation. Two of the acute anxiety conditions most commonly encountered in emergency room settings are panic attacks and dissociative states -- which may resemble psychosis.

Acute interventions include calming reassurance, reality orientations, breathing management, and when needed, sedative medications such as benzodiazepines. These interventions are nearly identical to those used for the two most common AOD-related anxiety emergencies: withdrawal from sedative-hypnotics (including alcohol) and intoxication from stimulants (including cocaine). While the use of benzodiazepines is generally not problematic during acute withdrawal, their use may be problematic for abstinent recovering people who experience panic attacks. Indeed, such people may have abused benzodiazepines before they became abstinent. Acute interventions should include behavioral, cognitive, and relaxation therapies, often in combination with long-term serotonergic and depressant medications. Cognitive therapy can be used; patient manuals and workbooks exist for such treatment.

During an acute panic attack, people often believe that they are having a heart attack, feel dizzy, and are unable to catch their breath. Enforced regular breathing through the use of a paper bag helps to regulate breathing and diminish excess release of carbon dioxide. Such breathing exercises, education about symptoms, and reassurance will diminish panic symptoms for many patients.

Subacute Treatment Strategies

For many patients in early recovery from AOD abuse, treatment of anxiety disorders can be postponed unless there is a certain or verifiable history that the anxiety preceded the addiction or is incapacitating. If symptoms are mild and not interfering with function, including participation in treatment, it is judicious to wait and see if the symptoms resolve as the addiction treatment progresses. Subacute withdrawal may be difficult to differentiate from anxiety disorders.

Antecedent traumas, as well as dysfunctional family situations that have been identified during the assessments, should be addressed in a supportive and calming manner. However, affect-liberating therapies should probably be deferred until stability with respect to AOD abuse and acute anxiety has been established. Issues of importance to the patient and raised by the patient should not be ignored, but exploration of underlying trauma should not be encouraged until the patient is stabilized.

Supportive, cognitive, behavioral, and dynamic therapies can all be used, but in early recovery, patients need significant support and will have very limited tolerance for anxiety and depression. The emphasis should be on supporting recovery, attending 12-step meetings, and participating in other self-help and group therapies. Insight-oriented treatments must be carefully measured and limited by their potential to increase anxiety and trigger relapse. When psychotherapy is required, patients should be referred to recovery-oriented psychotherapists who will integrate psychotherapy with 12-step program approaches.

Patients may overuse medications or relapse on illicit drugs. Certain medications that do not produce physical dependence or withdrawal and have much lower potential for abuse have been found to be effective for treating anxiety disorders. Many are as effective as the benzodiazepines but without the abuse liability. The antidepressants fluoxetine (Prozac) and sertraline (Zoloft) and the antianxiety medication buspirone (BuSpar) are relatively new medications that can be used to treat symptoms of anxiety disorders, have good safety profiles, are not euphorigenic, and have few drug interaction cautions. They can be used in the management of subacute withdrawal states. When these drugs do not produce the desired results, the tricyclic and monoamine oxidase inhibitors (MAOIs) antidepressants may be used. (See Chapter 9 for a discussion of psychiatric medication.)

Medications should be used in combination with nondrug treatment approaches. Although studies are still under way, acupuncture, aerobic exercise, stress reduction techniques, and visualization techniques appear to be useful components of treatment and recovery. These tools can be valuable adjuncts for the reduction of stress. It appears that acupuncture is more effective if used regularly for 2 weeks or more. Patients should be taught that efforts to improve their general health, such as eating more healthful foods and exercising regularly, can lead to better mental health.

Long-Term Treatment Issues

While medications are useful for anxiety disorders, they are not a substitute for addiction treatment or other activities related to recovery from other illnesses. Cognitive and behavioral techniques used in addiction are often as effective as medications in treatment of anxiety disorders but generally take longer to achieve an equivalent response. For patients with dual disorders, psychotherapy has significant advantages over AOD counseling alone. Many techniques of cognitive and behavioral therapy can be incorporated into AOD abuse treatment.

The consumption of foods containing stimulants should not be overlooked. People who consume significant amounts of caffeine and sugar may have a higher risk for episodes of anxiety and depressive symptoms. Chocolate should be avoided. Diets that cause significant variations in blood sugar levels should be avoided. It is important to be sure that eating habits don't imitate the rushes and crashes of AOD abuse. Diets that cause variations in blood sugar levels may tend to aggravate or induce both mood and anxiety states. Patients should avoid large quantities of refined carbohydrates.

Over the long term, special attention should be given to the resolution of preexisting and long-term trauma issues. Patients with dissociation and PTSDmay manifest poor social judgment, and special attention should be given to risky practices. People who continue to experience episodes of depersonalization or MPD will require special support and counseling, especially concerning sexually transmitted diseases and risk-reduction issues. Those who continue to experience these episodes may need special counseling about risk factors. During these episodes, people may be more likely to have sex, and may forget about the risk of HIV infection.

Experts in the treatment of these disorders have developed techniques of working with patients, including the management of behavior during trance and dissociated states, as well as fugue states in which people suddenly travel away from home or work, assume a new identity, and are unable to recall their previous identity. Many of the psychotherapeutic management issues that relate to patients with dissociative disorders run parallel to those outlined in the section of Chapter 7 on borderline personality disorder.

Use of 12-Step and Other Self-Help Programs

Participation in the 12-step programs provides valuable therapeutic experiences for many recovering people who have anxiety disorders. People who have a social phobia and the fear of public speaking are often extremely resistant to attending self-help meetings. Yet, such people can make tremendous recovery gains in terms of anxiety desensitization and AOD recovery.

There are few situations that are as safe, supportive, and predictable and less demanding than the average 12-step group meeting. For this reason, groups such as Alcoholics Anonymous provide ideal situations to help patients desensitize social fears. However, anxious patients must not simply be thrust unprepared into 12-step group meetings. Rather, AOD staff should educate and prepare such patients regarding the process and approach of 12-step group meetings or other self-help groups.