Individuals with anxiety-related problems i.e., Obsessive-compulsive disorder, posttraumatic stress disorder, and anxiety disorders are more likely to develop substance use disorders (SUDs) i.e., Obsessive-compulsive disorder, posttraumatic stress disorder, and anxiety disorders. SUDs and anxiety-related disorders have a complicated relationship. Some anxiety-related illnesses are linked to a higher chance of developing SUD, and they can affect how the disease manifests and how it is treated. SUD can affect how anxiety-related disorders are treated and how well they work.
The intricacy of these comorbidities stresses the need of recognizing and precisely assess each disorder’s characteristics. Potentially harmful drug-drug interactions, the risk of prescription addiction, and patient adherence must all be taken into account for effective therapy. Data from clinical studies of therapies for anxiety disorders and SUD when they occur concurrently is often insufficient to evaluate treatment effectiveness for the illnesses when they appear independently.
Diagnoses of drug abuse and substance dependence in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 4th Edition were substituted with a single diagnosis of SUD in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.
Treatment Strategies
It is vital to treat both anxiety-related disorders in patients with co-occurring anxiety disorders. Without addressing the anxiety-related diseases, treating the substance use disorder (SUD) may leave the patient vulnerable to relapse when anxiety symptoms arise. Treating anxiety-related diseases without first addressing and monitoring the SUD is likely to be ineffective, if not dangerous.
Your treatment should include the following to give you the best chance of a complete recovery:
- Drug addiction and mental health care specialists collaborate to meet your substance abuse and mental health requirements.
- Targeted therapy is equally important in the treatment of co-existing illnesses, but prescribed medication may be necessary as well.
- The most effective and extensively utilized strategy is a therapy that enables the consumer to make decisions.
Irrespective of whether they undergo individual therapy or participate in family sessions, all members of the family, including companions, spouses, kids, and any other resident of a household, should be included in the primary treatment.
Anxiety problems can jeopardize treatment results by acting as a catalyst for recurrence. Individuals with SUD must learn how to manage and/or accept trauma-related and anxiety symptoms without using drugs. People with panic disorder who are done with exposure or other anxiety-stimulating homework tasks while under the effect of drugs or alcohol, for instance, will not experience the natural fall and rise of anxiousness, nor will they gain knowledge of corrective information that anxiety does not last forever and that they can endure anxiety symptoms without ever using drugs or alcohol.
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Derived from empirical data from clinical studies and our medical knowledge, we recommend integrated cognitive-behavioral therapy (CBT) that treats both disorders as the first treatment for most individuals with an anxiety disorder and a co-existing SUD over other treatments. The evidence in favor of this combined intervention is minimal, and the effects have been mixed.
We recommend trauma-focused integrated CBT with exposure as a first-line treatment for patients with co-existing posttraumatic stress disorder and SUD, instead of other psychotherapies.
Treatment of the anxiety-related condition with a serotonin-norepinephrine reuptake inhibitor (SNRI) or a selective serotonin reuptake inhibitor (SSRI) is a suitable alternative for patients who choose medication over CBT or if CBT is unavailable. In such circumstances, the SUD should also be addressed.
In individuals with a co-existing anxiety-related disorder and a SUD, we recommend combination treatment with integrated CBT and an SSRI instead of either intervention alone if the:
- An SSRI has previously been used to treat anxiety disorders.
- Anxiety disorders are serious and debilitating.
- Other diseases are associated with disorders (eg, depression)
- Disorders do not respond well to either modality when used alone.
Other medicines are used to treat anxiety-related illnesses and SUDs that do not react well to SSRIs/SNRIs. The misuse potential of medications recommended for co-occurring anxiety-related disorders and SUDs must be considered, as well as the potential for toxic interactions between medicines and drugs/alcohol, as well as between medications and medical illnesses caused by drugs/alcohol. Furthermore, physicians should be aware of the higher risk of noncompliance with prescription drugs, which is common in this patient group.
Earlier on, a prescription may be required to help lower anxiety or trauma-related symptoms while the individual learns behavioral coping mechanisms, if there are withdrawal symptoms that would lead to relapse, and to help boost retention. In addition to integrated CBT, pharmacological treatments that address substance use withdrawal and compulsion may be beneficial.
The assumption that individuals with a co-existing anxiety-related disorder and SUD are required to abstain from drugs/alcohol for a longer length of time (e.g., 3 to 6 months) before treating the anxiety-related condition has been debunked by growing research findings. Trials of treatment for patients with posttraumatic stress disorder and SUD, for example, have demonstrated that tackling the trauma in the initial treatment improves posttraumatic stress disorder manifestations as well as drug and alcohol use. We have turned increasingly to commencing therapy for outpatients with an anxiety-related disease and a SUD upon their arrival to the clinic unless hospitalization is required for a detox under medical supervision.
Integrated CBT as a Way Forward For Anxiety And SUD Dual Diagnosis
For both anxiety-related illnesses and co-existing drug abuse disorders, integrated cognitive-behavioral treatment (CBT) integrates cognitive and behavioral interventions (SUDs). In reported studies, the components of integrated CBT for these disorders have varied, but they often include:
- Both diseases require coping strategies training and education.
- For anxiety disorders, exposure or other behavioral therapies are used.
- SUD recurrence prevention in individuals who have successfully completed abstinence
Positive results for obsessive-compulsive disorder (OCD), limited success for panic disorder, and negative outcomes for social anxiety disorder have been documented in clinical studies using integrated CBT for co-existing anxiety-related disorders and SUDs (SAD). Many more studies in patients with posttraumatic stress disorder have been undertaken (PTSD). Exposure-based interventions reduced PTSD symptoms without aggravating substance abuse, however, the results for SUD were inconsistent.
There are no clinical studies of combined therapies that address both generalized anxiety disorder and SUDs for generalized anxiety disorder.
An integrated CBT intervention was not found to be beneficial in patients with co-existing social anxiety disorder and SUD in a clinical investigation. The study assigned randomly ninety-three patients with SAD and alcohol dependence diagnosed by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) to obtain either individual CBT for alcohol dependence or personal, integrated CBT for both abnormalities. Three out of the four alcohol use indicators were worse in the group getting integrated psychotherapy both for social anxiety disorders and alcohol, whereas there were no significant changes in social anxiety measures.
Panic disorder — A clinical study involving 231 people with panic disorder and DSM-IV alcohol dependency who were getting inpatient care for the SUD found that adding group CBT for panic disorder did not yield advantageous outcomes for either condition. Although both groups improved, there were no differences in most indicators of panic symptoms and alcohol use at three, six, and twelve months after treatment between the CBT and non-CBT groups.
Obsessive-compulsive disorder — A combination cognitive and behavioral intervention improved both OCD and SUD symptoms in a randomized clinical trial of patients with co-existing SUD and OCD. The sixty patients with co-existing OCD and a SUD were selected randomly to either exposure and response presentation therapy (a form of Cognitive Behavioral Therapy utilized for OCD) in combination with behavioral therapy for the SUD, behavioral therapy for the SUD only, or behavioral therapy for the SUD coupled with progressive muscle relaxation (as a control intervention). When compared to the two groups, the group getting CBT for OCD plus behavioral therapy for SUD had a better reduction in Symptom severity for OCD, a greater abstinence rate, and increased treatment retention.
Posttraumatic stress disorder – Integrated, trauma-focused CBT has been demonstrated to be effective for individuals with both SUD and PTSD in multiple meta-analyses. When compared to non-exposure therapy, exposure-based therapies resulted in greater reductions in PTSD symptoms. There was no evidence that exposure increased substance use or relapse. Improvement in symptoms of PTSD was seen more frequently compared to improvement in SUD symptoms in general.
Personal (not group) trauma-focused CBT strategies, generally including exposure and presented along with a SUD treatment, were more efficacious for co – occurring SUD and PTSD than conventional therapy or other comparative conditions, according to a 2015 meta-analysis of fourteen experimental studies with 1506 attendees. In person or group forms, there was very little evidence for non-trauma-focused therapies. The use of integrated therapy for SUD and PTSD was linked to a reduction in substance abuse.
In a 2017 study, behavioral treatments for comorbid SUD and PTSD were studied in 24 randomized studies with 2296 patients. The interventions were classified as follows:
- Interventions based on exposure
- Interventions based on coping
- Interventions with a focus on addiction
Exposure-based interventions have been the most effective methodology for lowering PTSD symptoms. Most studies found no significant difference in results between exposure-based treatment and the controlled group when it came to lowering SUD severity. Approximately half of the patients with SUD and PTSD completed therapy, with no significant variations in completion rates between the three treatment methods.
Numerous integrated CBT program, both with and without exposure, have been studied, including trauma-focused PTSD therapies and non-trauma-focused interventions:
COPE (Concurrent treatment of SUD and PTSD with Prolonged Exposure) — COPE is a twelve-session manualized and personalized treatment that combines prolonged exposure therapy (imaginal and in vivo exposure) for PTSD and cognitive behavioral therapy (CBT) for SUD:
- Sessions 1–2 focus on psychoeducation about the interrelationship between SUD and PTSD, how to cope with urges and triggers for use (both drug and trauma-related triggers), and why prolonged exposure is necessary.
- In vivo exposures are covered in Sections 3 to 12.
- Imaginal exposures are included in sessions 4 through 11.
- SUD issues, such as managing thoughts about using, high-risk circumstances, and drink/drug refusal skills, are woven throughout the program.
COPE has been shown to be effective in lowering PTSD in people with co-occurring SUD and PTSD in multiple randomised studies when compared to other active therapies or control circumstances. When compared to control conditions, patients who were randomized to COPE had fewer PTSD symptoms and greater rates of PTSD diagnostic remission at the end of treatment. Patients who received COPE tended to have a similar reduction in SUD severity as those who got an SUD-only intervention.
Evidence for the efficacy of COPE
COPE is concurrent treatment of SUD and PTSD with Prolonged Exposure. Here are several examples from research trials:
In a 2019 randomized experiment, 119 military veterans with PTSD and alcohol use disorder were compared to COPE against Seeking Safety. COPE led in a greater reduction in the intensity of PTSD symptoms and a higher percentage of PTSD diagnostic remission, as well as a similar reduction in substance abuse. In all groups, the number of days abstinent roughly quadrupled from baseline through the completion of therapy. In COPE, the average number of sessions completed was lower than in Seeking Safety (8 versus 11). COPE, an exposure-based therapy, was more effective than Seeking Safety, which did not contain exposure, even with fewer sessions.
In a 2019 study, eighty-one military veterans with SUD and PTSD were compared to COPE and relapse prevention therapy. When compared to relapse prevention therapy, COPE resulted in greater decreases in PTSD severity and better rates of PTSD diagnostic recovery. During treatment, the severity of SUD was reduced in both groups. When compared to the relapse prevention group, the COPE group had less drinks per consuming day (about 4 less drinks per day) at 6 months.
Prolonged exposure therapy — In a clinical study of individuals with opioid abuse disorder and PTSD, prolonged exposure therapy decreased PTSD symptoms. All fifty-two people with PTSD and opioid abuse disorder were randomly randomised to either a modified form of prolonged exposure (60-minute sessions with breathing relaxation at the end of each imaginal exposure) or a non-trauma-focused comparative intervention. Modified longer exposure resulted in higher decreases in PTSD symptoms, sleep disruptions, and anxiety and depression symptoms at the end of the experiment.
SDPT (Substance Dependence PTSD Therapy) — SDPT is a 5-month, twice-weekly manualized individual CBT program that combines relapse prevention and coping skills training for SUD with patient education, stress inoculation preparation, and in vivo exposure for PTSD. SDPT was compared to 12-step facilitating therapy in the management of nineteen patients with DSM-IV cocaine dependence and PTSD in a small randomized experiment. There was no difference in the outcomes of substance addiction or PTSD symptoms across the therapy groups. When particularly in comparison to the 12-step facilitation group, the SDPT group had a higher rate of treatment retention (median of twenty-six versus sixteen sessions).
Seeking safety is a manualized, non-trauma-focused integrated CBT program that teaches psychoeducation and coping strategies. The 24-session intervention was originally created for group therapy, but it has also been studied in an individual setting. Seeking Safety has demonstrated mixed efficacy in randomized studies in women with SUD and PTSD. Here are several examples:
In a multitier clinical study conducted in 2019, 342 women with SUD and PTSD were randomly allocated to one of three groups: Seeking Safety plus usual care, relapse prevention psychotherapy plus usual care, or usual care. There were no significant changes in SUD or PTSD outcomes between the groups.
In a 2018 clinical study with 51 veterans with SUD and PTSD, Seeking Safety was compared to Creating Change, an alternate CBT intervention that includes an examination of previous trauma recollections. The results demonstrated that both treatments improved PTSD, drug abuse, and life quality in a similar way, with no significant dissimilarities.
In individuals with SUD and PTSD, other combined CBT approaches have been studied. The integrated treatment was shown to be usually well-tolerated to by participants in a review paper on clinical studies of cognitive processing psychotherapy.