The following information has been kindly supplied by Peter O’Loughlin, The Eden Lodge Practice www.edenlodgepractice.com
Alcohol misuse and anxiety based presenting problems.
Given that anxiety disorders are among the most common of presenting problems, it may be of interest to practitioners to be aware of how alcohol misuse can cause or aggravate such conditions. Such an understanding may provide insight as to why some anxiety based problems seem to be more difficult to resolve.
Many of us have discovered for ourselves how a drink or two seems to dispel anxiety. Generally speaking this occurrence is not uncommon for those who feel nervous or uncomfortable in some type of social settings. A couple of drinks appear to be the perfect antidote, inducing feelings of relaxation and in some cases mild euphoria. Since these feelings in turn generate a sense of confidence, and, in some cases, seem to enhance our eloquence, it is hardly surprising that many start to ‘self medicate’. Alas! Like so many other psychoactive drugs, sooner or later, sometimes too late, the discovery is made that increased quantities are required in order to obtain the same effect. Thus it is not uncommon for people to find themselves drinking more to ease their anxiety, without realizing that one of the many paradoxes of alcohol is that although it initially appears to alleviate anxiety, regular and long term use actually increases anxiety levels. (1)
There are widely differing views on whether it is anxiety that causes alcohol misuse, or abuse that causes anxiety. What has been established is that alcohol abuse can and does cause the following conditions:
Depression. Anxiety. Suicide Ideation Phobic Disorders. Memory Loss/Blanks. Panic Attacks. Hallucinations. Delusions. (2)
It is not intended to imply that everyone who abuses or becomes dependent on alcohol experience all of the above. Alcoholism is a complex disease affecting different people in differing ways. However because in its nature it is a progressive disease, continued abuse, will in time, allow any or all of the disorders to become more acute.
Where one or more of the conditions listed above co-exists together with alcohol misuse we have a condition that is referred to as comorbidity. (3) (This condition is sometimes referred to as Dual-Dependency.)
As may be assumed there are also medical and behavioral complications that can arise, and although some of these respond well to therapeutic intervention, it is not the intention of this article to address such issues.
Research has shown that people with anxiety disorders report that apart from seeking to avoid anxiety inducing situations, the use of alcohol is a primary method of coping. We also need to consider the probability that positive expectancy, or belief, by a client, that alcohol, regardless of all the evidence to the contrary, relieves anxiety. Therefore people with anxiety disorders may drink excessively because they believe that in so doing their anxiety levels will diminish. Once again such expectancy or belief is re-enforced but usually with increasing amounts of alcohol, thus rendering a client vulnerable to addiction and comorbidity.
It is only in the last decade that the condition of comorbidity has been identified and recognized, and even more recently since the importance of treating alcohol related mental disorders simultaneously has been acknowledged. Unfortunately it is regrettable to note that many therapists and agencies are still reluctant to acquire the necessary knowledge to effectively assess for the existence of comorbidity. Indeed as far as I’m aware the major training organizations in both Psycho & Hypnotherapy fail to include even the basic facts and affects of substance misuse and dependency in their syllabus. Given the documented psychological problems that such misuse either aggravates or induces, together with escalating presenting of such problems, it is to be hoped that the more enlightened training organisations will seek to address and rectify this omission.
For those who may think I’m being unduly alarmist about a condition that seems to be rare or obscure, the available evidence for the existence of comorbidity indicates that up to 75% of those who misuse alcohol may be so affected. (4) Earlier evidence in support of this emerges from Canada (5) wherein it is suggested that 17% of those who misuse alcohol suffer from severe depression. 16% experience significant Generalized Anxiety Disorder (GAD) and a staggering 26% Phobic Disorders.
Those statistics begs the question of how many of those presenting with anxiety based disorders are misusing alcohol. Lack of research based evidence prevents accurate indications, however based on the available information; one conservative extrapolation indicates it is approximately one third.
The importance of assessing for alcohol misuse when presented with anxiety based disorders, has until comparatively recently been overlooked. This is not surprising when we consider that the vast majority of GPs appear to lack the resources to routinely screen for the presence of alcohol misuse. (6)
The authors concluded that throughout the UK 20% of all patients presenting to GPs consume alcohol at excessive levels, yet 98% of these are not identified in the general practice setting. Readers may wish to draw their own conclusions as to how, under such circumstances, the scope this leaves for inappropriate and/or inadequate treatment protocols.
If that is the case in Primary Care one cannot help wondering what would be revealed if such extensive research were carried out among those who offer therapeutic intervention for anxiety based disorders. Unfortunately, although no such research has been carried out it is a matter of fact that many of the people who work in such settings have little or no knowledge of the psychoactive affects of alcohol, whilst those who are primarily engaged in counseling for alcohol problems are not trained to treat the underlying, or outcome problems. It is by no means uncommon that within both the NHS, voluntary and private agencies, those presenting with anxiety disorders and alcohol misuse, are informed that they need to address either their alcohol problem, or their anxiety disorder, before ‘therapy’ can be offered.
The latter, seemingly unhelpful attitude conceals an inescapable truth, which is that treating one condition without the other is unlikely to have lasting benefits. That sooner or later, relapse into either or both conditions will occur.
Equally many so called dedicated alcohol misuse agencies, decline to accept clients
who have other diagnosed mental disorders. With the increasing prevalence of comorbidity this is resulting more people ‘slipping through the net’, or receiving inadequate, and/or inappropriate interventions.
As therapists who have accepted that we have a ‘duty of care’ to our clients, I suggest that we are lacking in the fulfilling of that duty, if we fail to routinely screen for alcohol misuse in all anxiety based problems. By screening I do not mean simply asking the client whether or not he/she drinks, such a vague question will elicit an equally vague answer. Equally using the politically influenced recommended units per week will fail to produce accurate information, if only because the units of measurement referred to are based on the old imperial system of measurement , whereas for some time pubs, bars and restaurants have been dispersing metric units which are considerably larger. Incidentally it may be of interest to note that the so called safe number of units as indicated by the Dept of Health has never been approved by either the British Medical Association, or the Royal Institute of Psychiatrists.
There are a variety of tests for assessing the presence of alcohol abuse and/or dependence. The ‘tool’ I use was developed by the World Health Organisation (WHO) and rejoices under the acronym of AUDIT. This translates into Alcohol Use Disorders Identification Test. It is freely downloadable together with full instructions for use www.who.int/substance abuse/PDF files/auditbro.pdf. A companion document that you may also find useful is entitled ‘Brief Interventions for hazardous and harmful drinking.’ This can be downloaded from www.who.int/substance abuse/PDF files/bimanbro.pdf. AUDIT has been rated as being more clinically more effective in assessing alcohol misuse and/or dependence than blood tests (7)
At first sight it may seem a difficult task to complete the questionnaire and accurately interpret the results; applied diligence will be rewarded. However if it appears to be too complicated, a reasonably reliable result can be obtained by confining the questions to 1,2,4,5 & 10. If the cumulative score is less than 5, there is no adverse influence from alcohol. A score of 5-10 indicates a harmful affect, whilst a score above 10 can mean that dependency has, or is setting in. I must emphasis that the scoring is indicative only. Should the score be a10 or above, a specialist assessment may well be in your clients best interests.
The outcome is that you are now armed with information that allows you to have a reasonably informed opinion of not only the presenting problem, but also the extent to which alcohol abuse is influencing it, or causing other problems. At this stage I suggest that in order to fulfill our ‘duty of care’ obligation the client needs to be made aware of the self harm that he/she is imposing as the result of alcohol misuse. It is not unusual for the client to be unaware of the damage that alcohol is causing, and providing dependence has not set in, can be sufficient motivation for a change in lifestyle. However be prepared for a negative reaction.
Many people who abuse alcohol, particularly those who have become dependent on it, are not only defensive about their habit, they are also inclined to delude themselves that they drink because of their problems, whereas it is more than likely that their problems are the result of their drinking. This particular frame of mind is what is referred to by some of those specialising in Addictive Behaviours as the ‘Pre-Contemplation’ stage. (8) A polite way of describing someone, with a clinically diagnosed substance misuse problem, who is unwilling to acknowledge their condition.
Having completed the AUDIT and successfully interpreted the result, you are faced with some tough choices.
- If you are not trained or qualified to deal with alcohol dependency or misuse, do you refer the case to someone qualified to deal with comorbidity?
- Despite being aware of the potential problems chose to ignore the alcohol influence and address the presenting problem only?
- Advise the client that unless he/she is willing to seek help for the alcohol problem, that any interventions you are qualified to carry out in relation to the anxiety based presenting problem are unlikely to have lasting benefit?
Insofar as the first choice is concerned, given that the number of agencies/individuals who are qualified are so relatively few, it is likely to be more of a hypothetical situation than a reality.
The second choice is so unethical that any therapist who values their integrity would dismiss it.
The third choice is of course the most ethical and honest. However it has the potential disadvantage, that if the client is either unwilling to acknowledge that there is a problem with alcohol, or is unwilling to address that problem, but still wants to use your therapeutic skills, what does one do? That is decision for each individual to make according to their own standards.
If on the other hand the client is willing to acknowledge and address the alcohol problem, it would enhance our standing as professionals who care, if we were able to provide our client with contact details of community based Drug And Alcohol Action Teams. Details of these should be in your local telephone book or yellow pages. You may also find it beneficial to seek to establish a relationship with the manager of your local team. If your client would prefer a private consultation, you can find details of registered drug and alcohol counselors on the Federation of Drug and Alcohol Professionals www.fdap.org.uk unfortunately, few if any of those listed are qualified in hypnosis.
In addition we should not overlook the extent of the help offered by Alcoholics Anonymous. This fellowship which is sometimes maligned as a cult, or mistakenly as a religion, has for more than 70 years been helping those who have formed a dependency on alcohol. Further, according to independent research carried out by Harvard University it has been responsible for more successful recoveries than all other agencies combined. Speaking for myself, I urge all of my alcohol dependent clients to attend AA meetings on a regular basis. Those that do so tend to achieve recovery more quickly than others.
For those of you who would like to acquire more knowledge about alcohol abuse, and/or the basic skills in addressing this growing problem, some community drug and alcohol action teams run training courses for volunteers. If such is available in your area, it is as good a route as any to get one’s ‘feet wet’. Such schemes provide basic training in alcohol and drug awareness without the expense of more academically based courses. They also provide the unpaid opportunity of working alongside experienced counselors. A realistic and economical way, of increasing your skills and knowledge base, together with obtaining cpd credits.
Although I hope that this article has shed some light on dealing with anxiety based problems, that may be influenced, or caused by alcohol misuse, it needs to be remembered that where dependency, or addiction, has developed we have a threefold disease, of body, mind and spirit. It follows that attempts to assist recovery without the necessary training are not only unlikely to succeed, but are potentially detrimental to the client. For further clarification the author’s definition of addiction can be seen on his website. It should be noted that there are other and differing points of view on what constitutes addiction. In fact there are almost as many theories of dependency as there are brands of whiskey.
© Peter O’Loughlin. The Eden Lodge Practice Beckenham. May 2005. Updated April 27th 2006. www.edenlodgepractice.com
1 Linford –Hughes, A. Potokar, J. & Nutt, D. ‘Treating anxiety complicated by substance misuse.’ Advances in Psychiatric Treatment. * 107-106 2002
2 Medical Students Guide to Alcohol misuse and Alcoholism. Medical Council on Alcohol 1998.
3 Crome, L. B. “Psychiatric Disorder & Psychoactive Substance Use Disorder: towards improved service provision”. Centre for Research on Drugs & Health. London 1996.
4 Flanagan, M. An overview of comorbidity. Dept of Psychiatric Medicine St. Georges Medical School, London. 2002.
5 Unell, Ira. “Risking our sanity”. Druglink September/October 1997. Institute for the Study of Drug Dependence: citing Ross, H. et al “Sex differences in the prevalence of psychiatric disorders in Alcohol & Drug patients”. British Journal of Addiction: 1988: 83 1177-92.
6 Kaner, E. F. S. Heather, N. McAvoy, B. R. Loc k, C. A. & Gilvary, E. Intervention for excessive alcohol consumption in primary care: attitudes & practices of English General Practitioners. Alcohol & Alcoholism. 1999: 34.4 559-566.
7 Simon Coulton, Prof. Colin Drummond, Dr. Darren James. Prof. Christine Godfrey, Prof. J. Martin Bland. Prof. Timothy Peters. British Medical Journal 2006;332:511-517 (4 March)
8 Di Clemente CC. Self Efficacy and Addictive Behaviours. Journal of Social & Clinical Psychology. 4. 302 315. 1986.