Co-Occurring Anxiety and Substance Use Disorders

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Updated: June 12, 2020 

Anxiety disorders can develop due to a number of factors including exposure to certain life events as well as individual differences in personality, genetics, and brain chemistry.1 Over time, in those with anxiety disorders, feelings of uncontrollable fear or worry can get worse and will likely begin to interfere with daily life.2

In order to relieve symptoms of an otherwise under-managed anxiety disorder, some may turn to drugs or alcohol as a way to self-medicate.3 Studies indicate that over time, this could increase the likelihood of developing an independent co-occurring substance use disorder (SUD).3 And, while people who do attempt to self-medicate may be doing so to help themselves, substance use may also bring on or worsen anxiety.2

In some instances, anxiety is intermittent and related to fluctuations in alcohol use and is not a persisting mental health disorder. In these cases, the symptoms of anxiety may subside after a period of sustained abstinence.18 However, when treating a substance use disorder where a separate, but co-occurring anxiety disorder is present, both conditions will benefit from therapeutic attention with an aim towards improving overall treatment outcomes.18

Types of Anxiety Disorders

Anxiety disorders refer to a category of psychiatric disorders with a common feature of persistent, excessive, and sometimes irrational fear, anxiety, and related behavioral disturbances.7 Examples of relatively prevalent anxiety disorders include:2

  • Generalized anxiety disorders.
  • Phobias (e.g., social anxiety, agoraphobia).
  • Panic disorders (e.g., PTSD).

Previous 12-month prevalence estimates have pointed to roughly 19% of people having an anxiety disorder in the U.S.4 And although it may be the most common mental health disorder nationally, the Anxiety and Depression Association of America indicates that fewer than 37% of those suffering receive treatment.1

Like prevalent issues such as heart disease and diabetes, anxiety disorders are serious medical conditions and can have a similarly significant impact on an individual’s health.5 Thankfully, they are highly treatable and the symptoms can be effectively managed with a combination of behavioral therapy and medication.

Learn more about each type of disorder below:

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) involves excessive anxiety and worry about several events or activities occurring more days than not over the course of 6 months.2 Nationally, it affects 6.8 million Americans a year, with women being twice as likely to be affected.6

People with GAD are unable to stop the worry cycle even if they understand that their anxiety is excessive given the situation that may have led to it.6 The symptoms of generalized anxiety disorder can result in significant distress for the individual experiencing them, and may include:2,7

  • Being irritable.
  • Feeling on-edge or restless.
  • Difficulty concentrating.
  • Being easily fatigued.
  • Having tension in your muscles.
  • Issues controlling feelings of worry.
  • Having sleep problems such falling asleep, staying asleep, or restless and unsatisfying sleep.


Phobias involve extreme anxiety or fear related to certain types of objects, situations, or living things that is out of proportion to the actual threat present.2,7 Specific phobias typically last 6 months or more and affect around 19 million Americans.1,7

There are several types of phobia-related disorders including the aforementioned specific phobia (also called simple phobia), social anxiety, agoraphobia, and separation anxiety.2 People with phobias may:2

  • Actively try to avoid the feared object or situation.
  • Be irrationally or excessively worried about encountering the feared object or situation.
  • Experience intense anxiety when dealing with unavoidable objects and situations.
  • Experience instant excessive anxiety upon encountering the feared object or situation.

 Some examples of specific phobias include the fear of heights, flying, or receiving injections.2 In those with social anxiety, this manifests itself in an intense fear, or anxiety toward, performance or social situations in which they assume they may be negatively evaluated.2

Having an intense fear of two or more of the following situations would be considered agoraphobia: being in open spaces, using public transportation, being in enclosed spaces, standing in line or being crowded, or being outside of the home alone.2 When severe, individuals with agoraphobia can sometimes become housebound.2

Panic Disorder 

In the U.S., panic disorder affects 6 million adults, and women are twice as likely than men to struggle with the condition.1 Individuals who suffer from panic disorder experience recurrent unexpected panic attacks that come on quickly and reach their peak within minutes.2 Attacks can be triggered by certain objects or situations, but they may also develop unexpectedly.2

During a panic attack, people may experience trembling or shaking; feelings of impending doom; heart palpitations; or sensations of breath, smothering, or choking.2 People with panic disorder often become excessively worried about when the next one will happen as well as the consequences of having another one (e.g., losing control, feeling as if they are having a heart attack). Often, their lives become compromised as a result of trying to avoid experiencing another one.2

What is a Substance Use Disorder?

Addiction is characterized by the compulsive use of drugs or alcohol that often continues despite the harmful consequences of these substances.9 An addiction to drugs or alcohol is more formally diagnosed as a substance use disorder (SUD) or alcohol use disorder (AUD). To be diagnosed with SUD or AUD, an individual must meet at least 2 of 11 diagnostic criteria within the same 12-month period, as outlined by the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5).7

Although addiction is treatable, it is a chronic, relapsing disorder that benefits from professional treatment to address the behaviors that led to a person’s addiction.9 Relapse rates are similar to some other chronic medical illnesses (e.g., hypertension, diabetes) which necessitates the need for ongoing maintenance and long-term aftercare support following drug and/or alcohol addiction treatment.9

Anxiety Disorders and Addiction 

Many people with substance or alcohol use disorders and anxiety disorders experience them independently of each other; however, struggling with both can make things more complicated, as the symptoms of one can worsen those of the other.10 Together, they are among the most common psychiatric co-occurrences, or dual diagnoses, in the nation.11

Those with anxiety disorders may be 2 to 3 times more likely than the general population to have an SUD at some point in their lives.10,12 According to the Anxiety and Depression Association of America, about 20% of Americans with an anxiety or mood disorder have an SUD.10 Likewise, 20% of those with AUD or SUD also have an anxiety or mood disorder.10

Panic disorders (with and without agoraphobia) and GAD have the highest associations with substance use disorders. 11 Whereas, PTSD is associated with AUD and not drug use disorders according to one national study.11

This co-occurrence has been hypothesized to be influenced by three primary factors:11

  • Self-medication of anxiety disorder symptoms can increase the likelihood of SUD development.
  • Drug or alcohol use itself may be associated with a substance-induced anxiety disorder.
  • A shared variable such as a genetic predisposition to anxiety or anxiety sensitivity in those who develop both anxiety disorders and substance use disorders.

However, evidence from the National Epidemiologic Survey on Alcohol and Related Conditions study found that purely substance-induced anxiety disorders (as opposed to an independent anxiety disorder) only comprise 0.2% of comorbid cases in a population of people with the comborbidity.11

Current literature also shows that in at least 75% of cases, anxiety disorders develop prior to substance use disorders which suggests self-medication as a direct pathway versus alternative mechanisms.11

Research shows that when these two disorders co-occur, they are linked in both the development and maintenance of the comorbidity.11

Treating Anxiety Disorders and SUDs

Regardless of which comes first though, an integrated approach to treating both is beneficial in order to avoid the unmanaged condition eventually worsening the treatment outcome of the singularly targeted condition (whether it results in an exacerbation of mental health symptoms or increase substance use). Each condition may influence the course of the other and a simultaneous approach focuses on both disorders within the same sessions or interactions.

For individuals struggling with an SUD or AUD, medical detox is often the starting place on the road to recovery. Symptoms of withdrawal can be unpleasant and potentially dangerous when detoxing, especially in the instances of benzodiazepine or alcohol dependence.13,14

As symptoms of alcohol withdrawal progress in severity, individuals may begin to become disoriented and experience visual and/or auditory hallucinations, impaired attention, and/or seizures.14 Benzodiazepine withdrawal symptoms may include increased tension and anxiety, panic attacks, hand tremor, heart palpitations, or more serious issues such as seizures and psychotic reactions.13

Proper medical management can help ease any discomfort and/or address serious conditions that may occur and help you stay as safe and comfortable as possible while dealing with the symptoms of withdrawal.15

Following successful completion of detox, an inpatient or outpatient rehab program will allow for further work toward recovery and relapse prevention. Effective treatment strategies to manage co-occurring disorders may involve medical detox, medications to ease withdrawal symptoms, behavioral therapies, private and group counseling, and long-term aftercare planning (e.g., sober living arrangements, support groups/mutual help meetings).16

Anxiety disorders are typically treated with medication, psychotherapy, or a combination of the two.2 A variety of medications have also been found to be efficacious for treating both anxiety and alcohol use disorders such as selective serotonin reuptake inhibitors (SSRIs) when they occur concurrently.11

Behavioral therapies may include cognitive behavioral therapy, contingency management and dialectical behavioral therapy.17 Treatment may also include both substance abuse and mental health education to inform individuals on how they are related as well as teach healthy coping skills.9

How To Get Help

 If you feel you’re ready to seek professional help for a co-occurring anxiety disorder and substance use disorder, American Addiction Centers (AAC) can help. AAC is a nationwide provider of treatment facilities and is committed to making recovery accessible to everyone in need.

We offer a combination of proven therapies and services to meet your individual needs and are equipped to treat co-occurring disorders such as PTSD, depression, anxiety disorders, and others. Our team of treatment staff, ranging from nurses to doctors, psychiatrists, therapists, life skills coaches and residential counselors are knowledgeable in treating dual diagnosis conditions.

Your therapeutic team can tailor your recovery and mental health treatment plans in order to best address the comorbidity. Call our 24/7 hotline now to discuss your treatment options with one of our friendly admissions navigators. We’re here for you and ready to help you begin your path to recovery today.


1. Anxiety and Depression Association of America. (n.d.). Facts & Statistics.

2. National Institute of Mental Health. (2018). Anxiety Disorders.

3. 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 literatureDepression and anxiety35(9), 851–860. 

4. National Alliance on Mental Illness. (2019). Mental Health by the Numbers

5. Anxiety and Depression Association of America. (n.d.). Understand the Facts.

6. Anxiety and Depression Association of America. (n.d.). Generalized Anxiety Disorder (GAD).

7. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Publishing.

8. MedlinePlus. (2018). Substance Use Disorder.

9. National Institute on Drug Abuse. (2018). The Science of Drug Use and Addiction: The Basics.

10. Anxiety and Depression Association of America. (n.d.). Substance Use Disorders.

11. Smith, J. P., & Book, S. W. (2008). Anxiety and Substance Use Disorders: A ReviewThe Psychiatric times25(10), 19–23.

12. Institute of Alcohol Abuse and Alcoholism. (2006). Prevalence and Co-Occurrence of Substance Use Disorders and Independent Mood and Anxiety DisordersGeneral Psychiatry, 29(2), 107-120. 

13. U.S. National Library of Medicine. (1994). The benzodiazepine withdrawal syndrome. Addiction;89(11):1455-9.

14. UpToDate. (2020). Management of moderate and severe alcohol withdrawal syndromes.

15. Substance Abuse and Mental Health Services Administration. (2006). Detoxification and Substance Abuse. Treatment Improvement Protocol(TIP) Series, No. 45. HHS Publication No. (SMA) 15-4131.

16. National Institute on Drug Abuse. (2019). Treatment Approaches for Drug Addiction.  

17. National Institute on Drug Abuse. (2018). Comorbidity: Substance Use Disorders and Other Mental Illnesses

18. Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition.

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