Anxiety and addiction: How the cycle works and how to break it

Anxiety and addiction are closely linked. People with an anxiety disorder are around twice as likely as others to also have a problem with alcohol or drugs.

Many people first drink or use drugs to take the edge off anxiety. Alcohol and sedatives bring fast relief, but over time they make anxiety worse, which drives more use. Treating both conditions together gives people the best chance of breaking that cycle.

This article explains how common the combination is and how the cycle works. The article also covers:

• Which types of anxiety and which substances are most often involved
• Why prescription sedatives need particular care
• What treatment involves
• How families can help

How common are anxiety and addiction together?

Anxiety disorders are the most widespread mental health conditions in South Africa. The South African Stress and Health study was the country’s first large, nationally representative survey of mental disorders. The study found that almost one in three South African adults (30.3%) will experience a mental disorder in their lifetime. Anxiety disorders were the most common type.

Anxiety and substance use disorders frequently occur together. A meta-analysis of population surveys from around the world compared people with and without substance use disorders. People with a drug use disorder were almost three times as likely to have an anxiety disorder. For people with an alcohol use disorder, the figure was about twice as likely.

How the anxiety and addiction cycle works

The link between anxiety and substance use runs in both directions, and each condition can start or sustain the other. A review of research on anxiety and alcohol describes how the cycle typically develops:

• Alcohol or another substance brings short-term relief from anxiety
• Regular use, and withdrawal between episodes of use, increase anxiety over the longer term
• Higher anxiety creates a stronger urge to use again

Over time, the person needs the substance just to feel calm. Anxiety between uses also becomes harder to tell apart from withdrawal. The same review found that anxiety can contribute to relapse after a period of sobriety.

Self-medication raises the risk

Using alcohol or drugs to cope with anxiety raises the risk of addiction. A three-year study of more than 34,000 American adults followed people with anxiety disorders. Those who self-medicated with alcohol or drugs were 2.5 to 5 times more likely to develop a new substance use disorder.

The same study found a pattern in the other direction too. People with substance use disorders who used substances to manage their symptoms were more likely to develop social anxiety later.

Withdrawal can look like anxiety

Withdrawal from alcohol or benzodiazepines can cause restlessness, a racing heart, sweating, and panic-like feelings. People often read those symptoms as their anxiety returning and reach for the substance to relieve them. The substance itself may be causing the symptoms. Our article on alcohol detox describes alcohol withdrawal in more detail.

Types of anxiety linked to addiction

Anxiety takes several forms, and each can draw people towards substances for different reasons:

• Generalised anxiety disorder: Persistent, hard-to-control worry about many areas of life. People may drink in the evenings to switch off.
• Social anxiety disorder: Intense fear of being judged by others. Alcohol often becomes a way to get through social events.
• Panic disorder: Sudden, intense episodes of fear with physical symptoms. People may use sedatives to prevent or stop attacks.
• Post-traumatic stress disorder (PTSD): Anxiety, flashbacks, and hypervigilance after trauma. Our article on PTSD and addiction covers this combination in detail. 

Whatever the type of anxiety, an assessment that covers both conditions helps shape the right treatment.

Which substances are most often involved?

Alcohol is often the first substance people turn to for anxiety, since it’s legal and acts fast. Cannabis is also widely used for its calming effect.

Prescription sedatives are a particular concern. Benzodiazepines relieve anxiety quickly and are sometimes prescribed for it. Common examples include alprazolam (Xanax) and diazepam (Valium).

A review of benzodiazepine use in the journal *Addiction* weighed their benefits against their risks. The review concluded that benefits generally outweigh risks for short-term use of two to four weeks. Beyond that, the balance is unclear, largely because short courses so easily turn into long-term use and dependence.

Benzodiazepine dependence can develop even at prescribed doses, and stopping suddenly can be dangerous. Anyone taking benzodiazepines regularly should reduce them only under medical supervision. Our article on prescription medication addiction explains the risks in more detail.

Treatment for anxiety and addiction

Effective treatment addresses anxiety and addiction together. Treating the addiction alone leaves the original anxiety in place. Treating anxiety while substance use continues means the substance keeps feeding it.

Safe detox

Treatment begins with stopping substance use safely. Withdrawal from alcohol and benzodiazepines carries a risk of seizures, and medical supervision makes the process safer and more comfortable. At Houghton House, patients spend their first three days in our medical detox unit. They see a doctor daily and receive round-the-clock nursing care. Once withdrawal has passed, clinicians also have a clearer view of the underlying anxiety.

Psychiatric assessment

Houghton House is licensed as both a rehabilitation centre and a private psychiatric hospital. An in-house psychiatrist assesses every patient on admission. Where appropriate, the psychiatrist can prescribe medication for anxiety, taking the person’s addiction history into account.

Therapy for anxiety and addiction

Therapy teaches people to manage anxiety without substances. Our rehab programme runs for 30 days, extendable to 42 when clinically necessary. The programme includes:

• Cognitive behavioural therapy (CBT), which helps people challenge the anxious thoughts that trigger the urge to use
• Dialectical behaviour therapy (DBT), which builds skills for tolerating distress and managing strong emotions
• Mindfulness, which helps people notice anxiety without reacting to it automatically
• Individual and group counselling, along with 12-step facilitation

Biokinetics is also part of the programme, giving people a physical outlet for stress.

Aftercare

Anxiety can resurface after discharge, when the pressures of work and family return. Our aftercare programme continues therapy and peer support during that transition. Patients keep practising the skills they learned in treatment.

How families can help

If someone you love drinks or uses drugs to cope with anxiety, it can be hard to know where to start. A few approaches help:

• Talk about the anxiety as well as the substance use, since the person may find the first easier to discuss
• Avoid making social plans that revolve around alcohol
• Encourage an assessment that covers both conditions
• Look after your own wellbeing, since living with someone else’s addiction is stressful in its own right

Our family support programme runs weekly meetings for anyone affected by a loved one’s addiction, whether or not that person is in treatment.

Medical aid cover for anxiety and addiction treatment

Substance use disorders are prescribed minimum benefits (PMBs) in South Africa. All registered medical aids must therefore cover addiction treatment. Houghton House is also a licensed psychiatric hospital. Patients can claim for additional mental health services where a co-occurring condition qualifies under psychiatric PMBs.

Our admissions team checks your benefits and handles pre-authorisation for you. Visit our medical aid cover page, or contact our admissions team to find out what your scheme covers.

Frequently asked questions about anxiety and addiction

Can alcohol make anxiety worse?

Yes. Alcohol can relieve anxiety in the short term. Over time, though, regular drinking and the withdrawal between sessions make anxiety worse.

Is it safe to stop taking benzodiazepines on my own?

No. Stopping benzodiazepines suddenly after regular use can cause severe withdrawal, including seizures. Speak to a doctor about reducing the dose gradually, or about a medically supervised detox.

Should anxiety or addiction be treated first?

Both conditions are best treated together. Detox usually comes first, both for safety and because withdrawal can make anxiety look worse than it is. Anxiety treatment then runs alongside addiction treatment, rather than waiting until afterwards.

Where can I get help for anxiety and addiction in South Africa?

Houghton House in Johannesburg treats addiction alongside co-occurring mental health conditions, including anxiety disorders. Call our admissions team on +27 11 787 9142 for a free, no-obligation telephonic evaluation, or contact us online.

Sources

• Herman, A. A., Stein, D. J., Seedat, S., Heeringa, S. G., Moomal, H., & Williams, D. R. (2009). The South African Stress and Health (SASH) study: 12-month and lifetime prevalence of common mental disorders. South African Medical Journal, 99(5 Pt 2), 339–344. https://pubmed.ncbi.nlm.nih.gov/19588796/ 
• Kushner, M. G., Abrams, K., & Borchardt, C. (2000). The relationship between anxiety disorders and alcohol use disorders: A review of major perspectives and findings. Clinical Psychology Review, 20(2), 149–171. https://doi.org/10.1016/s0272-7358(99)00027-6 
• Lader, M. (2011). Benzodiazepines revisited: Will we ever learn? Addiction, 106(12), 2086–2109. https://doi.org/10.1111/j.1360-0443.2011.03563.x 
• Lai, H. M. X., Cleary, M., Sitharthan, T., & Hunt, G. E. (2015). Prevalence of comorbid substance use, anxiety and mood disorders in epidemiological surveys, 1990–2014: A systematic review and meta-analysis. Drug and Alcohol Dependence, 154, 1–13. https://doi.org/10.1016/j.drugalcdep.2015.05.031 
• Robinson, J., Sareen, J., Cox, B. J., & Bolton, J. M. (2011). Role of self-medication in the development of comorbid anxiety and substance use disorders: A longitudinal investigation. Archives of General Psychiatry, 68(8), 800–807. https://doi.org/10.1001/archgenpsychiatry.2011.75