Anxiety and Alcoholism – the missing piece of the puzzle:

Olivier Ameisen’s book “The End of my Addiction” showed me something I had never really considered before – the reason many alcoholics are so hard to treat is that their alcoholism is driven by anxiety.

Like many doctors, I assumed that anxiety was a RESULT of the alcoholism rather than the underlying cause. The classic wisdom was that depression and anxiety in alcoholics should firstly be dealt with by treating the alcoholism. When the patient stopped drinking, the psychiatric issues would resolve spontaneously.

I think it’s clear that alcoholism makes depression worse– alcohol is a depressant after the initial euphoria wears off. We are all familiar with the tears and melancholy which set in after too much alcohol. But alcohol has the opposite effect on anxiety. It HELPS anxiety – this why most people drink alcohol, alcoholic or not. It calms us down, helps us to relax and feel more at ease.

Reading Olivier Ameisen’s book “The End of my Addiction” was a revelation. I encourage you to read it too as it’s a rare and valuable insight into alcoholism through the eyes of a doctor who lived the problem.

Ameisen is able to clearly explain what alcoholism is and isn’t and why so many patients fail to get well with current treatments. He emphasised the role of his own severe anxiety in driving his alcoholism.

This made sense of something which had perplexed me over many years of ED practice –why did so many alcoholic patients relapse into heavy drinking so rapidly, often within days or even hours of leaving hospital, detox or even long term rehabilitation? These patients were no longer in withdrawal, were much healthier than on admission and left with a firm intention to stop drinking forever. The length of time they had been in hospital or rehab made little difference. They had seemed well, motivated and in control. When I asked patients why they had relapsed, it was some variation on “ I couldn’t help myself”.

In his book, Ameisen described how easy it was to stay sober and calm in hospital and rehab environments – he described rehabilitation as giving “respite” rather than rehabilitation. This resonated with what many patients had said to me over the years. It was easy to stay sober while in rehab but it didn’t help them to deal with the world outside. It wasn’t that anything terribly wrong happened when they got out of rehab, they just couldn’t seem to manage without alcohol in ordinary life.

The information gleaned from Ameisen’s book prompted me to ask alcoholic patients about WHY they drank alcohol, what it “did” for them. In their current situations, many alcoholic patients described drinking in response to cravings, to stave off withdrawal symptoms and to blot out pain and shame about the life they lived. They said that there was no pleasure in drinking, it was not a choice but a compulsion despite clearly understanding what harm the alcohol had done and was doing and the gloomy future which awaited them.

It was very revealing to ask about their life long relationship with alcohol: family history, alcohol in the home during their childhood, what their personality as a child was, when they first drank and how it made them feel, their pattern of drinking as they went through teen and young adult years and what role alcohol played in social and professional circles, what events affected their alcohol intake, what caused their drinking to get out of control and so on.

When I asked, what emerged was anxiety which these patients self treated with alcohol. It was either a primary anxiety disorder without an obvious cause but more often had arisen from traumatic events in childhood or later life that sapped the person’s confidence and resilience in the face of life’s difficult times. The anxiety might have arisen as the consequence of an abusive or unstable childhood, physical or sexual assault, military service or the death of critical people in a person’s life. For these people, life was not easy without something to dampen down their anxiety.

And alcohol is a wonderfully effective for anxiety. It’s also cheap, legal, very easily accessed, socially acceptable and rapidly effective for anxiety. None of the alternative anxiolytics like cannabis and benzodiazepines have all these advantages.

In fact we have pretty much all experienced the relaxing effects of alcohol– at the end of a stressful day’s work, at an awkward social gathering or before a public performance.

Now transpose that into the world of a chronically anxious patient and it’s easy to see how many fall into the trap of alcohol addiction trying to medicate their anxiety. Alcohol starts by helping to manage the anxiety. But if used too often, especially if daily, the patient needs to increase the amount of alcohol over time to get the same relaxing effect. As this happens, the addiction sets in. Any attempt to reduce or stop the alcohol now produces unpleasant withdrawal symptoms. These are the symptoms of anxiety – sweating, tremors, palpitations which alcohol will rapidly fix.

Many alcohol addicted people can keep partial control over alcohol, drinking only after work or only once the kids have gone to bed. But it doesn’t take much to cross the line to uncontrolled drinking. It could be the loss of a job, a relationship breakup or a death in the family. Life becomes more frightening and alcohol makes it more bearable.

When first assessing a patient, it can be hard to tell how much of their need to drink now is anxiety and how much is addiction. In reality it doesn’t really matter because both need to be addressed. This is one of the major advantages of baclofen – it treats both anxiety and cravings so is more likely to help this hard to treat group, the anxious alcoholic. Importantly the anxiolytic effect is felt at the lowest doses of baclofen, often well before the anticraving effect kicks in. This encourages the patient to stay on the baclofen while it is titrated up over a period of weeks, because they can feel a beneficial effect on their anxiety right from the start.

The other anti-craving medications currently used for alcohol addiction, naltrexone and acamprosate, don’t help anxiety. Diazepam is sometimes prescribed long term to anxious alcohol addicted patients on the basis that it’s preferable to replace the more harmful alcohol with less harmful benzodiazepine. However although benzodiazepines are effective for anxiety, they also have exactly the same problems as alcohol in terms of addiction risk and poor functioning.

Treating the anxious alcohol addicted patient can require baclofen alone but most benefit from additional treatments – these include SSRI or SNRI antidepressants or mirtazapine. Equally important are non-pharmacological treatments to help the patient deal with anxiety such as exercise, counselling, relaxation techniques, mindfulness techniques and re-framing techniques like CBT and DBT. The key is finding the right combination of treatments for each patient. Pharmacological and non-pharmacological treatments are not mutually exclusive at all – medication can support a patient through difficult times and until non-medication techniques can be learnt and established for coping with anxiety in daily life.