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The Clinical Issue of Comorbidity
The causes of comorbidity of panic disorder and addiction causes panic
Addiction to alcohol and other drugs produces disturbances in brain functioning during both intoxication and withdrawal, which can trigger panic attacks in people who are vulnerable to panic disorder. Marijuana, cocaine, and LSD, as well as other drugs, can produce panic attacks during intoxication, either initiating panic disorder in a person who had no prior history of panic disorder or precipitating panic in a person who had a prior history of panic attacks. Withdrawal from any substance that produces physical dependence can also precipitate panic attacks as part of the acute and profound disturbance of brain functioning caused by withdrawal. (See Table 2 for the definition of a panic attack.)
During the history-taking process of panic disorder patients, it is useful to ask about the initiating experiences, both of the original attacks and of the most recent episodes of panic, to identify possible connections to nonmedical substance use, as, for example, "Did you use or suddenly stop using marijuana, cocaine, LSD, methampheta-mines, or other drugs prior to the onset of your panic attacks?" While most panic disorder patients give a resounding "no" in answer to this question, a minority will say "yes," giving their physicians an opening to discuss substance abuse and its treatment.
Similarly, addicted patients can be asked, "Do you ever have panic attacks?" If the patient says "yes," the physician has a good opportunity to explore the connection of panic to alcohol and drug use, looking especially for prolonged periods of sobriety to see if the panic attacks occurred then, or only during use or withdrawal from addicting substances.
Panic causes addiction
It is not uncommon to find patients with panic disorder, especially socially phobic patients, who have discovered that their panic is lessened acutely by using alcohol. In some patients, this discovery leads to repeated use of alcohol to calm the panic-sensitized nervous system, including inappropriate and excessive doses of alcohol. Most patients with panic disorder have tried alcohol in their lives and have not found it to be helpful. In fact, they are frightened of the out-of-control feelings they have when they drink. However, the connection of drinking and panic disorder has led some clinicians to observe that patients are "self-medicating" with alcohol and that this is a major road to addiction to alcohol (and perhaps to other nonmedical drugs as well).
The "self-medication hypothesis" is the result of this clinical observation. Although intellectually attractive, it is seldom a reasonable hypothesis, in my experience. When clinically anxious patients who are not addicted to alcohol or other drugs experience panic, they are not likely to try alcohol as a treatment because they fear the alcohol's effects. If they do try it, they are likely to find the beneficial effects to be both short-lived and unreliable. Most telling of all however, is the observation, unfortunately frequently repeated, that sound treatment of panic disorder does not lessen the alcohol abuse in alcoholic patients (or the drug abuse of drug-addicted patients).
A simple way to understand this connection of panic and alcohol, which is not only commonly misunderstood but which often leads to serious errors in treatment, is that panic leads sufferers to seek ways of reducing the terrible discomfort that panic produces. They may try alcohol, and in fact they are often encouraged by others to do so, to quiet their unruly nervous systems. When they do try alcohol, those people who are not predisposed to alcoholism (the large majority of panic disorder patients/find it unsatisfactory and move away from it, while those people who are genetically predisposed to alcoholism find the alcohol not only helpful with their panic, but also attractive in its own right. They dive into the bottle the way newly hatched ducks get into the water. While panic may be a reason for trying alcohol, it is seldom, if ever, a reason for addiction to alcohol (DuPont & Gold, 1995).
The connection between panic and addiction is most often seen in the context of addiction treatment where the self-medication hypothesis is proffered as a reason for addiction to alcohol and other drugs, an excuse or extenuating explanation for addiction. If that is all it is, it seems harmless. On the other hand, this hypothesis has a darker side: It implies that if the comorbid patient gets good care for the panic disorder, the alcoholism will simply disappear, since it is a derivative or secondary disorder. In my experience, this is unlikely to happen. Moreover, the pursuit of this seductive hypothesis is likely to delay entry into addiction treatment, which is precisely what these addicted patients most need. See Vaillant (1995) for a comprehensive discussion of anxiety and alcohol.
Addiction and panic are unrelated
Both panic disorder and addiction are prevalent in the general population, and thus, even if they were not causally related to each other, they would be expected to be comorbid with considerable regularity. While panic disorder may be triggered by addiction, and addiction may be triggered by panic disorder, it is usually wisest to consider them to be separate disorders, each of which requires thoughtful diagnosis and effective treatment.
What are the implications for treatment of comorbidity of panic disorder and addiction?
The first order of business for any clinician is to make the diagnosis. Given the high prevalence of panic disorder and addiction, as well as the importance of identifying comorbidity, it is important to make both diagnoses and not to let one stand as the only diagnosis when both exist in particular patients (DuPont, 1992). In the first instance, this means that clinicians should have a high index of suspicion about these disorders and, when one disorder is found, they should look for the other (just as clinicians need to look for comorbid depression when they make a diagnosis of either panic disorder or addiction) (Galanter &: Kleber, 1994).
Two good ideas
1. Identify both disorders--panic disorder and addiction--when they are comorbid, and consider the full range of treatments for both diseases. It is seldom either helpful or accurate to consider either panic disorder or addiction to be secondary conditions (if the panic persists more than a few weeks once the patient is drug and alcohol free). Usually, comorbid patients are best treated as if both disorders were primary diseases. Optimization of the treatment of both panic disorder and addiction is the appropriate clinical goal. With the single exception of the use of a benzodiazepine in the treatment of active (using) addicts, no alteration is needed in the treatment of comorbid patients. Panic disorder patients should be treated the same whether they are addicted to drugs and alcohol or not (except that if they are addicted, they also need treatment for their addiction). Similarly, addicted patients should be treated the same whether they are comorbid for panic disorder or not. The clinician's goal is to identify both disorders and to provide fully effective treatments for both conditions (see Tables 4 and 5).
2. Prioritize addiction treatment, if one treatment must be prioritized over the other, since it is more likely that recovery will stop the panic than it is that panic disorder treatment will stop the addiction. There is one other reason to prioritize addiction treatment: Addiction is a progressive and potentially fatal disease. Leaving addiction untreated, even briefly, is hazardous to the patient's life.
Panic disorder is one of the most painful and distressing illnesses from which a patient can suffer. It is serious, biologically based, and apt to be lifelong and to run in families. Panic disorder is highly treatable. It is important for clinicians to take panic disorder seriously, to recognize the biological basis of the disorder, and to provide effective treatment (Marks, 1981). The benzodiazepines are often underutilized due to inappropriate fear of addiction.
Addiction is a life-threatening, lifelong disease that also often runs in families. Addiction is highly treatable, mostly by addiction treatment that introduces patients to 12-step fellowships and that encourages lifelong attendance at 12-step meetings.
-DuPont, Robert; Panic disorder and addiction: the clinical issues of comorbidity; Bulletin of the Menninger Clinic; 1997; Vol. 61 Issue 2.
The article above contains foundational information. Articles below contain optional updates.
Reflection Exercise #8
The preceding section contained information
about the comorbidity of addiction and panic disorder. Write
three case study examples regarding how you might use the content of this section
in your practice.
What hypothesis, identified by DuPont, is proffered as a reason for addiction to alcohol and other drugs in clients experiencing panic attack? Record the letter of the correct answer
for this course