Anxiety is a very common emotion. It can arise when we suddenly remember something we should have done but forgotten to do, and it’s due now! It can also occur as part of a very primitive survival process when we identify a significant threat and, often, automatically set in process a ‘fight or flight’ response, or a third less recognised response, numbing or immobilisation. It is likely that without a healthy appropriate fear of situations that may injure us, we might have a very short life indeed. We develop perception of some risks at a very young age, which suggests some ‘hardwiring’ in our central nervous system. In other circumstances surges of adrenalin and arousal of senses may result in an enhanced response – watch many athletes as they ‘psych’ themselves up in preparation for their event. In any of these situations a level of anxiety is a normal response to our environment, is functional and could generally be described as healthy.

However, for many people, anxiety is not an occasional or functional event, but is the daily norm and serves little behavioural purpose. For these people anxiety is detrimental to their wellbeing, restricts their life, and has little relationship to an actual risk in their present environment. For many of these people, it may heighten the risk for addictive behaviour, or in some cases compulsive behaviour, that may offer them a brief respite from anxious thoughts and feelings that persist on a daily basis. For some, compulsive rituals may be displayed as a way to rid themselves of, or avoid, obsessive negative thoughts and may meet criteria of Obsessive Compulsive Disorder. For others, the connection between the reduction of anxiety and often harmful behaviour e.g. addictive behaviour, is not as obvious.

A group of conditions
Anxiety disorders are not representative of a single condition. They are a

‘complex grouping of specific mental disorders ranging from general anxiety disorder, panic attacks, obsessive-compulsive disorder to post-traumatic stress disorder’
(Shaffer & Korn 2002).

This complexity may be the reason that addiction treatment practitioners may not often focus upon the identification of anxiety amongst their clients, but may perceive it

Addiction and coexisting anxiety conditions
High levels of anxiety are common amongst those presenting with addictive behaviour. Many of those affected by addiction describe debilitating panic attacks, their constant fear of them, and describe rituals to avoid for example, contamination by germs (obsessive-compulsive behaviour), common phobias such as fear of embarrassment that have dogged their lives, and other daily worries over matters unlikely to occur. In a gambling addiction example, (although this can be typical of other addictions: Kessler et al, 1996) a later study by Zimmerman and colleagues (2006) identified that anxiety disorders were commonplace, far exceeding general community prevalence rates.

For many others, a traumatic event had occurred in their past which would often involve panic attacks in the present as images presented themselves, prompted by cues of the event. These symptoms may meet criteria for Post-Traumatic Stress Disorder, a persistent and debilitating disorder, which is often under-recognised.

Does the addiction cause the anxiety?
A recent study has concerningly identified that for those identified as meeting Pathological Gambling Disorder, a behavioural addiction, just over 60% also were affected by a co-existing anxiety disorder, and for over 82% of these, the anxiety disorder pre-dated the gambling addiction (Kessler et al 2008). In the majority of these cases, the addiction developed long after the anxiety condition, and the addictive behaviour may appear to provide a dysfunctional means of alleviating or escaping the anxiety. This addictive behaviour may provide an ‘instant gratification’ effect of reliable, but temporary, control of the negative thoughts/emotions that contrasts strongly with the uncertainty accompanying the anxiety based fear, and therefore provides a ‘self-medication’ for the condition.

It appears that although the consequences addictive behaviour may produce anxiety (e.g. lying to cover up, funding the addiction), in many cases the anxiety predates the addiction. It is not possible from this to say the anxiety causes the addiction, but the General Addiction Theory posits this possibility (Jacobs 1989). Jacobs believes that early life trauma, resulting in obsessive negative mental scenes/memories, is often addressed by learning to dissociate from stressful reality, in effect by switching off the obsessive scenes/memories. Addictive behaviours help this switching off to occur and, rather than addressing the trauma directly, prompt avoidance is reinforced as a functional process, but inadvertently is costly in the long term.

A brief process description
In line with the tenets of learning theory, a promptly rewarded behaviour is far more likely to be learned than one with delayed rewards. For addictions, the negative consequences happen at a later stage (hangovers, financial consequences, health problems) and we find it harder to learn from our mistakes the greater the distance that the negative consequences are from the behaviour. Where the escape is from a powerful, persistent negative condition, there appears little wonder that such people will be at greater risk for addiction, and once learned, the harder it is to change the addictive behaviour.

Recognising anxiety
It is now somewhat accepted that the best practice is to identify as comprehensively as is reasonably possible, what issues clients present with, and provide interventions that may not only include the presenting condition, but also interventions that may address coexisting traits or disorders. Many of these coexisting issues may be below the client’s awareness threshold, or may not seem appropriate to discuss with the counsellor, especially if they are embarrassing. As an example of co-existing problems, more than two-thirds of problem gamblers will present with a depressive disorder (or many of its traits). This is a common feature for those affected by alcohol or drug misuse, with typical estimates of between 50%-75% of those in substance abuse programmes having co-existing mental health disorders (SAMSHA).

While depression is often screened for, what is less recognised is that many will also be suffering from an anxiety condition. Indeed, some researchers in the field of gambling addiction state that the anxiety that problem gamblers present with is more representative of anxious depression (Shaffer & Korn 2002), while others will be more explicit and state that there is ‘insufficient data to support the theory that anxiety disorders are comorbid with pathological gambling’ (Crockford & el-Guebaly 1998).

However, research appears to be limited and insufficient to make such a comprehensive statement, particularly in the field of problem gambling. In a small New Zealand study (Sullivan 2003), 26% of clients responding to two anxiety screen questions answered at least one positively, while 17% responded positively to both questions and that they often found the fear of something stopped them enjoying life and often found themselves shaking or nauseous at the thought of something. Although the anxiety-depression association can be difficult to extract purely anxiety or depression traits from, both of these questions appear to be outside of the agitated depression spectrum.

Anecdotally, in the absence of reliable evidence, it appears that sufficient anxiety exists with clients seeking help for addictions to warrant brief interventions such as screening.

A brief screen may be the first step towards a more comprehensive assessment for anxiety (see attached).

Why address anxiety in an addiction treatment setting?
There appear to be a number of factors for and against this approach.

Reasons for addressing anxiety may be:

• Clients may be using the addictive behaviour to self-medicate their anxiety. If the addiction is addressed, and the behaviour ceases, the anxiety condition may reassert itself, with resulting high risk of relapse if the anxiety is not addressed.
• The anxiety may increase with the client’s knowledge that they can no longer self-medicate with the addiction.
• Anxiety may be the predominant condition, and addressing it may allow the client to experience improved wellbeing.
• A holistic approach in dealing with client needs may be best practice and this is becoming acknowledged (WHO 2004).
• Clients with addictions prefer a ‘one-stop shop’ to deal with their issues and do not refer well (Sullivan 2003).
• Greater counsellor satisfaction through applying skills that may improve client outcomes.

Reasons for not addressing anxiety may be:

• Anxiety may not be associated with the presenting addiction if it does exist.
• Anxiety may arise from the addiction and dissipate when the addiction is addressed.
• Although anxiety may affect a relatively significant proportion of clients presenting for help for addictions, resources are limited and best applied elsewhere.
• Few counsellors may feel competent to address the anxiety.
• Counsellors may feel that adding a further condition to address may over-extend an already excessive workload.
• Funding may not identify anxiety as a priority in addiction services.

Certainly, further research is required to competently assess these possibilities. One recent barrier to referral out of an addiction service is the relative paucity of specialist counselling services for dealing with anxiety, while many of the professionals with these skills may require payment, which could be a difficulty for many impoverished clients affected by addiction.

Dealing with anxiety
There are a number of approaches that may reduce the effects of anxiety.

• Medication is a common approach, with many targeting specific anxiety disorders. For example SSRIs like Prozac have been often prescribed for panic disorders, social phobia, obsessive-compulsive disorder, and where depression coexists. Tricyclic antidepressants have been prescribed for generalised anxiety disorder, while benzodiazepines are sparingly prescribed for a number of anxiety conditions, despite this being an important drug for anxiety in the past.
• Counselling alongside medication is common for high anxiety levels, or counselling alone, where levels are lower. Behavioural and CBT counselling approaches are most common.
• Relaxation therapy is a common approach that can be taught as a self-help skill alongside the counselling.
• Acupuncture, hypnotherapy, diet managem ent and alternative medications (rescue remedy, vitamin B, lavender, chamomile) are often used.

Conclusion
Anxiety may be a common condition for many clients although they may not disclose these emotions and associated behaviours unless specifically screened for. There may be little thought by clients as to the addiction and anxiety being connected, or there may be shame that will prevent the client from discussing their behaviour. In many cases, the client will know that the fear is unreasonable, but this knowledge doesn’t affect their level of stress. Many addiction counsellors will already have skills and an understanding of stress reduction strategies that can successfully be applied to identified anxiety disorders and traits. Many clients may not be aware of available help that can reduce daily anxiety which is substantially affecting their wellbeing. Up-skilling of counsellors to deal with anxiety, alongside other common conditions such as depression, may be a future trend that has been signalled as appropriate by health authorities. This trend may benefit clients that seek out from health professionals, solutions for problems that they can no longer tolerate. As recipients of that trust, addiction practitioners may be obliged to provide clients with the best help they can as professionals, based upon knowledge and skills that result from ongoing research, practice and client outcomes.

References

Crockford D & el-Guebaly N (1998) Psychiatric comorbidity in pathological gambling: a critical review. Can. J Psychiatry 43:43-50.

APA. Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. Washington DC: American Psychiatric Association, 1994.

Jacobs DF. A general theory of addictions: Rationale for and evidence supporting a new approach for understanding and treating addictive behaviors. In HJ Shaffer, SA Stein, B Gambino & TN Cummings (eds.), Compulsive Gambling: Theory, Research and Practice (pp.35-64). Lexington, MS: Lexington Books, 1989.

Kessler R, Nelson C et al (1996) The epidemiology of co-occuring addictive and mental disorders. American J Orthopsychiatry, 66, 17-31.

Kessler R, Hwang I, LaBrie R, Petukhova M, Sampson N, Winters K, et al (in press) DSM-IV pathological gambling in the National Comorbidity Survey Replication. Psychological Medicine (preprint available).

SAMHSA. Substance abuse treatment for persons with co-occurring disorders. TIP 42. www.samhsa.gov

Shaffer H & Korn D (2002) Gambling and related mental health disorders: a public health analysis. Annu. Rev. Public Health 23:171-212.

Sullivan S. Non-improving client project. Paper presented at the Gambling Symposium held at Auckland by the PGPA, 19-21 June 2003.

WHO (2004) Neuroscience of psychoactive substance use and dependence. Geneva: Author Zimmerman M, Chelminski I & Young D (2006) Prevalence of diagnostic correlates of DSM-IV pathological gambling in psychiatric outpatients. Journal of Gambling Studies, 22, 255-262.