Anxiety and Substance Use Disorders SERIES IN ANXIETY AND RELATED DISORDERS Series Editor: Martin M. Antony, Department of Psychology, Ryerson University, Toronto, Ontario, Canada ACCEPTANCE AND MINDFULNESS-BASED APPROACHES TO ANXIETY Conceptualization and Treatment Edited by Susan M. Orsillo and Lizabeth Roemer CONCEPTS AND CONTROVERSIES IN OBSESSIVE-COMPULSIVE DISORDER Edited by Jonathan S. Abramowitz and Arthur C. Houts SOCIAL ANXIETY AND SOCIAL PHOBIA IN YOUTH Characteristics, Assessment, and Psychological Treatment Christopher A. Kearney TREATING HEALTH ANXIETY AND FEAR OF DEATH A Practitioner’s Guide Patricia Furer, John R. Walker, and Murray B. Stein TREATING TRICHOTILLOMANIA Cognitive-Behavioral Therapy for Hairpulling and Related Problems Martin E. Franklin and David F. Tolin ANXIETY AND SUBSTANCE USE DISORDERS The Vicious Cycle of Comorbidity Edited by Sherry H. Stewart and Patricia J. Conrod Sherry H. Stewart Patricia J. Conrod Editors Anxiety and Substance Use Disorders The Vicious Cycle of Comorbidity Editors Sherry H. Stewart Patricia J. Conrod Departments of Psychiatry Institute of Psychiatry and Psychology King’s College, London Dalhousie University London, SE5 8AF Halifax, NS B3H 4J1 UK Canada [email protected] [email protected] ISBN: 978-0-387-74289-2 e-ISBN: 978-0-387-74290-8 Library of Congress Control Number: 2007936619 © 2008 Springer Science+Business Media, LLC All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identifi ed as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper 9 8 7 6 5 4 3 2 1 springer.com For Laila and Ali Epigraph Whoseis...theanxiety?...Thosewholingerlateovertheirwine,thosewhoare alwaystryingsomenewspicedliquor. Proverbs23:29–30 . vii Preface TheideaforthisbookoriginatedwithaninvitationfromDr.MartinAntonyin thefallof2002tocontributeanauthoredoreditedbookonthetopicofanxiety disorder co-morbidity with substance use disorder, to his planned series of booksonanxietydisorders.Thisinvitationconvergednicelywithconversations that the two of us (S.H.S. and P.J.C.) had been having around that time of eventuallywritingabookondifferentpathwaystosubstanceusedisorder,one ofwhichourownworkindicatesinvolvesanxiety-relatedprocesses.Wedecided onaneditedbooksothateachchaptercouldbewrittenbyanexpertinthefield andsowecouldfeaturetheexcitingworkinthisfieldthatistakingplacearound the world. We were thrilled to be able to involve such an outstanding and international set of chapter authors in the process of putting together this volume.Wehavebothworkedrathertirelesslyincarefullyeditingthechapters authoredbyothers,andinwritingourownsectionsofthebook,overthemany months that have passed since first receiving the invitation from Dr. Antony andsigningthecontractwithSpringer.Wehavehadtheopportunitytowork onthesetaskstogetherandseparatelyinsuchdiverseandinspiringlocationsas ParisandChamonixinFrance,LondonintheUnitedKingdom,Vancouverin BritishColumbia,Canada,andHalifaxandEvangelineBeachinNovaScotia, Canada. Over the time that this project has developed, we have seen friends, clients, and patients with substance use and anxiety disorders both thrive under currently available treatments models, and fatally deteriorate. The co-morbidity of anxiety and substance use disorders remains a prevalent pro- blemthattraditionaltreatmentmodelsfailtoaddressadequately. The overall purposes of this edited book are to fully (1) review recent literature on anxiety disorder and substance use disorder co-morbidity, (2)presentbiologicandpsychosocialtheoriesthatexplaintheirco-occurrence, and(3)coverrecenttreatmentmodelsbasedonsuchtheoriesandtheliterature evaluatingtheiroutcomes. Forsometimenow,researchhasbeenaccumulatingontheprevalenceand nature of the co-occurrence between various forms of anxiety disorders and substance use problems. With increased understanding of the nature of these relationships,morerecently,newinterventionstargetingthisco-morbidityhave been developed and tested. One of the goals of this book is to disseminate . ix x Preface knowledge about the content and efficacy of these newly-developed approaches. Moreover, emerging findings on efficacy of these approaches to co-morbidity and the things we are learning from efficacy trials have led to a furtherunderstandingoftheinter-relationsandthestrategiesneededtoaddress them clinically. We felt that a critical analysis of this emerging literature is sorelyneededtomovethisfieldforward,makingthisvolumeverytimely. Ourintendedaudienceforthevolumeisquitebroad.Wehaveattemptedto makethetextrelevantforresearchers,clinicians,academics,andstudentsalike. Those who work in the area at the intersection of substance use and anxiety- relatedpsychopathologies,andthosedeliveringpsychosocialormedicalinter- ventions for substance use and/or anxiety disorders should find this volume mostappealing. Thetheoreticalbasisforthisbookintegratesthebiologicalandpsychosocial approachestounderstandinganxiety,substanceabuse,andtheirinteractions. Various theoretical models within this larger framework are reviewed in rele- vant chapters, including the tension reduction/self-medication/stress-response dampeningmodels,andmodelsinvolvingsubstance-inducedanxietyintensifi- cation. We explore the idea of reciprocal relations between anxiety and sub- stanceabusethroughoutthecourseofco-morbidityofthesetwodisorders,with special attention devoted to mechanisms explaining substance-induced anxio- lysis, as well as substance-induced anxiogenesis. This book is unique in its attempttoreviewtheoreticalandempiricalliteratureonthereciprocalrelations betweenanxietyandsubstancemisuseacrossavarietyofanxietydisorders.The bookalsoexplorestheconditionsunderwhichpathologicalanxietymotivates problematicsubstanceuse,misuse,andevensubstanceavoidance. The theoretical orientations of the treatments presented in this book are empirically-supported,andlargelycognitive-behavioral.Allarepresentedwith consideration of the potential reciprocal relations between anxiety and sub- stanceuseandthebiologicalandpsychosocialmechanismsthatmediatethese relations. Ourapproachincompilingandeditingthisbookhasbeentofocusonbasic research on the biologic, social, and cognitive factors mediating anxiety and addictive behaviors and their interaction. Treatment approaches reviewed in this book have at least some preliminary empirical support and have largely beenderivedfromtheknowledgegainedfrombasicscienceresearch.Wealso take the field a step forward by attempting to integrate different theoretical perspectivesonthenatureoftheco-morbidityintheconcludingsectionofthe book.Toourknowledge,thisbookisthefirsttoexamineco-morbidityacross different forms of anxiety/substance use disorder co-morbidity. This has allowed us to come to some tentative conclusions regarding commonalities and distinct processes within each pattern of co-morbidity and implications fortreatment. Thepresentvolumeisdividedintofourparts.PartIisintendedtoprovidean overviewoftheoreticalissuesregardinganxietyandsubstanceusedisordersin general. In Chapter 1, Kushner, Krueger, Frye, and Peterson provide an Preface xi overviewofepidemiologicalperspectivesonco-occurringanxietydisorderand substance use disorders. In Chapter 2, McNaughton provides a thorough review of the neurobiological aspects of anxiety with implications for under- standingco-morbidanxietyandsubstanceusedisorders. PartIIofthisvolumeisintendedtoprovideareviewofresearchfindingson thenature,etiology,andfunctionalrelationsbetweenanxietyandsubstanceuse disorders.Eachchapterreviewsevidencefortheoriesthatexplainco-morbidity and may include emphasis on both psychosocial and biologic theories. Each chapterfocusesonaspecificformofco-morbidity.InChapter3,Coffey,Read, and Norberg provide a review of the co-morbidity of post-traumatic stress disorder (PTSD) and substance use disorder with emphasis on neuroimaging, neuroendocrine,andpsychophysiologicfindingsonthenatureofthisformof co-morbidity.InChapter4,TranandSmithprovidetheoreticalinsightsonthe natureoftherelationshipbetweensocialphobiaandalcoholusedisorders;their chapter provides an up-to-date review of relevant psychopathology research findings.InChapter5,Norton,Norton,Cox,andBelikprovideareviewofthe research on the nature and etiology/maintenance of co-occurring panic spec- trumdisordersandvariousformsofsubstanceuse. PartIIIconsistsofasetofchaptersfocusingontreatmentmodelsandtheir effectiveness. Once again, each chapter is devoted to a specific form of co-morbidity. The emphasis of each chapter is on a review of empirically- validated treatments. Authors were asked to include case material whenever possible.Ineachcase,authorsprovidesignificantdetailabouttheintervention anditsimplementation.InChapter6,KlostermanandFals-Stewartreviewthe evidenceonthetreatmentofco-morbidobsessive-compulsivedisorder(OCD) and substance use disorders. In Chapter 7, Riggs and Foa provide a state-of- the-artreviewofwhatisknownabouteffectivetreatmentsforco-morbidPTSD andsubstanceusedisorders.Chapter8consistsofareviewbyRandall,Book, Carrigan, and Thomas of the research evidence on various approaches that havebeentestedforthetreatmentofco-occurringsocialphobiaandalcoholuse disorders. Toneatto and Rector focus on the treatment of co-morbid panic disorderandsubstanceusedisorderinChapter9;theyfirstreviewthetreatment outcome literature, and then detail a functional analysis type of approach to treatmentofthisformofco-morbiditythatmightusefullybeappliedtoother forms of co-morbid anxiety and substance use disorder. In Chapter 10, Zvolensky, Bernstein, Yartz, McLeish, and Feldner provide a review of the cognitive-behavioraltreatmenttheyhavedevelopedforpatientswithco-morbid panic disorder and tobacco dependence. Watt, Stewart, Conrod, and Schmidt provide a review of a novel approach to the treatment and prevention of co-morbidanxietyandsubstanceusedisorderinChapter11–i.e.,anintervention aimedatthelevelofpersonalityvulnerabilitytothesedisorders.Andinthefinal chapter of this section (Chapter 12), Marshall provides an overview of the medicalmanagementofco-morbidanxietyandsubstanceusedisorder. Finally,inPartIVofthecurrentvolume,Chapter13containsandintegra- tion of the material presented in the earlier sections, written by the volume