How to Treat Phobias with Concurrent Substance Abuse

Steps should follow to treat dual diagnosisBoth substance use disorders and anxiety disorders, including all kinds of phobias, are the most frequently diagnosed mental health conditions in the US. The presence of one disorder puts a person at risk of developing the other disorder; when this occurs, it is known as co-occurring disorders, originally called a dual diagnosis.

Although specific phobias, such as acrophobia or dentophobia, can be related to substance abuse disorders, the two categories of complex phobias are more likely to be correlated with addiction or substance abuse. These phobias are social anxiety disorder or social phobia, and agoraphobia. People who have an anxiety disorder, such as a phobia, are twice as likely to suffer from drug abuse; and, similarly, people who struggle with drug abuse are about twice as likely to also have an anxiety or mood disorder.

The Steps to Treating Phobias

When a person struggles with a phobia and an addiction to drugs or alcohol concurrently, they may be self-medicating the symptoms of anxiety with an intoxicating substance, or they could have developed the anxiety disorder because of brain chemistry or brain structure changes caused by the addiction.

Phobias That Lead to Addiction

People who struggle with an anxiety disorder, especially complex phobias, may begin to self-medicate to ease their symptoms. For example, people who struggle with social anxiety disorder may develop an addiction to alcohol because alcohol is widely available in adult social situations. This legal intoxicant is a central nervous system (CNS) depressant, meaning it slows down neuronal signaling and firing, which can ease stress and increase sociability.

For people struggling with social phobia, this relaxation may begin to feel necessary in order to enter any social situation and can become problematic in other areas of daily life. Social phobia combined with alcohol abuse is one of the more common combinations of anxiety and substance abuse; about 24 percent of people who struggle with social phobia also struggle with alcohol abuse or addiction, according to one overview study.

When phobias co-occur with substance abuse issues, specialized treatment is necessary. The steps to effectively treat phobias that led to substance abuse are outlined below.

Step 1: Recognize the signs of a substance abuse problem.

For people who believe they may struggle with a substance abuse problem that is comorbid with an existing or potential anxiety or phobia disorder, it is important to know the symptoms of substance abuse in order to get help. Anyone can struggle with an addiction to prescription or illicit drugs, and it is more likely to occur in people who struggle with anxiety disorders or phobias.

According to Mayo Clinic, symptoms of substance abuse include:

  • Intense cravings for the substance between doses
  • Feeling as though the drug helps to stabilize mood or reach normalcy
  • Feeling like the drug must be taken regularly
  • Carefully maintaining a supply of the drug, or becoming worried when unable to maintain a supply of the drug
  • Failing to meet obligations, like work or school, in order to take the drug
  • Unable to stop taking the drug
  • Focusing a lot of time and energy to getting the drug, or doing things like stealing or lying to get the drug
  • Lying about use of the drug or lashing out at those who question use of the drug
  • Experiencing withdrawal symptoms when unable to take the drug

People who feel like an intoxicating substance, whether prescription or illicit, is needed to feel normal, may struggle with a mental health issue like a phobia and may have developed a substance abuse problem in order to cope with the symptoms of the mental health disorder. Regardless of how or why the substance abuse problem developed, it is important to get help to overcome this issue. If the underlying cause of the substance abuse problem is social anxiety disorder, agoraphobia, or a specific phobia, then it is important that treatment also address that condition.

Step 2: Diagnose phobia as a co-occurring mental health issue.

As the link between mental health and substance abuse is becoming clearer, more rehabilitation programs are offering therapies to help those who have co-occurring disorders. A psychologist or psychiatrist in a rehabilitation program should be able to diagnose social anxiety disorder, agoraphobia, or a specific phobia if a pre-existing diagnosis has not been established.

Mayo Clinic outlines symptoms of phobias:

  • Specific phobias: These are characterized by an irrational, overwhelming, and persistent fear of a specific thing, out of proportion to the danger posed by it. Specific fears include fear of animals or insects (e.g., spiders, snakes, or dogs), fear of specific natural phenomena (e.g., thunderstorms or tornadoes), fear of spaces (e.g., heights or elevators), fear of medical procedures (e.g., blood draws, injections, or dental cleanings), or other phobias (e.g., the police or clowns). For many people, these do not often get in the way of daily life, although the fear of an upcoming experience involving the object of the phobia, like a birthday party, could trigger a high level of anxiety or a panic attack.
  • Social phobia: As of publication of the DSM-5, this is referred to as social anxiety disorder, which broadens the criteria for diagnosis. It is a general fear of being around other people, typically due to feeling judged or disliked. This complex phobia can rapidly get in the way of holding a job, attending school, making friends, or maintaining intimate relationships. The stress of this phobia is highly correlated with substance abuse.
  • Agoraphobia: The fear of open spaces in this complex phobia may lead a person to become a “shut-in,” refusing to leave their house, or it could be tied to the fear of being outside or alone in a space. This complex phobia, too, greatly limits a person’s ability to enjoy life, and the stress can lead to substance abuse problems.

To be diagnosed with a phobia by a medical professional, the person must have experienced a persistence of their fear for at least six months. A physician may conduct a medical examination to determine whether or not other underlying conditions, such as a thyroid problem, could be the cause of the issue, or to determine if the substance abuse problem has changed the brain enough to induce the anxiety or phobia. A therapist will offer a ranking scale and a questionnaire to determine severity of symptoms, as well as how long they have occurred. This, along with understanding the person’s substance abuse problem, will help guide course of treatment.

Step 3: Undergo detox.

Getting a person’s body to end its dependence on a substance is an important part of stabilizing them before they go into the intense work of overcoming their addiction and managing their phobia. It is important to work with a rehabilitation program to get medical oversight to safely detox. Most withdrawal symptoms are not harmful, but they can be uncomfortable, and without help, this can lead to relapse. Medial detox is always required for certain substances of abuse, such as withdrawal from alcohol, benzodiazepines, and opioids.

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Step 4: Enroll in rehab.

A full rehabilitation program, either inpatient or outpatient, officially begins once detox has been completed. Rehabilitation offers customized therapy and support groups to help clients achieve stabilization in recovery.

Step 5: Take medications and participate in therapy, as advised.

People who struggle with social phobia may be very resistant to the idea of attending group therapy sessions and may even be resistant to meeting face to face with one therapist. For some people, the first intake appointment can be conducted over the phone or even online, but it is important for therapists to insist that the individual appear in person for appointments, as this exposure can reduce some of the social anxiety symptoms. If a person struggles with agoraphobia, they may have difficulty leaving their home and entering a new environment. Again, the same encouragement should apply to those working to overcome social anxiety disorder; it forces the person to confront their anxiety with proper support.

Complex phobias may require pharmaceutical help in conjunction with therapy. Monoamine oxidase inhibitors (MAOIs) are a class of antidepressant medications that appear to work well to treat anxiety disorders, although people who are prescribed these medications must restrict their diets and be careful with other prescription medications. Benzodiazepines can be a good temporary solution to ease extreme anxiety and panic attacks, although they can lead to addiction in people who already struggle with abuse of CNS depressants. Ultimately, the decision whether to use prescription psychiatric medications is a personal one made between the patient and their doctor.

When a person suffers from a specific phobia, like arachnophobia, they are less likely to resist leaving their home and encountering other people unless they believe the new environment will trigger their specific phobia. For people suffering specific phobias, exposure therapy appears to work very well. Desensitizing these individuals to the stimuli that trigger them helps reduce, and eventually eliminate, symptoms.

However, exposure to traumatic events, such as a plane crash that leads to a specific fear of flying, can lead the person to also struggle with substance abuse. It is important to determine whether the trauma has led to a specific phobia or if the trauma is more associated with post-traumatic stress disorder (PTSD). This can change the approach psychotherapists use to help their clients.

A style of therapy called Assertive Community Treatment (ACT) has been shown to help co-occurring disorders. Relaxation training and techniques have also been shown to ease anxiety and allow the individual to focus on overcoming their phobia. Relaxation and mindfulness are more frequently being applied to addiction recovery too.

Phobias Due to Addiction

For many anxiety and phobia disorders, substance abuse is an attempt to self-medicate symptoms and feel normal or happy. However, in some cases, a phobia can be induced due to brain changes caused by long-term substance abuse. Drugs like cocaine, methamphetamines, MDMA, inhalants, marijuana, and alcohol can all damage structures in the brain if they are chronically abused for a long period of time or in excessively large doses. This is called an acquired brain injury.

The steps to address phobias that develop due to substance abuse or addiction are outlined below.

Step 1: Undergo a physical exam to determine extent of brain damage.

In order to diagnose the brain changes or injury, a physician may conduct a few types of scans. These can include:

  • Cranial CT scan: This scan uses x-rays to create an image of the head, including brain, skull, eye sockets, and sinuses.
  • Head MRI scan: A combination of magnets and radio waves creates a full image of all the tissues in the head and, sometimes, how active they are.
  • Positron emission tomography (PET) scan: A dye with radioactive tracers is injected into a vein and allowed to spread throughout the body. This highlights damaged areas, including in the head and brain.
  • Electroencephalogram (EEG): This measures electrical activity in the brain compared to normal levels in healthy brains.

The physician may also run blood tests to determine if abnormal hormone levels could cause chemical changes in the brain. That would indicate a gland, such as the thyroid or pituitary, had suffered damage.

Step 2: Detox safely.

People who have struggled with substance abuse and addiction so long that they have changed the structure of their brain will need extra medical attention and, often, a longer-term taper to ease their bodies off dependence on these substances. Medical supervision during this time is extremely important, and replacement medications, such as buprenorphine or diazepam, may be used to ease withdrawal symptoms. If the phobia is directly caused by the substance of abuse, mental health should begin to improve as the body detoxes from the drug. However, some changes to the brain may be permanent, and those changes could permanently change personality or behavior.

Step 3: Continue engaging in therapy and taking medications.

A person overcoming a long-term substance use disorder, which has changed their brain chemistry and induced an anxiety disorder, is likely to benefit from maintenance medications. For example, a person who struggles with long-term heroin addiction will benefit from a buprenorphine maintenance therapy, which can ease withdrawal symptoms. The medication can slowly be tapered down to help the body slowly adjust to the change. This tapered approach can also ease psychological symptoms, including cravings and anxiety, which may otherwise trigger severe phobic reactions.

Benzodiazepines can be used as maintenance medications for people who are overcoming alcohol use disorder. If a person struggles with addiction to alcohol for a long time, their body may experience delirium tremens if they attempt to withdraw without medical help. This condition can lead to panic attacks, intense anxiety, and seizures, among other dangerous physical symptoms. Using benzodiazepines reduces the risk of these harmful side effects, while allowing the person to stop using alcohol. Benzodiazepines should be tapered off in a safe way and should never be stopped suddenly.

The individual may also undergo physical, occupational, or speech therapy. While these treatments are more often used for people who have a severe traumatic brain injury that damages the motor or speech centers in their brain, people who abuse substances like synthetic marijuana may damage these areas of their brains as well.

Step 4: Transition to sober life.

Regardless of whether substance abuse or the phobia came first, a successful treatment plan including detox, rehabilitation, counseling, support groups, and prescription medication (as needed), can help a person overcome both of these conditions and lead a healthy, sober life. Many rehabilitation programs are prepared to help people struggling with co-occurring disorders, including addiction and phobic disorders. With comprehensive care, both phobias and substance use disorders can be effectively managed on a long-term basis so individuals can lead healthy, balanced lives in recovery.

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