What is the treatment for anxiety in alcoholism?

Treatment of Anxiety in Alcoholism

Benzodiazepines are the first-line treatment for anxiety in alcoholism, particularly during alcohol withdrawal, while SSRIs are recommended for persistent anxiety after detoxification. 1, 2

Understanding the Relationship Between Anxiety and Alcoholism

Anxiety and alcoholism frequently co-occur, with anxiety symptoms being prevalent in individuals seeking treatment for alcohol use disorder. This relationship is complex and bidirectional:

• Anxiety can precede and contribute to alcohol use (self-medication)
• Alcohol withdrawal commonly produces anxiety symptoms
• Chronic alcohol use can induce anxiety disorders
• Both conditions may share underlying genetic or neurobiological factors 3

Treatment Algorithm

Step 1: Determine if Anxiety is Related to Alcohol Withdrawal

• Assessment tools:

  • CIWA-Ar scale to evaluate withdrawal severity (mild <8, moderate 8-14, severe ≥15) 2
  • AUDIT questionnaire to assess alcohol use severity 1
  • Confusion Assessment Method (CAM) to assess for delirium 2

• Timing of symptoms:

  • Withdrawal anxiety typically begins 6-24 hours after last drink
  • Peaks at 24-72 hours
  • May persist for weeks in some cases 2, 4

Step 2: Treat Alcohol Withdrawal Syndrome (if present)

• First-line treatment: Benzodiazepines 1, 2

  • Preferred options:

    • Diazepam (5-10 mg PO/IV every 6-8 hours) - preferred for rapid symptom control and smoother withdrawal
    • Chlordiazepoxide (25-100 mg PO every 4-6 hours)
    • Lorazepam (1-4 mg PO/IV/IM every 4-8 hours) - preferred in patients with liver dysfunction

  • Administration approach:

    • Symptom-triggered dosing based on CIWA-Ar scores
    • Initial dose of 6-12 mg/day, tapered following symptom resolution

• Supportive care:

  • Thiamine supplementation (100-300 mg/day)
  • IV fluids to correct dehydration
  • Electrolyte replacement (especially potassium, magnesium, phosphate) 2

Step 3: Treat Persistent Anxiety After Withdrawal

• First-line pharmacotherapy: SSRIs 1

  • Effective for social anxiety disorder and other anxiety disorders
  • Safe in patients with alcohol use disorder
  • No abuse potential

• Alternative pharmacotherapy options:

  • Escitalopram has shown efficacy in combination therapy 1
  • Venlafaxine (SNRI) may be considered 1

• Avoid:

  • Long-term benzodiazepine use due to addiction potential
  • Antipsychotics as standalone treatment (may lower seizure threshold) 2

Step 4: Implement Psychotherapy

• Cognitive Behavioral Therapy (CBT):

  • Primary approach for treating both alcohol use disorder and anxiety disorders 2
  • Addresses underlying thought patterns that contribute to both conditions

• Other effective approaches:

  • Motivational Enhancement Therapy (MET)
  • Coping Skills Training (CST) 1

Step 5: Consider Medications to Maintain Alcohol Abstinence

• Naltrexone:

  • 50 mg once daily
  • Can be safely continued during benzodiazepine-managed withdrawal
  • Does not affect benzodiazepine efficacy 2, 5
  • Helps maintain abstinence motivation during and after detox

• Acamprosate:

  • Effective for maintaining abstinence
  • May be combined with naltrexone for better outcomes 1, 2

Special Considerations

Comorbid Psychiatric Disorders

• Alcoholics have high psychiatric comorbidity including anxiety disorders, affective disorders, and schizophrenia 1
• Independent disorders require specific treatment, while concurrent disorders may resolve with alcohol abstinence

Monitoring and Follow-up

• Anxiety symptoms typically decrease significantly with each week of continued abstinence 4
• Higher anxiety at follow-up is associated with relapse risk
• Regular assessment of both anxiety symptoms and alcohol use is essential

Emergency Referral Criteria

• CIWA-Ar score ≥15
• Seizure activity
• Hallucinations
• Significant vital sign abnormalities
• Inability to take oral medications
• Inadequate home support 2

Common Pitfalls to Avoid

1. Failing to distinguish between alcohol-induced anxiety and primary anxiety disorders

   • Alcohol-induced anxiety typically improves with abstinence
   • Primary anxiety disorders require specific treatment even after withdrawal 6

2. Prolonged benzodiazepine use

   • Benzodiazepines are indicated for withdrawal management but not for long-term anxiety treatment in alcoholics due to addiction risk 7

3. Treating anxiety without addressing alcohol use

   • Treatment of anxiety alone rarely resolves alcoholism
   • Simultaneous treatment aimed at establishing and maintaining sobriety is essential 6

4. Overlooking the need for integrated treatment

   • Combine substance use disorder treatment with medical care
   • Refer to specialized addiction services for ongoing care 2