Sunday, July 26, 2009

Jittery and Paranoid is My Normal

Recent studies indicate that adolescents who engage in substance abuse are highly likely to present with a variety of mental heath issues. These include conduct disorder, attention deficient disorders, mood disorders, and anxiety disorders (Brown, p. 1). When this happens, the adolescent is considered to have co-occurring disorders.

In my experience, anxiety disorders are among the most common mental health challenge in this population. I’ve found that it is also common for anxiety disorders to “travel with” other mental health challenges. In other words, a youth would have a substance-related disorder, a primary mental health challenges (such as depression), and an anxiety disorder.

In this post I’ll be looking at causal issues related to co-occurring anxiety disorders and substance abuse among adolescents. Before proceeding, though, defining the terms anxiety disorder and substance abuse is warranted. Evans and Sullivan wrote that that the defining features of anxiety disorders are “anxious arousal and avoidance of the anxiety-provoking situation.” They then identified several specific conditions that are considered anxiety disorders. These include panic disorder with or without agoraphobia, agoraphobia, social phobia, specific phobia, obsessive-compulsive disorder, post-traumatic stress disorder, acute distress disorder, and generalized anxiety disorder (p. 115).

According to the DSM-IV-TR Desk Reference, a diagnosis of substance abuse requires at least one of the following: recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home; recurrent substance use in situations in which it is physically hazardous, such as driving a car or using heavy machinery; recurrent substance-related legal problems; or, continued substance use despite persistent or recurrent social or interpersonal problems caused or exacerbated by use (American Psychiatric Association, p. 115).

In my experience, adolescents with any mental health problem, especially anxiety disorders, frequently report self-medication as a primary reason for their use of alcohol and other drugs. It is not uncommon for these adolescents to report that substance use makes them “feel better” and causes their problems to “go away.” Alcohol and other drugs can, indeed, be effective in this regard, but as we shall see, this is only temporary relief.

In the long term, substance abuse actually increases anxiety symptoms. Meanwhile, the youth has likely not developed other more adaptive coping skills. Often this leads the adolescent to do the only thing that has worked in the past, abuse more substances, leading to a co-evolutionary cycle of increasing abuse and anxiety disorders.

For adolescents stuck in this loop, an integrated treatment strategy can be essential to end the cycle. This requires an understanding of both substance abuse and anxiety disorders, as well as the complex interconnections between them. In a future post, I’ll explore the use of experiential learning to develop emotion regulation and distress tolerance skills.

Which Came First?
According to Brown, approximately two-thirds of all adolescents enrolled in a substance abuse program meet the diagnostic criteria for at least one mental health problem (p. 1). Other studies have suggested up to 90% of teens in treatment warrant a mental health diagnosis. Most prevalent are anxiety disorders (Evans & Sullivan, p. 117). In adolescents, co-occurring substance abuse and mental health disorders most often reflect common risk factors, such as genetic predisposition or environmental influences, for both problems.

However, this is not always the case. Some studies have shown that one problem can cause or exacerbate the other (Brown, p. 1). Even moderate use of alcohol and other drugs has been shown to increase anxiety symptoms (Evans & Sullivan, p. 117), and conversely adolescents with an anxiety disorder have an increased likelihood of substance abuse problems (Evans & Sullivan, p. 147).

From a clinical perspective, it can sometimes be useful to determine which can first, the anxiety disorder or the substance abuse. Either way, though, adolescents can quickly enter into a seemingly endless looping cycle of substance use leading to increased anxiety which then leads to attempted relief through additional use.

Evans and Sullivan wrote, “Individuals with severe anxiety use substances to seek relief, and this can start the abuse cycle. Taking a drink or tranquillizers ‘just in case’ becomes behavior that reinforces avoidance” (p. 117). As we saw in the definition above, this avoidance is considered a diagnostic criterion for a clinical diagnosis of an anxiety disorder. As such, not only can substance abuse be problematic itself, it could actually be considered symptomatic of an anxiety disorder.

“Mark,” a client with a history of early childhood abuse, substance abuse and two recent physical assaults, said, “My whole life I’ve felt like I never knew what would come next. Getting high didn’t make that stop, I just cared less.” Ironically, both of Mark’s recent assaults occurred while he was under the influence of alcohol. Thus, although Mark used alcohol and other drugs in an attempt to seek relief from his anxiety, his substance abuse actually increased the likelihood of him being exposed to traumatic experiences, further perpetuating the cycle of anxiety and substance abuse.

This cycle is quite common. Indeed, I’ve worked with adolescents who have suffered a wide variety of trauma and environmental stressors while under the influence, attempting to obtain alcohol or other drugs, or as a direct result of their substance abuse. These include engaging in prostitution, sexual assaults, physical assaults, severe injuries, homelessness, and incarceration.

As Long As I’m High, Everything Seems Okay
In my experience, youth with anxiety disorders have an especially difficult time committing to, engaging in, and remaining abstinent during and after treatment. Most often, I see this expressed through high levels of ambivalence regarding treatment, poor attendance at group sessions, and frequent situational relapses. These observations are supported by studies that indicate anxiety disorders are associated with a variety of adverse outcomes, including school drop out, poor treatment outcomes, and the development of other mental health disorders (Romer & Walker, p. 219).

Sustained exposure to environmental stressors has been shown to lead to a diverse range of high-risk conditions, including anxiety and “dysfunctional cognitive processing of potentially threatening stimuli” (Romer & Walker, p. 149). I have frequently had adolescent clients report situations or behaviors that are clearly dangerous, with an apparent lack of understanding about the dangers involved. “Sam,” a sixteen-year-old client is a good example. Sam has a history of using stimulants and then engaging in dangerous activities such as mountain biking. Initially, he denied the risk involved in his behavior, even when confronted about it. Although there may be a developmental aspect to this, based on a history of early childhood neglect it seems likely that dysfunctional cognitive processing may have played a part in Sam’s decision-making process.

If environmental stressors lead to dysfunctional cognitive processing, it seems likely that additional stress or anxiety could be created. In other words, anxiety that is ignored will likely lead to more anxiety. For an adolescent caught in such an anxiety loop, the use of alcohol and other drugs could be considered a reasonable response.

“Sarah” has diagnoses of Generalized Anxiety Disorder and Cannabis Dependence, plus a history of self-harming behavior and disordered eating. She said, “When I smoke weed, all the anxiety goes away. I don’t want to cut. I don’t want to purge. As long as I’m high, everything seems okay.” Anxiety is considered pathological when it “disrupts functioning and interferes with the successful completion of daily living tasks… [and] when the degree of distress is extreme, in terms of intensity, frequency, and duration” (Romer & Walker, p. 221). For Sarah, this level of disruption is clearly evident.

Even when anxiety does not rise to a diagnostic level it can still be problematic in the lives of adolescents. Based on my experience, even clients who do not exhibit diagnosable anxiety disorders frequently present a heightened level of anxiety and poor skills at dealing with stress. This is supported by the observation that adolescence is “marked by heightened vulnerability for affective dysregulation and distress” (Romer & Walker, p. 219).

Both affective dysregulation and distress can be considered an expected part of adolescence, a result of normal brain development. However, when an adolescent is predisposed to mental health challenges or when substance abuse complicates this normal developmental process, problems can occur, especially if the individual has been exposed to significant environmental stressors during early childhood.

Environmental Stressors in Early Childhood
Research indicates that adolescents who enter substance abuse treatment are more likely than their peers to have experienced childhood neglect, abuse, and other significant family problems (Riggs, p. 19). In fact, these types of stressors have been found in studies to be “a powerful predicator of alcohol and other drug abuse” in both adolescents and adults (Romer & Walker, p. 392). In addition, early childhood environmental stressors—especially abuse and neglect—are closely “correlated with increased incidence of psychiatric illnesses,” including anxiety disorders (Romer & Walker, p. 350).

“Adversity in early life alters the development of neural systems in a manner that predisposes individuals to disease in adulthood,” both physical and psychiatric (Romer & Walker, p. 149). In addition, “childhood adversity, in the form of trauma, neglect, deprivation, or abuse, may be especially harmful during critical periods in brain development… [E]xternal stressors impact the structure, organization, and activity of the CNS [central nervous system]” (Romer & Walker, p. 350).

Several laboratory studies on the impact of neglect and early childhood stress have been conducted on rats. “[M]aternal care [in rats] alters the expression of genes in brain regions that subserve emotional, cognitive, and endocrine responses to stress” (Romer & Walker, p. 161). This conclusion comes from a study that tracked levels of maternal care based on licking and grooming behavior exhibited, both natural variations and imposed differences. When less maternal licking and grooming occurred, the rat pups exhibited increased fearfulness, heightened HPA (hypothalamus-pituitary-adrenal) axis responses to stress, and reduced performances on tasks requiring sustained attention or declarative learning, especially when under stressful conditions (Romer &Walker, p. 163).

Romer and Walker stated that the HPA axis is “a neural system activated by stress” (p. 481). It is “sensitive to environmental challenges and is activated in response to physical and psychological factors that threaten homeostasis” (Romer & Walker, p. 265). When activated, a chain of events occurs that leads to the release of cortisol, a hormone that increases blood pressure, blood sugar levels and has an immunosuppressive action (Romer & Walker, p. 478), helping to assure a quick return to normal functioning following stressful events.

The hippocampus is “the major center for conscious, declarative, explicit memory processing” (Siegel, p. 178). In rats, studies suggest that maternal care influences the development of the hippocampus by effecting the expression of genes involved in neuron survival and synaptic development (Romer & Walker, p. 155). If this is true in humans as well, then neglect and other early childhood environmental stressors could have negative impacts on the hippocampus. Indeed, the hippocampus has been found to be particularly vulnerable to the effects of trauma and environmental stress.

Siegel wrote that high levels of stress, especially when severe or ongoing, can block hippocampal functioning and even lead to “neuronal death” and decreased hippocampal volume (p. 50). Additionally, the use of alcohol and other drugs has been found to negatively impact the hippocampus (Romer & Walker, p. 393). This is true at all ages of life, but during adolescence the hippocampus may be especially vulnerable (Romer & Walker, p. 271). Here again, we can see the potential for a looping cyclic pattern. Stress leads to hippocampal impairment, leading to decreased ability to endure anxiety, leading to substance abuse in an attempt to self-medicate, resulting in further impairment of the hippocampus.

Moving Into Their Teens
When individuals already exposed to significant childhood stressors move into adolescence, they face a new cascade of problems. These can include a higher incidence of mental health disorders, school-related concerns, placement in separate classes, and increased association with peers who exhibit similar maladaptive issues. This cascade of life problems frequently results in youth with limited academic success, a continued escalation of behavioral problems, social marginalization, interactions with deviant peers, and a significantly increased likelihood of substance abuse (Riggs, p. 19).

In addition to these new environmental concerns, it is likely that the “neurobiological alterations associated with early adverse experience confers vulnerability or sensitizes” the individual to the future development of various anxiety disorders (Romer &Walker, p. 350). Studies have shown that “deficient neurocognitive function may also be associated with increased risk for alcohol and other substance abuse” (Romer & Walker, p. 446). Here again we see a cyclic loop of problems as adverse childhood experiences, anxiety disorders, and substance abuse co-evolve in the lives of high-risk youth.

An additional factor in this co-evolution is brain development. For an adolescent already suffering the negative impacts on the hippocampus due to early childhood environmental stressors, the additional impact caused by these problems would contribute to the looping cycle of anxiety and substance abuse that we have already seen. This cycle can be readily seen in many of my client’s life histories. One example is “Andrew.”

By the time he was three-years-old, Andrew’s parents were both heroin dependent and the family was homeless, living in a car. It is reasonable to make two assumptions at this point. First, the environmental stressors caused by addicted parents and homelessness had already negatively impacted his hippocampus and general brain development. Second, with both parents being heroin dependent, Andrew was born with a high genetic predisposition for addiction.

At four-years-old, Andrew witnessed the death by overdose of both parents. With no relatives to provide care, he entered the foster care system. Between the ages four and fifteen, he had over a dozen different placements. Andrew reported, “I was moved around so much that I wouldn’t even unpack my suitcase.” Not surprisingly, his behavior became increasing maladaptive. He reported first use of alcohol at age eleven and first use of marijuana shortly thereafter. At thirteen he went to detention for the first time. At fifteen, he ran away from the group home where he was living.

When I met Andrew at sixteen, he had just moved into a shelter after being homeless for almost a year. He reported two recent assaults and had mental health diagnoses that included PTSD, Conduct Disorder, ADHD, and Major Depressive Disorder. He also had diagnoses for substance abuse disorders including Alcohol Dependence, Cannabis Dependence, and Amphetamine Abuse. In addition, he had difficulty remembering details, time frames, and other factual information.

Andrew reported that using “makes me feel normal,” even though he acknowledged amphetamines made him “jittery and paranoid.” With a blank look he continued, “I guess jittery and paranoid is my normal.”

Substance abuse and mental health counselors frequently attempt to determine which came first, the substance abuse or the mental health issues. As we can see with Andrew’s case, as well as the others presented in this paper, it is often not that simple. Co-occurring substance abuse and anxiety disorders are often not progressive. Instead, they are frequently an intricate, co-evolving, cycling loop. Breaking that loop requires addressing both problems.

Works Cited
American Psychiatric Association. (2000). Desk Reference to the Diagnostic Criteria from DSM-IV-TR. Arlington, VA: American Psychiatric Association.

Brown, S. (2008). Comorbidity. Retrieved May 26, 2008, from
http://www.drugstrategies.org/teens/comorbidity.html.

Riggs, P. (2003) Treating Adolescents for Substance Abuse and Comorbid Psychiatric Disorders. Science & Practice Perspectives, 18-28.

Romer, D. and Walker, E. (Eds.). (2007). Adolescent Psychopathology and the Developing Brain. New York: Oxford University Press.

Siegel, D. (1999). The Developing Mind. New York: Guilford Press.