relapse among alcoholics with phobic and panic symptoms

Addictive Behaviors, Vol. I I, pp. 9-15, 1992 Printed in the USA. All rights reserved.

03M-4603192 $5.00 + .OO Copyright 0 1992 Pergamon Press plc

RELAPSE AMONG ALCOHOLICS WITH PHOBIC AND PANIC SYMPTOMS

LYNDA PAULSON LABOUNTY, DOROTHY HATSUKAMI, STEVEN F. MORGAN, and LIANNE NELSON

Macalester College, University of Minnesota and Hazelden

Abstract - A group of 35 alcoholics who indicated they had symptoms of phobia, panic, or both (the anxiety problem group) were compared to their matched controls who did not indicate having anxiety problems. Comparisons of relapse rates, reasons for relapse, and rates of emotional problems at six months posttreatment were made. Results showed that although relapse rates were similar between the two groups, significantly more anxious subjects reported relapsing to cope with depression and experiencing problems with nervousness, tension, and anger posttreatment. Implications for treatment and the need for further research are dis- cussed.

The high prevalence of anxiety disorders, primarily phobias, in alcoholics has been demonstrated in a number of studies, with rates ranging from approximately 13% (Weiss & Rosenberg, 1985) to 33% (Bowen, Cipywnyk, D’Arcy, & Keegan, 1984; Mul- laney & Trippett, 1979). These figures match or exceed the rates expected in the general population (2% to 13.5%, Kushner, Sher, & Beitman, 1990; Marks & Lader, 1973; Rob- ins et al., 1984). Even higher rates among alcoholics have been obtained when milder levels of severity were included. For example, Mullaney and Trippett ( 1979) reported that K of alcoholics studied had at least mild phobias, while Smail, Stockwell, Canter, and Hodgson ( 1984) found that 53% of their population had some degree of phobia.

The prevalence of panic in alcoholics is also greater than in the general population. Whereas the lifetime prevalence of occurrence in the general population is about 1.5% (Robins et al., 1984), lifetime rates among hospitalized men and women alcoholics have been found to range from approximately 4% (Weiss & Rosenberg, 1985) to 2 1% (Bowen et al., 1984). Nunes, Quitkin, and Berman (1988) found an even higher rate of panic (32%) among alcoholic women in an inpatient detoxification unit.

Given the above findings, it has been speculated that alcoholics with the anxiety disorders of phobia and/or panic not addressed in treatment may be at greater risk for relapse (Mullaney & Trippett, 1979; Weiss & Rosenberg, 1985). There is, however, little empirical research for guidance in this area, since there are no extensive studies exam- ining the relationship between panic and phobia and alcoholism treatment outcome. The major goal of the following study was to empirically examine the posttreatment relationship between panic/phobic symptoms and substance use among a sample of chemically dependent patients admitted to treatment.

This study was supported by a grant from the Hazelden Foundation. Requests for reprints should be sent to Lynda P. LaBounty, Macalester College, Department ofPsychology,

St. Paul, MN 55105.

9

10 LYNDA PAULSON LABOUNTY et al.

METHOD

Subjects The subjects were drawn from patients who were admitted to a private alcohol or

drug dependency residential treatment facility from February 1987 to March 1987. The demographic characteristics of people admitted to this facility’during all of 1987 can be summarized as follows. Two-thirds of the patients were male, average age was 38 years, one-third were single, and 43% were married. The majority of the patients had at least a high school diploma, and 44% were college graduates or had received advanced degrees. Over three-fourths were employed full-time at admission; 12% were unem- ployed. Statistics on substance abuse problems were not available for 1987; however, in 1988,7 1% of patients were diagnosed with both an alcohol and drug problem, 25% had only alcohol problems, and 3% had only drug problems. An interdisciplinary team which included a psychologist and a chemical dependency counselor made the formal diagnosis of dependence or nondependent abuse of drugs (and alcohol).

The sample for this study consisted of 243 patients (175 men and 68 women) who entered treatment during the aforementioned period. Of these, 45 subjects were excluded from the study because they had been admitted for assessment or short-term treatment only, were return patients who were already in another follow-up study, were transferred to another program, refused permission to be followed, or had died, leaving 198 subjects.

A follow-up questionnaire was sent to all 198 subjects six months after discharge from treatment. Seventy-five returned their mailed questionnaires. The 123 subjects who had not responded to the mailing were then contacted and asked to participate in a tele- phone interview; 95 subjects agreed, 28 refused, had returned to treatment and were therefore unavailable, could not be located, or had died. In total, 170 subjects (122 men and 48 women) responded to the questionnaire by mail or phone. The rate of response was, therefore, 86%.

Of the 170 subjects who responded to the questionnaire, 6 subjects who abused drugs but not alcohol were excluded, and 3 were excluded because of incomplete records. Thus, the final sample consisted of 16 1 subjects (116 men and 45 women) at the six- month follow-up. Informed consent was obtained in writing from all subjects partici- pating in the study.

The follow-up questionnaire consisted of two parts. Part one was the standard six- month follow-up questionnaire used by the residential treatment center. Those data were not used in the current study. Part two of the questionnaire was a special six- month follow-up survey specifically devised for this study. It included questions about drug and alcohol use since treatment, whether chemical use was a coping strategy for dealing with certain emotions, emotional problems since treatment, and health and mental health care from professionals since treatment, including medications. In addition, questions derived from the Diagnostic Interview Schedule (Robins, Helzer, Croughan, & Ratcliff, 198 1) for phobia and panic attacks were included. These questions are listed in Table 1. Subjects were classified as having symptoms of panic or phobia based upon the special questionnaire responses according to the following criteria: (a) a positive response to both questions 1 Oa and 1 Ob on the special survey resulted in a classification of panic symptoms, (b) a positive response to 11 identified the subject as having phobia symptoms, and (c) positive responses to 1 Oa, 1 Ob, and 11 resulted in a classification of both phobia and panic symptoms. Positive responses to questions 9a, 9b, and 9c were categorized as general anxiety responses. No attempt was made to make a diagnosis since the questions were too limited to do so.

Relapse among alcoholics with phobia and panic symptoms 11

Table 1. Questions related to panic and phobic symptoms

9. (a)

(b)

(c)

10. (a)

(b) Have you ever had three spells of suddenly being frightened or anxious close together (i.e., within a three-week time period); or one or more spells followed by a period of at least one month of continuous fear of another attack?

(1)Yes ____ (2) No ^ ^ 1 1. Some people have unreasonable tears, that IS, such a strong lear ot somethmg or some situatton that tt

causes them sign$cant distress, and they try to avoid it even though they know there is no real danger. Have you had any unreasonable fears that have been significantly disabling (such as heights. being in a crowd, being alone, going out of the house alone, etc.)?

(l)Yes (2) No

Have you ever considered yourself to be a nervous or anxious person? (I) Yes; answer Question 9b-9c

~ (2) No; skip to Question IO Has your nervous/anxious mood ever persisted (i.e., been present continuous/_v) for a one-month period of time?

(1)Yes ~ (2) No How about for a six-month period of time?

(1)Yes ___ (2) No Have you ever had a spell or attack when suddenly you felt frightened or very uneasy in situations (e.g., a sudden rush ofintense fear or anxiety or feeling ofimpending doom accompanied by shortness of breath, dizziness, heart pounding, trembling, etc.) when mosf people would not be q/kid?

(I) Yes; answer Question (b) (2) No; skip to Question I I

Table 2 summarizes the prevalence of anxiety problems found among the 16 1 subjects based upon self-report at the six-month follow-up. The rate of phobia symptoms only was 10% (N = 16), panic symptoms only was 4% (N = 7) panic and phobia symptoms was 7% (N = 12). Thus, the rate of panic and/or phobia symptoms was 22% (N = 35).

The 35 subjects who met our criteria for having phobia, panic problems, or both will hereinafter be referred to as the anxiety problem group. In order to control for age, sex, education, and drug use pattern, these 35 subjects were matched on a person-by-person basis on each of the above variables to 35 controls from the remainder of the sample who were judged not to have experienced any phobic or panic symptoms. Those who responded positively to general anxiety items were excluded from the matching.

The following priorities were followed in the matching process: Sex matching had the highest priority; all but one subject were matched on sex. Matching of age, education, and chemical use pattern according to the categories in Table 3 was undertaken. When an adequate match was not available, an attempt was made to minimize the deviation on the above four variables. When more than one match was possible, occupation was considered to break ties. Where ties could not be broken, selection between equivalent matching candidates was random.

Table 2. Prevalence of anxiety problems among alcohol and drug abuse population

Problem N %

Phobia only Panic only Panic and phobia Total

16/161 10% 71161 4%

12/161 7% 35/161 22%


Table 3. Demographics of controls and alcohol and drug abusers with anxiety problems

Variables Anxiety problems group Controls

Sex 15F,20M 14F,21 M

Age 18-23 1 I 24-29 10 9 30-35 I 8 36-39 4 5 40-49 12 8 50 & over 1 4

Education -Z H.S. Brad. 1 H.S. grad. : 9 Some college 10 10 College grad. 10 12 Grad./prof. 4 3

Chemical use Alcohol only II 15 Ale. & barb. + 0 to 1 other, no stim. 4 1 Ale. & stim. + 0 to I other, no barbs. 5 6 Ale. + polydrug (4 or more drugs) II 12 Ale., barb., stim. (total LT 4) 2 I Ale. + I or 2 other, no barb., no stim. 2 0

Data analysis We used chi-square analysis to test significant differences in prevalence of relapse,

health, and emotional problems experienced. A two-tailed Students’s t test was used to determine if there were significant differences in number of treatments for medical problems or number of medical hospitalizations as reported in the follow-up survey. Corrected &i-squares were used in all cases involving 2 by 2 matrices.

RESULTS

The anxiety group did not differ significantly from their matched controls on the variables of sex, age, education, or drug use pattern. The results of these tests of concordance are presented in Table 3.

Table 4 summarizes some of the data obtained from the follow-up questionnaire. Relapse rates were similar for both groups at the six-month follow-up. Further, there were no differences between the groups in the choice of drug used in relapse. There were differences in reported reasons for relapse, however. A significantly greater number of anxious individuals reported relapsing to cope with depression compared to controls. Further, significantly more anxious subjects reported having problems with nervousness, tension and/or anger since treatment than did their controls. Abstinence was not related to whether or not anxious subjects reported any emotional problems since treatment (p > . 10).

There were no significant differences in the number of medical outpatient treatments (anxious x = 1.2, [.33] vs. control x = .97 [.30]; t = .53; df = 64; p = .6) or hospitalizations (anxious x = .34 [.16] vs. control x = .18 [.OS]; t = .92; a!! = 49; p = .36) reported at follow-up.


Table 4. Treatment outcome for 35 alcohol and drug abusers with anxiety problems and their matched controls at six-month follow-up

Variables Anxiety problems group

(NJ Controls

(NJ Chi-sq P

One or more relapses Relapse to cope with

Anxiety Panic Fear Depression Other emotions

12 IO .21 .65

7 7 7

10 I

Rx for emotion/psych problem 11 Current psych med 3 Current medications 6

Psych problems since Rx Tension Nervousness Anger Depression Sleep problems None of above

17 3 6.49 18 2 7.68 21 6 5.33 16 5 2.95 13 4 I .74 10 12 .41

.30 .59 1.93 .I6 3.59 .06 5.06 .02* 2.08 .15

3.05 .08 .OO -

1.34 .51

.01*

.006*

.02*

.09

.19

.52

*p<.o5

DISCUSSION

The results indicate that over 20% of our sample self-reported phobia and/or panic problems, which is well within the range of rates previously reported in the literature (e.g., Bowen et al., 1984; Mullaney & Trippett, 1979; Weiss & Rosenberg, 1985). Fur- ther, the results showed that relapse rates were similar for the anxiety problem group and their matched controls at the six-month follow-up. However, significantly more anxious subjects compared to the control group reported relapsing to cope with depression, a diagnosis which had appeared at high rates among this group at intake compared to the control group (77% vs. 6%, respectively). Much previous research has also shown concordance between anxiety disorders and depression (Breier, Chamey, & Heninger, 1984; Buller, Maier, & Benkert, 1986; Lesser et al., 1988). In addition, the results from this study showed a greater number of anxious subjects reported relapsing to cope with fear than did their matched controls, although these differences only reached near significance (p < . 10).

Studies which have retrospectively examined the onset of phobic disorders and alcoholism generally find that phobic disorders tend to precede the onset of alcoholic drink- ing patterns (Hesselbrock, Meyer, & Keener, 1985; Mullaney & Trippett, 1979; Stock- well, Smail, Hodgson, & Canter, 1984), although considerable individual variability has been noted (Bowen et al., 1984). This pattern is consistent with hypotheses that, at least in part, alcoholism in persons with phobic disorders may be related to attempts to self- medicate (e.g., Bibb & Chambless, 1986; Chambless, Chemey, Caputo, & Rheinstein, 1987; Quitkin, R&in, Kaplan, & Klein, 1972). Indeed, phobic alcoholics do attribute tension reducing properties to alcohol. Smail et al. (1984) and Bibb and Chambless (1986) reported that 91-97% of agoraphobics with alcoholism say they self-medicate with alcohol. If self-medication is a learned coping mechanism, it is likely that self-medication attempts would play a role in relapse for those with emotional problems after treatment.


On the other hand, there were no differences in reported rates of emotional problems for relapsing as opposed to nonrelapsing anxiety problem group members (chi square all p > .25). Two possible explanations consistent with the self-medication hypothesis but beyond our data are: (a) It is possible that those with more severe problems or who had not learned alternative coping strategies were those that relapsed, and (b) distinc- tion among specific anxiety disorders may have revealed differences between relapsing and nonrelapsing anxiety group members. Recently, agoraphobia and social phobia have been found to be related to self-medication attempts while other forms of anxiety disorder, for example, panic disorder and simple phobia were not (Kushner, Sher, & Beitman, 1990).

Until future research clearly indicates to the contrary, the most prudent course for now is to assume that relapse rates among substance abusers with anxiety problems might be reduced if the anxiety symptoms, particularly those of agoraphobia and social phobia, were addressed during treatment and, where necessary, referrals made after treatment. The work of Marlatt and Gordon ( 1985) on relapse prevention would sup- port this view.

It must be noted that in addition to the above, our study was limited in four impor- tant ways: (a) our questions were insufficient to make a diagnosis of any anxiety disorder, (b) there was no validity or reliability testing of the questionnaire, (c) all follow-up information was obtained entirely through self-report, and (d) the population from which our sample was drawn may not be representative of most treatment populations. However, the possible clinical significance of these limited findings underscores the need for additional research in this area.

REFERENCES

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Bowen, R. C., Cipywnyk, D., D’Arcy, C., & Keegan, D. (1984). Alcoholism, anxiety disorders, and agoraphobia. Alcoholism: Clinical and Experimental Research, 8,48-50.

Breier, A., Chamey, D. S., & Heninger, G. R. (1984). Major depression in patients with agoraphobia and panic disorders. Archives ofGenera Psychiatry, 41, 1129-l 135.

Buller, R., Maier, W., & Benkert, 0. (1986). Clinical subtypes in panic disorder: Their descriptive and pro- spective validity. Journal ofAffective Disorder, 11, 105- 114.

Chambless, D. L., Chemey, J., Caputo, G. C., & Rheinstein, B. J. G. (1987). Anxiety disorders and alcoholism: A study with inpatient alcoholics. Journal ofAnxiety Disorders, 1, 29-40.

Hesselbrock, M. N., Meyer, R. E., & Keener, J. J. (1985). Psychopathology in hospitalized alcoholics. Archives of General Psychiatry, 42, 1050-1055.

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Lesser, I. M., Rubin, R. T., Pecknold, J. C., Rilkin, A., Swinson, R. P., Lydiard, R. B., Barrows, G. G., Noyes, R., & DuPont, R. L., Jr. (1988). Secondary depression in panic disorder and agoraphobia. Archives of General Psychiatry. 45,437-443.

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Robins, L., Helzer, J., Weissman, M., Orvaschel, H., Gruenberg, E., Burke, J. D., & Regier, D. A. (1984). Lifetime prevalence of specific psychiatric disorders in three sites. Archives of General Psychiatry, 41, 949-958.

Smail, P., Stockwell, T., Canter, S., & Hodgson, R. (1984). Alcohol dependence and phobic anxiety states I. A orevalence study. British Journal ofpsychiatry, 144,53-57.

Stock&ell, T., Smail, P:, Hodgson, R., & canter, S. (1984). Alcohol dependence and phobic anxiety states II. A retrospective study. British Journal of Psychiatry, 144,58-63.

Weiss, K. J., & Rosenberg, D. J. (1985). Prevalence of anxiety disorder among alcoholics. Journal of Clinical Psychiatry, 46,3-5.

relapse among alcoholics with phobic and panic symptoms

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