Substance Use, Anxiety and Fear: Causes And Correlations In An Age Of Adolescent Anxiety

By Daniel P. Villiers, Ph.D

Substance Use

There are 73 million school-aged children in the United States and approxmately 10 million of them experience daily and intrusive levels of anxiety. I am astounded by the fact that anxiety disorders are the most common mental health condition in the US across all age groups and that there has been a 700% increase in the last 40 years among school-aged children. These statistics support my belief that we are living in an age of adolescent anxiety, making the awareness of this epidemic, and the impact it is having on our children even more pertinent. Despite the destructive qualities of the anxiety disorder on all facets of life, they are generally considered the most treatable psychological condition, yet only one third gets any form of treatment. Did you know that there are as many as 3 million kids refusing to go to school due to severe anxiety and related conditions, most of who either already are, or will become, virtually housebound? I refer to this latter group as a generation of “Children in Hiding;” a lost generation of boys and girls in basements and bedrooms who have become dependent on avoidance as a way to cope. From developing nocturnal sleep schedules, nighttime computer use, and daytime sleep, they have discovered a way to connect with the outside world while not having to connect with the outside world.

Whether the child’s anxiety is moderate and manageable or has evolved into something severe and paralyzing, anxious kids are some of the most vulnerable to developing problems with alcohol and drugs. The purpose of this article is to create awareness of the nature, experience, and prevalence of this epidemic, and inform and inspire the victims, and their families, to break free from the cycle of anxiety, self-medication, and addiction.

I met Jim when he was 16 years old. He had been housebound for 11 months. I would meet him in his home as the severity of his panic disorder and social anxiety prohibited therapy in my office. Jim was a bright, well-behaved, a sweet natured child. With the onset of puberty and some mild school bullying, he began missing a few days a week of school. Jim received an IEP, and was provided a home school tutor. I attended the IEP meeting and remember saying clearly, “This academic accommodation of allowing him to study at home will only worsen his school avoidance as his avoidance is his was to cope with anxiety.” The team didn’t seem to get it, or didn’t want to. Within months, Jim went from a place of intermittent school attendance to complete school refusal and social isolation. With the passing of each week, Jim was learning that the self-medicating benefits of avoidance in preventing his anxiety and fear were more powerful that the most productive 50 minute hour of CBT that I could give. He refused to continue therapy three weeks after that meeting. Three years later, I found out from Jim’s parents that his anxiety had worsen, he refused any home schooling or therapy, had developed frequent suicidal ideation, had recently become dependent on marijuana and Xanax, and was on the computer playing video games for 12 hour day.

Jim’s experience is not a unique case; in fact he is one of many children trapped in a cycle of anxiety, fear, and avoidance, or “AFA” as I call it, where avoidance is used as a self-prescribed coping strategy.

What are the Anxiety Disorders?

Anxiety is a normal reaction to stress, and fear; an evolved cognitive mechanism to prepare or protect oneself from a real or perceived threat. Paradoxically, what was once a mechanism to solely prepare and protect us from harm, seems to have evolved into something annoyingly unnecessary at best and pervasively destructive at worst. Individuals with an anxiety disorder are at great risk of going from serving a beneficial function to something that is intrusive, controlling. Without treatment, it can infect a person’s natural ability to be the arbiter of real threat and more the victim of perceived danger.

While there are a wide range of anxiety disorders, the following are the most prevalent among adolescents and young adults: Social Anxiety Disorder, Generalized Anxiety Disorder, Panic Disorder, Specific Phobias, Obsessive Compulsive Disorder, and Post-Traumatic Stress disorder (PTSD).

Social anxiety disorder involves an overwhelming fear of evaluation and judgment from others, and the experience of anxious symptoms, feelings of embarrassment, and a self concept unfairly portrayed as weak and inadequate.

Panic Disorder involves feelings of terror that strike suddenly and repeatedly, and often involve an increased or irregular heart rate, sweating, and chest pain. With time, symptoms of panic can become the cues for potential panic, where the fear of panic itself can be equally as frightening as the panic attack itself. In teenagers, symptoms can include muscle tension, a refusal to move (also known as the freeze response), and crying or tantrums. While these behaviors may look like an act of defiance, in children and adolescents, it also serves a purpose of avoiding going somewhere where anxiety and panic might be triggered, or as a response to prevent an emotionally dysregulating state. This can lead to the development of agoraphobia, a condition involving avoidance of places and situations where escape would be difficult or embarrassing should a panic attack occur.

Obsessive Compulsive Disorder sufferers experience intrusive thoughts related to a fear (obsession), that cause them to perform certain compulsions or routines to decrease the associated anxiety. Adolescents and adults can have a range of clearly distinguishable obsessions and compulsions, such as an obsessive fear of contamination leading to compulsive hand washing to more subtle forms, such as an obsessive fear of academic imperfection leading to re-writing a paper 10 times. Some individuals may suffer from Pure Obsessional OCD where obsessions are reported without clear or observable compulsions.  These obsessions present as intrusive, unwanted thoughts, or “mental images,” of them doing something they consider to be harmful, immoral, and/or sexually inappropriate. These thoughts can be frightening due to the fact that they contradict their own beliefs, intent, and desires.

Post-traumatic stress disorder (PTSD) is a condition that can develop following a traumatic and/or terrifying event, such as a sexual or physical assault, the unexpected death of a loved one, or a natural disaster. People with PTSD often have lasting and frightening thoughts and memories of the event, and tend to be emotionally detached or numb in adulthood, or emotional and behavioral unpredictable during adolescence.

Specific phobia is an intense fear of a specific object or situation, such as driving over a bridge, snakes, heights, or flying. The level of fear or perceived threat is significantly out of proportion to the actual threat and may cause the person to become avoidant of places where the threat might arise. A common specific fear among children and young teens may be of their parent dying which is often perpetuated by separation anxiety disorder. Separation anxiety disorder is frequent and intrusive displays of fear and distress when confronted with situations of separation from the home or from a specific attachment figure.

Generalized Anxiety Disorder involves excessive, unrealistic worry and tension, even if there is little or nothing to provoke the anxiety. Among adolescents, academic anxiety and chronic perfectionism are common additional features depending on the social and cultural values of the home and/or school environment.

Prevalence and Comorbidity

Current research demonstrates that anxiety disorders are the most common mental health condition across all age groups with prevalence rates ranging from 18-24%. After depression, substance abuse has the third highest prevalence rate of 10-14% among adolescents, with anxiety and depression having the highest comorbidity rate. The term comorbidity refers to two disorders occurring together, and research clearly shows that more than half of individuals with a substance use disorder also suffer from another mental health condition. Multiple studies utilizing data from the National Epidemiology Survey (2011) have found between 40-60 percent of adolescents diagnosed with an anxiety disorder have a comorbid substance use disorder. Further, that generalized anxiety disorder (GAD) and panic disorder (PD) have the highest associations with drug use disorders, and PTSD and OCD were both most commonly associated with alcohol use disorders versus drug use disorders.

There are at least three scenarios in regard to the origin of co-occurring anxiety and substance use: 1) drug abuse can cause a mental illness, 2) mental illness can lead to drug abuse, and 3) drug abuse and mental disorders are both caused by other common risk factors. In regard to the anxiety disorders, especially among adolescents, there is overwhelming support the self-medication hypothesis, also known as “the tension-reduction” hypothesis.” This asserts that attempts to reduce anxiety with the use of substances can then lead to the development of a comorbid substance use disorder. For example, Kushner et al. (2008) found consistent evidence for anxiety disorders occurring before a substance use disorders in at least 75% of cases, and that other risk factors, such as family history of drug abuse plays an influential role. In regard to the remaining 25% from Kuchner’s study, substance use and abuse can lead to the development of anxiety in later adolescence.

In regard to the “drug of choice” among adolescents with teenagers, the research is somewhat inconclusive. There is evidence to support that marijuana dependence is the most common among individuals with an anxiety disorder who are 13 to 20 years old, with comorbidity rates ranging from 35% to 67%. Studies have generally found that alcohol abuse is the second most prevalent (rates from 18%-45%, followed by benzodiazepine abuse (rates from 10-24%). Cocaine, opiates, hallucinogens, and other prescription medication abuse had rates from 3% to 6%, with some proposing that anxiety and fear among teens serves a protecting factor against the use of harder drugs.

Future Directions

My life as a teenager was circumscribed by anxiety; the decisions it made for me and the chronic avoidance I used to cope. My teenage experience with severe anxiety, and ultimate recovery, inspired my personal and professional commitment to helping teenagers suffering from anxiety disorders. In 2011, with the support of the Becket Family of Services, I founded the Mountain Valley Treatment Center, a not-for-profit short term residential program exclusive to the treatment of adolescent anxiety. While many cases of anxiety can be treated in outpatient settings, residential treatment is the logical next step when anxiety starts to interfere with a child’s academic functioning and school attendance. Mountain Valley sought to fill the void in highly specialized treatment options for teenage anxiety disorders, where residents could benefit from being around other kids with the same or similar challenges. The power of this shared experience couples with 2-3 months of intensive exposure therapy, and other evidence-based treatments for anxiety disorders, treatment has proved highly effective.

The success of Mountain Valley’s specialization inspired Jay Wolter, president of the Becket Family of Services, and Dr. Francis Moriarty, clinical director of the Mountain Valley Treatment Center (www.mountainvalleytreatment.org) to open the Penikese program. Located on a small island off the coast of Martha’s Vineyard, Penikese serves adolescent males suffering with both “internalizing” mental health conditions (i.e., disorders of anxiety and depression) and mild substance use disorders. Cofounder, Dr. Moriarty states:

One common assumption about a substance use disorders is that one must hit “rock bottom” in order to be ready for treatment. At Penikese we believe quite the opposite. Our goal is to catch a young person at the earliest possible recognition of use and abuse and to simultaneously treat the underlying internalizing mental health condition.

Over the last few years, I have discovered an abundance of kids who, due to AFA with or without depression, have kept under the radar. While these kids are often very bright and well-behaved, they are just, if not more, vulnerable to going from a place where substance use was their ‘self-medication discovery,’ to that slippery road of a life of dependency and addiction.

As the research illustrates, adolescents with an anxiety disorders are some of the most vulnerable to substance use. The addition of substance abuse makes the vicious cycle of AFA only harder to break. While the developmental relationship of anxiety and substance abuse is of great importance to guide treatment, it is important for parents to know that there is hope for their child. It is my hope that with a greater awareness of the common relationship between anxiety disorders and substance use, we can help understand and inspire victims of addiction to start their journey to recovery.

Dr. Dan Villiers is the founder and director of admissions of the Mountain Valley Treatment Center, the first non-hospital residential program for the treatment of adolescent anxiety in the United States. Dan is a graduate of Kenyon College, received Master’s Degrees from Kent State University and Dartmouth College, and a Combined Ph.D. in Counseling and School Psychology from Northeastern University. Dr. Villiers has published several
peer-reviewed articles, presented at conferences across the country, and has appeared on radio and TV in the area of child & adolescent anxiety and related disorders. For further information and support, please contact Dr. Dan Villiers at dvilliers@mountainvalleytreatment.org