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Section 7
Patterns of Substance Use in Panic Disorder

Question 7 | Test | Table of Contents | Anxiety CEU Courses
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In the last section, we discussed three types of phobias which result in anxiety. They were simple phobias; blood-injury phobias; and illness phobias.

In this section, we will examine the three substances that panic disorder clients misuse most commonly: caffeine; illicit drugs; and alcohol.

Three Commonly Misused Substances

♦ Substance #1 - Caffeine
The first substance abuse is caffeine. Although this may seem trite compared to such commonly known abuses as alcohol and cocaine, for a client with anxiety disorder, caffeine could be almost as dangerous. Depending on individual sensitivity, a cup of coffee in the morning may be enough to trigger anxiety symptoms in those clients suffering from panic disorder. The extra jolt that caffeine gives a client includes such symptoms as:  jitteriness; indecisiveness; low blood sugar; and sleeplessness.

Those with panic disorder have, at times, been found to be more sensitive to caffeine than the average beverage drinker. One of the more concerning side effects is sleeplessness. Disturbing the circadian rhythms through caffeine usage will often cause a spike in anxiety attacks. Nancy, a 21 year old client of mine, had been a chronic coffee drinker since the age of 15.  However, it wasn’t until she was 19 that she began to notice that the jitteriness she had become used to had intensified.  After entering college, the panic attacks only increased. 

When I asked Nancy about her coffee drinking habits, she stated, "On average, I drink about four cups of coffee a day. It keeps me going well into the night."  I suggested that Nancy slowly decrease her intake of caffeine until she was taking none at all.  To do this, Nancy first reduced the amount of cups she drank every day.  Eventually, Nancy began to drink tea in substitute for coffee and finally, she found that with a good night’s rest, she didn’t need any caffeine at all. Her sleep rhythms stabilized and her panic attacks became less and less frequent.

♦ Substance #2 - Illicit Drugs
The second common substance abuse is illicit drugs.  The most common drug that panic disorder clients take is marijuana. Clients who experiment with marijuana or cannabis may suffer from short-lived, acute anxiety states, which may reach an intensity equal to that of a panic attack.  Other negative psychological side effects have been found in clients who frequently use amphetamines. 

Anxiety and fear to the point of acute panic have been reported.  Cocaine can also, obviously, cause extreme feelings of paranoia and anxiousness, which intensify in clients with anxiety disorder. Stephen was a 25 year old anxiety disorder client of mine whose cocaine addiction increased his panic attacks. Once Stephen had confessed to me that he had a drug problem, I immediately referred him to a rehabilitation center. Once Stephen had rid himself of his habit, the panic attacks became much less intense and frequent.  Think of your Stephen.  Has he or she reached such a point in their drug use that drug rehabilitation is absolutely necessary?

♦ Substance #3 - Alcohol
In addition to caffeine and illicit drugs, the third type of substance abuse we will discuss is alcohol abuse. Commonly, clients will understate or completely exclude alcohol use from their medical history. Often, clients will self-medicate themselves with alcoholic beverages because they feel that it will calm them down. 

D.W. Goodwin, a researcher on alcoholism and anxiety, states, "Alcoholism is often found in the families of people with panic disorder. Since alcoholics commonly have anxiety attacks, particularly when hung over, it is hard to tell which came first—panic disorder or alcoholism.  Both typically begin in the teens and twenties." 

As we stated before, alcohol is used as a means to reduce anxiety symptoms, however there is a second connection between panic disorder and alcohol abuse. When a client suffers from agoraphobia, he or she may use alcohol as a coping mechanism. However, studies have shown that males are more likely to abuse alcohol, which is consistent with society’s expectations for males. Women are more likely to seclude themselves by staying at home.

♦ Technique:  Bath Visualization
Ian was a 34 year old client of mine who suffered from frequent panic attacks.  Generally, Ian reported feeling emotions of anxiousness throughout the day.  Ian stated, "It’s as though something is just waiting for me around the corner.  I haven’t seen it yet, but it’s there. To help, I drink. A lot. At first, I tried to keep myself limited to a glass or two of wine, but it wasn’t enough.  I then tried gin, rum, and brandy. Later, I went to just drinking straight whiskey. That didn’t help either because the next day I would have a panic attack when I was hungover. Then I would just go back to drinking. It was a bad cycle." 

As you can see, Ian had medicated himself with alcohol, thinking that the effects would numb his feelings of anxiousness.  To keep Ian from spiraling down into alcoholism, I asked that he try the "Bath Visualization."  Many of my clients have reported that a warm bath often calms their symptoms down. The heat and movement of the water relaxes the muscles and the panic attack slowly diminishes. I then asked Ian to record the following visualization so he could listen to it while in the tub:

Step #1 - Take a full, deep breath and exhale fully and completely.
Step #2 - Slowly close your eyes and feel your heart beating strongly, and then begin to slow down.
Step #3 - Let your thoughts just drift through your consciousness, as you allow them to leave with the warm air.
Step #4 - Imagine with each breath that you can breathe away tension or anxiety as you allow yourself to relax more and more. All the day’s burdens, worries, and expectations are leaving your consciousness and evaporating with the hot, moist steam.
Step #5 - Feel your arms floating on the water. As you continue to breathe slowly and naturally, let go of any thoughts still remaining in your mind.
Step #6 - Watch as your thoughts flow through you and out of you, and see them disappear into the air, leaving your mind clear and calm.

The next time Ian felt the urge to drink, he tried this technique. He stated, "It actually helped me quite a bit. I was completely relaxed and I didn’t have the panic attacks the next day." Think of your Ian. Could he or she benefit from the "Bath Visualization"?

In this section, we discussed the three substances that panic disorder clients misuse most commonly, which are caffeine; illicit drugs; and alcohol.

In the next section, we will discuss three steps in treating OCD clients, which are identification; exposure; and self-talk.

- DuPont, R. (1997). Panic disorder and addiction: The clinical issues of comorbidity. Bulletin of the Menninger Clinic, 61.
- Goodwin, D. W. (1987). Anxiety. New York: Ballantine Books.
- Swede, S., & Jaffe, S. S., M.D. (2000). The Panic Attack Recovery Book: Step-by-Step Techniques to Reduce Anxiety and Change Your Life—Natural, Drug-Free, Fast Results. New York, NY: Penguin Putnam.

Peer-Reviewed Journal Article References:
Reese, E. D., Conway, C. C., Anand, D., Bauer, D. J., & Daughters, S. B. (2019). Distress tolerance trajectories following substance use treatment. Journal of Consulting and Clinical Psychology, 87(7), 645–656.

Roos, C. R., Bowen, S., & Witkiewitz, K. (2017). Baseline patterns of substance use disorder severity and depression and anxiety symptoms moderate the efficacy of mindfulness-based relapse prevention. Journal of Consulting and Clinical Psychology, 85(11), 1041–1051.

Wolitzky-Taylor, K., Krull, J., Rawson, R., Roy-Byrne, P., Ries, R., & Craske, M. G. (2018). Randomized clinical trial evaluating the preliminary effectiveness of an integrated anxiety disorder treatment in substance use disorder specialty clinics. Journal of Consulting and Clinical Psychology, 86(1), 81–88.

What are three types of substances that panic disorder clients misuse most commonly? To select and enter your answer go to Test.

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