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Concurrent Disorders: Anxiety

Hope Rehab Dual Diagnosis Depression

Anxiety is a common feeling shared by all addicts and alcoholics. Anxiety can suck all the joy out of living. It can turn the world into a dark place where there are threats to our well-being around every corner. This feeling of apprehension can mean we feel alienated from those we love, and it can lead to depression, hopelessness, and despair. Some of us turned to alcohol or drugs in an attempt to deal with this discomfort*, but this only made things worse.

*We strongly suggest that anyone self-medicating using alcohol read the following article – how drinking makes anxiety worse.

Anxiety is one of the Most Frequently Diagnosed Mental Health Concerns of our Time

Next to depression, anxiety is the most frequently diagnosed mental health concerns of our time, and substance users are 20-40% more likely to experience anxiety disorders as compared to the general population. Conversely, individuals diagnosed with any Anxiety Disorders are at higher risk of developing addictive behaviours, and Generalized Anxiety Disorder was most frequently associated with alcohol and drug problems. Anxiety is also often experienced by those suffering from depression.

What is Anxiety?

Next to depression, anxiety is the most frequently diagnosed mental health concerns of our time, and substance users are 20-40% more likely to experience anxiety disorders as compared to the general population. Conversely, individuals diagnosed with any Anxiety Disorders are at higher risk of developing addictive behaviours, and Generalized Anxiety Disorder was most frequently associated with alcohol and drug problems. Anxiety is also often experienced by those suffering from depression.

…anxiety is a more enduring experience than fear. It’s a state of apprehension and physical arousal in which you believe you can’t control or predict potentially aversive future events.

– David A. Clark (Anxiety and Worry Workbook)

If Everyone Experiences Anxiety, Why is it a Problem?

Our stress response can be seen as a smoke alarm: it is very helpful when real danger exists, such as a fire. It is not so helpful when this alarm system goes off indiscriminately, constantly and for no good reason. For individuals suffering from General Anxiety Disorder (GAD), this is the case: they constantly worry about potential and disastrous ‘what ifs’ of the future, they experience chronic bodily symptoms such as angina or Irritable Bowel Syndrome (IBS), and they feel tense and unable to relax or sleep. Among the various forms of anxiety disorders, GAD is the one most often experienced by substance users.

How do I Know that my Levels of Anxiety are Beyond what is Considered ‘Normal’?

We all experience anxiety sometimes; no doubt about that. It is very normal, for example, to experience anxiety when going for a job interview or entering rehab for the first time; in short, when we face uncertainty and when circumstances and events are outside of our control. While most of us manage these short-lived anxiety provoking situations without lasting problems, individuals suffering from anxiety disorders may feel so stressed and become so worried about all the potential ‘what ifs’ of the situation that they feel unable to cope, and they are thus inclined to avoid and withdraw.

When Anxiety Interferes with Day to Day Functioning it’s Time to Seek Help

This typically starts in one area of one’s life, for example when we are socially anxious we may avoid invitations to social events. Over time, anxiety silently slithers into other areas of our life, making us believe we don’t have what it takes to meet the challenge at hand. Eventually, if we let it, anxiety tends to shrink our life to the point where we are afraid to face any challenge at all, no matter how minor. In short, if anxiety interferes with day to day functioning as it pertains to social relationships, works or leisure, or if it renders us unable live life fully, then it is time to seek help.

Are there Different Types of Anxiety, and What is the Overlap with Substance Abuse?

Anxiety Disorders often precede substance use, and they are the most common mental health concern experienced among individuals suffering from alcoholism. For example, individuals diagnosed with an anxiety disorder are 50% more likely to engage in problematic alcohol use compared to the general population. Apart from the aforementioned Generalized Anxiety Disorder (GAD), anxiety symptoms can be a reflection of the following specific anxiety disorders:

Post-Traumatic Stress Disorder (PTSD):

Trauma is unfortunately rather common in substance users, either in the form of childhood trauma preceding addictive behaviours, or trauma (such as sexual assault) experienced as a consequence of substance abuse. Individuals suffering from PTSD are 20-40% more likely to develop problematic substance use or other addictive behaviours compared to those not affected by PTSD, and conversely, PTSD prevalence among substance users is at least 50% higher compared to the general population.

Obsessive-Compulsive Disorder (OCD):

This can involve highly intrusive and unwanted thoughts, coupled with some compulsive behaviour such as repeated checking or hand washing. While many of us double-check things and tasks to ensure we have done them to our satisfaction, individuals suffering from OCD are never satisfied that they’ve done things right, and they may, therefore, be unable to complete any task for fear of not doing it well enough. Based on current research, OCD is least associated with substance misuse, potentially due to low levels of impulsive behaviours so commonly observed in substance users.

Social Anxiety Disorder (SAD)

involves fear of social contacts and relationships. SAD is often, but not always, a consequence of interpersonal trauma such as bullying or violence. Individuals suffering from social anxiety report fear of being embarrassed, judged or ridiculed by others, and they often avoid social events like the plague. Individuals with SAD are two to three times more likely to abuse alcohol compared to the general population. Entering any form of treatment, especially treatment involving group therapy, is especially frightening to SAD sufferers and needs to be addressed if treatment is to be successful. At Hope Rehab, we assist individuals affected by SAD by initially limiting and only gradually increasing group therapy time, by allowing participation at their own pace, and by providing initial extra support, for example by assigning a buddy.

Fear and anxiety are like a pair of overzealous bodyguards… Rather than bringing you peace of mind, they commandeer your attention until everything seems like a potential threat, making it hard to pursue what matters to you most.

– Susan M. Orsillo & Lizabeth Roemer (The Mindful Way through Anxiety)

Symptoms of Anxiety

The old-fashioned remedy for dealing with anxiety was to try to avoid stressful situations. This is an ineffective solution because stress is a normal part of everyday life. It’s also usually the case that those of us who suffer due to anxiety are always going to be able to find something to worry about.

People don’t get anxious because of stress, but because of their inability to deal with stress. This is why at Hope Rehab we are going to provide you with some tools for managing your anxiety.

How are Anxiety Disorders Treated?

As anxiety symptoms can be mimicked, exacerbated or caused by substance use or withdrawal from substance use, abstinence alone may suffice to alleviate or eliminate symptoms of anxiety. For those symptoms persisting or even increasing past the initial withdrawal phase, treatment options range from medicationcognitive-behavioural therapy and mindfulness approaches. Comprehensive anxiety treatment will address physical, mental, emotional and behavioural aspects of anxiety, including:

Fear and anxiety are like a pair of overzealous bodyguards… Rather than bringing you peace of mind, they commandeer your attention until everything seems like a potential threat, making it hard to pursue what matters to you most.

– Susan M. Orsillo & Lizabeth Roemer (The Mindful Way through Anxiety)

Importance of Being Able to Manage Anxiety in Recovery

If you have been using alcohol or drugs to help you manage your anxiety, it is vital that you have an effective coping strategy to replace this. Otherwise, there is going to be a temptation to relapse as soon as life becomes challenging. We are going to provide you with a selection of evidence-based tools for dealing with anxiety, so you will be able to face the future with confidence.

Anxiety Treatment Program at Hope Rehab

At Hope Rehab we provide you with effective tools for managing anxiety, so you can start to experience what it is like to be joyous, happy, and free. Hope’s multiple interventions that can help address difficulties anxiety include:

Group Therapy & CBT

Group Therapy & Cognitive Behavioural Therapy (CBT): Hope Rehab Center offers daily group therapy sessions and weekly CBT workshops as well as supervised CBT exercises every afternoon during which residents learn to identify, challenge and change anxious types of thinking, such as catastrophizing, overestimation of the likelihood feared disasters will happen, and the underestimation of one’s own ability to cope.


Mindfulness & Mediation: At Hope Rehab, we offer daily guided meditation practice, as well as weekly individual and group mindfulness sessions. Mindfulness can teach those suffering from anxiety grounding practices, and how to live with uncertainty. It invites us to stay non-judgmental and curious about our emotions, rather than to judge or avoid them with some sort of quick ‘fix it’. Most importantly, mindfulness teaches us how to intentionally bring our attention to this present moment, rather than chronically worrying about imagined ‘what ifs’ of the future. Regular meditation practice can work to calm an anxious mind and ultimately make for lessened reactivity.


Individual Counselling Sessions: Every resident has two weekly individual counselling sessions to address issues specific to the individual, such as avoidance behaviours, which typically work to maintain and increase problems with anxiety.


Yoga: At Hope Rehab Center, we offer various styles of yoga to ensure everyone can participate in, and harvest yoga’s vast benefits. Types of yoga offered include flow yoga, hot stone meditation and yoga or restorative yoga. Pranayama or breathing practices taught in yoga are particularly helpful to counter an unquiet and anxious mind, and a restless body.

Recovery Meetings

Recovery Meetings: Hope Rehab Center offers addictions focused recovery meetings three times weekly, each with a slightly different focus. This allows attendees to connect with others through sharing of individual struggles and stories of survival pertaining to addictions and mental health recovery. For individuals struggling with social anxiety, in particular, learning to share one’s story in front of a group and being nevertheless accepted into a community, can be powerful exposure therapy and thus counter typical avoidance behaviours.

Activities & Excursions

Afternoon Activities & Weekly Excursions: Following our mandatory morning program, residents have the opportunity to engage in sports, such as Muay Thai boxing, or art and social activities. Through participation in initially challenging activities, individuals with anxiety counter avoidance behaviours and gradually regain self-confidence. Participation in weekly art activities may help anxious individuals to express and self soothe difficult emotions through art.

Healthy Lifestyle

Healthy Lifestyle: At Hope Rehab, we emphasise a healthy lifestyle, which includes daily physical exercise, healthy nutritious meals, solid routines around bedtime and mandatory therapy sessions, and a strong community focus to enhance social and emotional health.

Hope Medication Policy

Note: Please bring your doctor’s contact details with you so you and the Hope team can seek appropriate advice if necessary.

Prescribed Medications: Any long-term medications from your Doctor, are best to bring in a plentiful supply to cover you for up to 2 months minimum. Most clients extend longer than a month. We can source some meds from our local Doctor and Hospital.

Medication storage: All medication must be handed over to Hope staff on admission. We generally store all medication in our safe and dispense from the support office at structured times, whether prescribed by your doctor or ours. After a client settles in, we may decide to allow some meds or vitamins deemed harmless, to be taken to rooms and self-supervised.

Narcotic (intoxicants) medications (including pain meds and Benzodiazepines)

Some “mood-altering” drugs and medications (e.g. Xanax/Codeine) are not encouraged in the Hope therapeutic program, as we require all clients to be on a similar emotional level in the community. So, substitutes or careful reduction may be necessary and are effective and manageable. This may require consultation with your doctor or our local doctor. Please let your doctor know about our specific policy regarding this group of medications, as they may be willing to help change medications before you join us.

Anxiety and sleep medication

Beta blockers for enduring anxiety and natural sleep meds are allowed at Hope, so long as they are supervised. Simple and mild medications such as low dose ‘Seroquel’ for short periods can be highly effective in helping clients through difficulties in the early stages of our program. Our resident nurse or hospital doctor will screen anyone requiring such help. The team at Hope have valuable experience and training that we use to help our clients in accordance with accepted good practice.

General medication issues

Many clients arrive on anti-depressants and mood-stabilizers prescribed by their doctors. Clients often ask to stop these meds which is a healthy sign of commitment to recovery. However, Hope staff are not permitted to make these kinds of decisions. So we ask that before coming to Hope you contact the prescribing doctor to get his/her feedback and consent. We can also help you contact the doctor for advice once you have arrived. Family and people close to you may also provide a different perspective so may be consulted. You may additionally be asked to sign a waiver stating that you have taken appropriate advice and are making an informed decision with our support.

Psychiatric medications are very sensitive and must be properly adhered to for safety. We feel it would be irresponsible for Hope staff to allow clients to stop taking psychiatric drugs. If not carefully coordinated by the prescribing doctor, this could trigger unnecessary MH episodes. When making changes to medications, it may also be a good idea to get feedback from those people who are closest to you.

Please arrange to bring the correct supply of your regular medication. Some meds are not available in Thailand or are very expensive and timely to acquire. We suggest at least two months’ supply.

Standard detox (Heroin and Alcohol)

At Hope Rehab we follow common detox protocols for Alcohol and Heroin detoxes. We work together with doctors at our local hospital who provide Diazepam prescriptions for alcohol detox. We also work together with the Bangkok Methadone/Subutex program who provide the prescriptions covering opiate detox and reductions. Some clients bring their own detox medication from their country of origin. Staff at Hope are specially trained by the Royal College of General Practitioners UK to administer and coordinate standard detox programs. We aim to keep all clients safe and comfortable whilst withdrawing. You may be asked to take anti-seizure meds for a short period to ensure safety. For more information please check our detox page.

ADHD & ADD medication

Stimulants such as Adderall, Concerta, or Ritalin are not suited to the Hope community or program. These drugs are far from ideal for addicts as they pump up the human reward system. Some clients who are prescribed these meds have found it triggered their addiction and caused serious life problems so are keen to stop, which we support. Some clients wish to continue using these medications, so we ask them to reduce to a low dose. This is because we have noticed hyper-manic behavior and a lack of emotional connection with others. We suggest Strattera (non-stimulant) as an alternative appropriate ADHD medication. Please let your prescribing doctor know about our policy.

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