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Joseph Troncale, M.D. FASAM
Joseph Troncale M.D.

Anxiety and Addiction

The limbic system and the cycle of self-medication

Part of the disease of addiction is a number of personality disorder-like behaviors that tag along like an annoying little brother.

In previous blogs, we discussed the matter of the limbic system of the brain as being the focus of addiction. The limbic system apparatus is the fight-or-flight part of the brain, but it is much more than that. The addiction center, mood and attention, parts of memory and rage and sex are all regulated in part by the limbic system.

One of the behaviors seen in persons with addiction that is disproportionate to the rest of the population is anxiety. Anxiety’s self-treatment with drugs and alcohol gives an individual temporary relief, but there is long-term damage done to the mechanisms that help relieve the symptoms of anxiety. This cycle of self-medication and rebound anxiety digs a deeper and deeper hole for the addicted person, making treatment and breaking this downward spiral harder and harder as time goes by.

For a moment, let us forget about the underlying cause of anxiety. (Not that getting to the underlying factors is not important; I just need to discuss what keeps it going in addiction.) Let us, for the sake of argument, say that the person in question always remembers being anxious and nervous and never felt that anything would take care of the anxiety short of drugs and alcohol. Also, let’s assume the person is one of those individuals who had the right genetic make-up for addiction.

Self-medication begins with a few drinks and a few benzodiazepines and a cigarette. What is happening in the brain is the building of receptors that have to be filled with alcohol or drugs to achieve a calm state. So tolerance develops, and one needs more and more alcohol or benzodiazepines or nicotine to calm the individual. As more and more receptors build in the brain, more drugs, alcohol, and nicotine are needed to bring the person to a state of calm.

When someone comes in for help, one of the biggest hurdles in keeping the person in treatment is monitoring that person for withdrawal and giving time to allow those receptors to start to go away, while at the same time weaning down the medications, so that panic and anxiety do not ensue. If this is done too aggressively, the person is groggy and “out of it.” If the medication is not given aggressively enough, the person will be anxious, experience panic and withdrawal, and may even have a seizure because of the extreme over-activity of the brain in withdrawal.

This hyper-anxiety can last for weeks or months if not properly monitored and treated. If the detox is not done gradually and appropriately, the person leaves treatment, goes back to the former use, and then gets blamed by the medical care system for their relapse.

I had a patient here yesterday who was coming out of her skin because of protracted withdrawal. We got behind on her medications, and she needed some additional time for withdrawal. Her symptoms were panic and extreme restlessness and anxiety. She is feeling better today. She understands that the medications will continue to be withdrawn day by day.

There is a lot of fear for people going through withdrawal. It is like putting someone on the high dive at the pool when they have a fear of heights. For someone who does not want to jump, it is much more humane to walk them back down the ladder one step at a time.

About the Author
Joseph Troncale, M.D. FASAM

Joseph Troncale, M.D. FASAM, has been working in addiction medicine for 20 years. He is the Medical Director of the Retreat.

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