Internalizing and Alcohol Use Disorders

Do internalizing symptoms contribute to alcohol problems?

Severe and long-lasting Internalizing symptoms (e.g., anxiety) and disorders (e.g., major depression) are common in people with alcohol use disorders

The key takeaway: Internalizing issues increase risk for developing alcohol problems, and they make these problems more difficult and complicated to treat.

What are Internalizing Problems?

Illustration of a silhouette of a man with door opening from inside himInternalizing issues refer to problems with negative emotions such as anxiety, fear, sadness, and depression. While almost everyone has experienced these emotions, for some people they may be so strong or long-lasting that they interfere with everyday functioning. For example, severe, persistent anxiety may discourage an individual from socializing with others. Similarly, depressive feelings may be powerful enough to disrupt school or work or lead to a suicide attempt. In such cases, a significant behavioral health problem, like major depression, may be present.

Are Internalizing Problems Related to Alcohol Use Disorders (AUD)?

People with (sidenote: Disorders associated with negative emotions: Major Depression, Anxiety Disorders (e.g., Social Phobia, PTSD, Panic Disorder)) are 2 to 11 times more likely to have an AUD than those without internalizing conditions. In addition, people with AUD who also have internalizing problems tend to have more severe alcohol problems. Also, people who receive treatment for drinking problems are more likely to have continuing issues with alcohol after treatment if they are also struggling with an internalizing disorder. Heavy drinkers at greatest risk for AUD are those who have high levels of both internalizing and externalizing problems.

For some people, anxiety and depression occur before drinking becomes a problem. For others, heavy drinking occurs before anxiety and depression begin. Regardless of which comes first, internalizing problems and drinking problems tend to make each other worse over time.

How are internalizing conditions linked to AUD?

Illustration of a person looking glum with dots behind themOne reason is that some of the same genes that increase risk for AUD also increase risk for depression. It is not uncommon to find families in which depression and AUD are both unusually frequent, suggesting a shared genetic basis. A second reason is self-medication. When someone feels very stressed or experiences strong feelings of sadness or anxiety, they may get in the habit of using alcohol to help numb these emotions. Over time, this way of coping may backfire, because heavy drinking or attempts to reduce it can lead to more emotional problems — and more drinking. Research suggests that the connection between internalizing problems and alcohol misuse is stronger in women than in men. It is also more common in older individuals, where heavy drinking may be triggered by job loss, illness, death of a loved one, divorce, or other stressful life events. Koob and other researchers have found that alcohol addiction has several phases. In the early part of addiction, people drink primarily for stimulation and pleasure.  For those who continue to drink heavily, these positive effects of alcohol decrease and are replaced by alcohol withdrawal, depression, and/or anxiety. At this point, the main motive for drinking changes from increasing pleasure to reducing these painful symptoms. People who stop their heavy drinking at this point may still be at risk to go back to their old patterns, especially if they encounter major stress.

What about Treatment?

For people who have AUD as well as internalizing problems, it is best to address both at the same time. For example, someone with major depression and AUD has the best chance of success if he or she is treated for them together, rather than tackling AUD first or depression first. Importantly, if medication for depression, anxiety, or AUD is given, it is often more effective if combined with counseling or psychotherapy. Although treatment may be difficult and sometimes takes repeated efforts, it can be successful and is well worth the effort.

Featured Suggested Readings & References

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