A compelling introduction to the intricate relationship between anxiety and alcohol use disorder, the science that explains it, and the promising treatments that can break the cycle.
For many, a drink after a stressful day is a common way to unwind. But for a significant number of people, this common practice crosses a dangerous threshold, evolving into a compulsive cycle where alcohol use disorder (AUD) and anxiety fuel one another. This isn't just a casual observation; research has shown that up to 50% of individuals receiving treatment for problematic alcohol use also meet diagnostic criteria for one or more anxiety disorders 1 . This co-occurrence is one of the most consistently documented observations in psychiatry, creating a complex challenge for both those who experience it and the clinicians who treat it 1 . Understanding this link is not just an academic exercise—it's crucial for breaking the cycle and paving the way toward recovery.
The high rate of co-occurrence between AUD and anxiety disorders is not a coincidence. It is the product of multiple interwoven factors, explained by different scientific perspectives.
Epidemiological studies reveal that the relationship between anxiety and AUD is often bidirectional. Having either an anxiety-related diagnosis or an alcohol-related diagnosis elevates the prospective risk for developing the other disorder 1 . This means that chronic anxiety can predispose someone to develop problems with alcohol, and conversely, long-term, problematic alcohol use can set the stage for an anxiety disorder.
From a psychological standpoint, the motive to drink is a critical factor. Behavioral research demonstrates that drinking to cope with negative affect is a potent marker for current and future problems with alcohol 1 . This is a form of negative reinforcement—the behavior of drinking is reinforced because it temporarily removes or alleviates the unpleasant state of anxiety. However, this short-term strategy leads to long-term consequences, including a higher risk of heavier alcohol consumption and alcohol-related problems 3 .
Neuroscience has uncovered that anxiety and alcohol misuse are linked by overlapping neurobiological systems and psychological processes 1 . They may share underlying, mutually exacerbating neurobiological pathways, rather than being entirely distinct conditions 1 . This means that the same brain circuits and neurotransmitters involved in the body's stress response and reward system are implicated in both anxiety and AUD, creating a biological vulnerability that can manifest as either or both conditions.
To move beyond observational studies and establish cause and effect, researchers have designed clever experiments to test whether anxiety directly influences the choice to drink.
In a 2020 laboratory study, researchers used a safe and reliable human experimental model known as the 7.5% carbon dioxide (CO2) challenge to investigate the direct effect of state anxiety on alcohol-related decisions 3 .
The study had a repeated-measures design, meaning each participant underwent both the experimental and control conditions. Participants inhaled two different gas mixtures through a mask in a counterbalanced order: medical air (control condition) and a 7.5% CO2 mixture (anxiety condition). The CO2 mixture is known to reliably induce temporary feelings of state anxiety, increased heart rate, and other physical symptoms similar to generalized anxiety 3 .
The key outcome measured was alcohol choice. After inhaling each gas, participants completed a computer task called the Concurrent Pictorial Choice Measure (CPCM). On each trial, they were shown a picture of wine and a picture of food. They had to choose which picture to enlarge, and their percentage of alcohol choices was recorded 3 .
Researchers also explored whether the motive of "drinking to cope" (DTC) influenced the results. Participants completed a Drinking Motives Questionnaire to identify those who typically drink to manage negative emotions 3 .
The results provided compelling, albeit nuanced, evidence for the anxiety-alcohol link.
To conduct this kind of sophisticated research, scientists rely on a specific set of tools and measures. The table below details some of the essential "research reagents" used in the featured study and the broader field.
| Tool/Measure | Function & Explanation | Context of Use |
|---|---|---|
| 7.5% CO2 Challenge | A safe, reversible physiological stressor that reliably induces state anxiety and physical symptoms (e.g., increased heart rate) to study its causal effects 3 . | Experimental anxiety induction. |
| Concurrent Pictorial Choice (CPCM) | A behavioral task measuring the relative value of alcohol vs. alternative rewards (like food) by tracking choice preferences, providing an objective measure of motivation 3 . | Primary outcome measure for alcohol seeking. |
| Drinking Motives Questionnaire (DMQ) | A self-report questionnaire that identifies an individual's primary reasons for drinking (e.g., social, coping, enhancement). The "coping" motive is a key predictor of problems 3 . | Identifying moderators like "drinking to cope". |
| Alcohol Use Disorders Identification Test (AUDIT) | A gold-standard 10-item screening measure that assesses alcohol consumption, dependence symptoms, and alcohol-related problems to determine severity 8 . | Screening and characterizing study samples. |
| Spielberger State-Trait Anxiety Inventory (STAI) | A widely used questionnaire that differentiates between temporary "state anxiety" and long-standing "trait anxiety" 3 . | Measuring anxiety levels. |
The recognition that AUD and anxiety are deeply intertwined has led to a critical shift in treatment philosophy. The old practice of treating one disorder first and then the other is now considered outdated. Instead, integrated treatment approaches that address both conditions simultaneously are considered best practice .
Integrated treatment addressing both anxiety and alcohol use disorder simultaneously is significantly more effective than sequential treatment approaches.
is particularly promising because it is highly flexible and effective for both AUD and anxiety disorders. Integrated CBT helps individuals understand the cycle between their thoughts, feelings, and behaviors, teaching them healthier coping skills to manage anxiety without resorting to alcohol .
shows that patients with alcohol problems in primary care can be effectively treated for anxiety disorders. While baseline alcohol problems can be associated with somewhat poorer long-term outcomes, this does not mean anxiety treatment should be postponed. Treatment can be successful even while alcohol problems are present 8 .
| AUD Severity | Anxiety Severity | Suggested Level of Care |
|---|---|---|
| Mild to Moderate | Mild to Moderate | Primary Care Setting: Medications for AUD and mild-moderate anxiety can be started here. |
| More Severe | Mild to Moderate | Addiction or Mental Health Specialist |
| Any Severity | More Severe | Mental Health or Addiction Specialist |
| Source: Adapted from NIAAA guidance 5 | ||
The dangerous dance between anxiety and alcohol use disorder is fueled by a powerful combination of psychology, biology, and learned behavior. The experimental evidence makes it clear: anxiety can directly drive the choice to drink, creating a self-medication trap that only deepens both conditions over time.
However, there is profound hope in this understanding. By recognizing this cycle, we can dismantle it. The move toward integrated treatments that tackle both issues together, the use of therapies like CBT to build healthier coping skills, and the knowledge that recovery is possible without having to conquer one disorder before the other, represent a more compassionate and effective path forward. Breaking the cycle begins with seeing it clearly—not as two separate problems, but as one that requires a unified solution.