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Dual Diagnosis: Anxiety and Substance Use Disorder

Dual Diagnosis: Anxiety and Substance Use Disorder

Anxiety, stress, and fear are common emotions people experience through the course of everyday life.  Anxiety disorders, on the other hand, go beyond our daily worries and fears. Stress and pressure is subjective to each person – anxiety disorders can induce heavy stress and pressure, and these feelings can become more intense over time. Issues that crop up for anxiety disorder sufferers range from anodyne to hair-raising. For example, some people are terrified of meeting new people and having to interact with strangers, while others suffer panic attacks when memories of past traumas surface. The most common types of anxiety disorders are diagnosed as:

  • Panic Disorder (PD)
  • Generalised Anxiety Disorder (GAD)
  • Social Anxiety Disorder (Social Phobia)
  • Agoraphobia (Perception of certain environments as unsafe, with no easy escape)
  • Obsessive Compulsive Disorder (OCD)
  • Post Traumatic Stress Disorder (PTSD)

Not only are there psychological symptoms, people dealing with anxiety disorders may also experience a litany of physical symptoms such as insomnia; inability to concentrate or relax; heart palpitations; gastroenterological issues; and sexual frustration, among others. When all these problems start impinging on one’s behaviour, mood and thoughts, life can start to feel like a slog through quicksand. A once “normal life” now appears out of reach, and getting there again can feel like a Sisyphean task.

What makes people suffering from an anxiety disorder seek out substances?

It’s important to understand a little more about addiction before dealing with this question. Addiction is indubitably a very uncomfortable disorder, and that’s characterising it mildly. For a “preference” to devolve into full blown addiction, a person must keep making the same conscious decisions every day, day after day, that facilitate  indulgence in his or her vice – in spite of a mounting cornucopia of problems. Maintaining an addiction certainly is tiresome. People suffering from addiction make these choices because their addiction serves them a purpose. Concomitant discomfort is tolerated in light of perceived benefits garnered from substance abuse.

A parsimonious way to think about addiction is to assume that it is a simple cost-benefit analysis. For someone struggling with an anxiety disorder, the allure of a “quick-fix” in the form of a suitable drug or drink is hard to ignore. What may begin as a misguided attempt to ameliorate paralysing fear can eventually develop into a fully-fledged addiction. With this in mind, it is now a lot clearer why substance use disorder (SUD) is a co-occurring psychiatric disorder that is one of the most prevalent among people with an anxiety disorder. The most recent and largest comorbidity study to date (with over 43,000 participants), the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), found that 17.7% of respondents with an addiction problem also had an anxiety disorder.

Ironically, the problem with the “solution” of substance abuse is that the ”solution” hurts more than helps. It can often exacerbate the anxiety disorder – which becomes ensnared in the convoluted mess that is addiction. Thus comes the slippery slope of anxiety, substance use, and elevated tolerance.

Chronic dependence is the likely consequence of this chain of events. For example, a person who suffers from social phobia might employ stimulants or anxiolytics to engender artificial confidence during a social situation. This can feel liberating, exhilarating, even, for someone who has spent a lifetime on the sidelines. The folly in this endeavour lies in the eventual normalising of this ‘chemically induced courage’ – if you turn it into a precondition to interacting with other human beings, you will only succeed in erecting progressively more imposing barriers in a completely self-defeating, tautological situation.

Are there psychotherapies out there that treat anxiety and addiction together?

Diagnosing a mental disorder in a person who also suffers from an addiction is challenging.

It may be hard to determine which came first, the addiction or the anxiety/depression. A clinical history, which is triangulated with loved ones, teachers and others may assist to know which came first. In any case, both the addiction and the disorders have to be treated at the same time. Otherwise, if untreated, the anxiety and depression may lead to the resumption of drug or alcohol use.  Cognitive behavioural therapies (CBT), meditation and mindfulness therapies, experiential therapies and medication can assist to address both compulsive behaviour and anxiety and depressive disorders.

A trained and experienced mental health professional can help you navigate your addiction recovery journey to ensure that you get the best possible outcome within the guidelines of your values and needs. While this article is about substance addiction, you will find that our team of psychiatrists, psychologists and therapists have the expertise and experience to work with a variety of addictions, and mental health issues such as anxiety disorders.

Living with a Sex Addict – Pt. 1

Living with a Sex Addict – Pt. 1

My partner says his sexual behavior is normal – but he is hiding it and I know something is wrong. Am I crazy? What are the signs of compulsive sexual behavior disorder?

Partners of people with sexual compulsivity often come to the clinic in great distress.

They have just learned about the latest infidelity, daily Internet porn use, visits to Orchard Towers, massage parlors or KTV lounges. The images accidently left on the family computer may be shocking or alarming.   

Perhaps they have discovered condoms in the person’s luggage after a business trip, unexplained expenses on their credit cards, and unexplained absences from their hotel rooms late at night when they tried to call the person. Childrens’ birthdays, graduations and family celebrations may be mysteriously abandoned for “essential” business trips.

Partners may notice strange messages or nude photos on the mobiles; or perhaps odd phone calls at night, that seem to make the person excited or embarrassed. They may come home intoxicated at 3:00 am, after a night out with colleagues, with unexplained credit cards slips in their pockets for hundreds or thousands of dollars. They may find an STI clinic report.   

The person acting out will likely try to vigorously “manage” all this fallout with their partners.  

They may rationalize, minimize, intellectualize, normalize – or simply lie, to explain away all this overwhelming cumulative evidence. They may “gaslight” their partner, making them think they are crazy.

And it may work…for a time.

Meanwhile partners may feel: shocked; rejected; confused; angry, even rageful; anxious; and depressed. They may even blame themselves and feel inadequate as a partner and  ashamed.

They may: become irritable, angry or overly anxious with their children; stop doing things they enjoyed, stop seeing people; forego self-care and grooming; or try to become overly sexual and breach their own boundaries to save the relationship.

They may become sleepless, without appetite and lose weight – or over eat and gain weight; and they may use medication and alcohol to numb their emotional pain. They may keep getting flus and colds that refuse to go away; or chronic backaches and neck aches that make sleep or activities painful.

The shame may be crushing.

Some partners may have experienced earlier traumas in their own childhood or adulthood, in which emotional and sexual or other physical abuse, neglect and rejection were prevalent.  The acting out person’s behavior may therefore trigger strong trauma reactions, and lead to bonded relationship traumas, resulting in self-harm or even attempted suicide.

How can a partner respond when they get a feeling something is not quite right?

If they can persuade the person acting out to undertake a clinical assessment, the person will be able to understand that their behavior has become a serious self-destructive compulsion, and that they need treatment.

Even if the person won’t attend therapy, the partner can take an assessment of the extent of their trauma, and the role of the person acting out. The partner can then receive sex addiction treatment, and explore the options for the family. Do they stay or go?

Promises Healthcare Pte Ltd. provides therapy for both those with compulsive sexual behavior and their partners, so that together they can find a way out of their suffering and plan a better future for their families.  

Living with a Sex Addict – Pt. 2

Living with a Sex Addict – Pt. 2

“My partner’s sexual behaviour has left me devastated – should I stay or should I go?”

Many clients come to therapy wondering whether they should leave or stay, after they have discovered their partner’s infidelity, or other compulsive sexual behavior. This may include a combination of: serial affairs at work; Internet pornography; sexual massages; use of sex workers; and use of anonymous dating Apps. Excessive alcohol, drugs and workaholism may also be involved.  

Even though the behavior is intolerable or very risky, and causing great suffering – there may often seem compelling reasons to stay.

Young children may be involved. If the acting out partner has been a “good enough” parent, the children will suffer greatly if they leave. Further, the burden of parenting the children alone may seem too much.

The client may worry about the family finances – that they may not be able to support themselves and their children if the partner withholds money or does not agree to split the money appropriately.

The client may have to return to their country of origin and may not be able to bring the children with them, if their partner contests this.

Leaving may cause the client great shame, particularly with their family, friends and work colleagues.

The client may fear loneliness; or may ardently fantasize that things will get back to the way they were – eventually. After all, the couple may have a long, shared history, and may have weathered many other difficulties together.

Starting with a new relationship in future may be as daunting as living alone forever.

Some clients may be so angry and resentful, that leaving may seem like the partner getting away it. Leaving may appear like giving the partner a license to continue their intolerable behavior – unchecked and unavenged. It may result in the partners frittering the family money away.

Friends and family may be unhelpful – full of directive and conflicting advice.  Clients may be ashamed, or too anxious of the reaction they will receive to even share about their suffering.

However, some clients are unaware that there may be a solution to sex addiction.

If the partner is assessed for a compulsive sexual behavior disorder and subsequently undertakes recovery; and the client works in therapy on taking care of themselves; learning and growing from the experience; and improving their relationship – there may still be hope in keeping the family together.

Ultimately, both need to work on themselves and the relationship, if it is to be saved.

But the first step may just be contacting a professional to seek help.

Promises Healthcare Pte. Ltd. provides support for both the partner and the person suffering from compulsive sexual behavior and can help the couple to work on the solution.  

Do I Have a Sex Addiction? Is My Partner a Sex Addict?

Do I Have a Sex Addiction? Is My Partner a Sex Addict?

DO I HAVE A SEX ADDICTION?    IS MY PARTNER A SEX ADDICT? 


These questions become urgent when your or your loved ones’ repeated sexual behaviour cause you acute distress. 


It may be that you feel empty, frustrated, anxious, depressed or ashamed by your behaviour.  Or you may be a loved one who suddenly discovers their partner is sexually acting out, and you feel betrayed, angry, raging, resentful, humiliated, confused or depressed; and have nagging doubts about your own adequacy as a partner. You may be worried for your children and your family life. Your health – or your finances – may be in serious jeopardy.   


Not all sexual behaviour that causes you or a loved one suffering is a sex addiction – even if the suffering is profound and long lasting, or the behaviour is considered by others “deviant” or even “risky”. 
However, if it amounts to an sex addiction, there is a solution in recovery, and a loved one can play an important role. 


It is therefore important to know – is it an addiction?   
Once sexual behaviour is persistent, it sometimes becomes impossible for a person to know whether their behaviour has become compulsive, obsessive, impulsive or even dangerous or intrusive. 
People can become confused.

“There is a way through – and that is to take a clinical assessment and discuss the results with a professional therapist, trained in interpreting them. “


Is the behaviour continuing because they consciously choose not to change? Is it just “normal”, “natural”, “justifiable”, or “cultural”? Is it the loved ones or others who are mainly at fault, because they can’t or won’t give the sexual intimacy needed? Is it just “temporary” or “a one off”.

Is it just a product of some unusual circumstances – such as being in a new country, starting a new job, having a baby, going on business trips, or feeling bored, stressed, anxious, lonely, isolated, neglected, or depressed?     

If the behaviour has been persistent for a period of time, a person may think that it is safer than it really is, or that the risks of being found out, and the consequences, are minimal, manageable and within their control.

Sometimes a person my think that their chosen sexual partners are freely consenting, or that they enjoyed the experience – but  the truth is otherwise. 


Sometimes a person may lie, cover up, tell half truths and keep silent about their behaviour, because they want to protect their loved ones. They may not be willing to admit to themselves or others that they mainly wish to avoid the painful consequences of their behaviour.

After a while, they may even become confused or uncertain about what the real truth is. Being persistently deceitful and living a double life, can become a crushing burden.


There is a way through – and that is to take a clinical sex addiction assessment and discuss the results with a professional therapist, trained in interpreting them.

There are a number of assessments available online. However, some are not thorough or confidential enough, or they cause unnecessary alarm. Many do not provide a clear interpretation; and some do not provide a path towards a workable therapeutic solution.


The International Institute for Trauma and Addiction Professionals (IITAP) provide Certified Sex Addiction Therapists (CSATs) with an anonymised, online questionnaire, called the “Sexual Dependency Inventory – 4.0”. 
It takes a client 2 hours or so to complete, and a confidential, detailed client report is automatically generated for the therapist to view online – and subsequently share it with the client. 


The report compares the client’s responses with the responses of many thousands of other respondents, both with and without sex addiction, to gauge whether the sexual behaviour and preoccupation are likely to indicate a sex addiction.  


The report provides the client and therapist with a thorough review of the client’s: sexual behaviour and preoccupations; the consequences; the possible origins of the behaviour; and the potential future course and direction of the behaviour. 


The report also helps the client articulate their motivation to change their behaviour.  


This report is coupled with a subsequent clinical interview session, that assesses: sexual, medical and psychiatric history; family of origin history; education and employment history; intimate and social relationships; and other information. Together, this information permits clients and the therapist to determine the next steps. 


If the client’s behaviour is likely to amount to an addiction, the recovery path has been clearly mapped by the IITAP programme; and CSATs are trained and skilled in helping client’s navigate through their recovery using workbooks, videos, books, articles, and other therapeutic interventions.


The recovery path engenders great hope for those who start on it. Life gets better quickly, and keeps getting better with each recovery step that is conscientiously taken. 


What causes the greatest suffering is not knowing. Am I a sex addict? Is my partner a sex addict? 

Contact us today to take a free clinical assessment.

Why am I an addict?

Why am I an addict?

Promises Healthcare Singapore Addiction, Andrew Da Roza

Clients and their families often want to know: how do people become addicts?

We are all very complex beings and it is almost impossible to give a definitive answer to this question. Addiction professionals often describe it as a bio-psycho-social “disease” that involves multiple personal risk factors. In order to understand what one’s personal risk factors are, it would be best to seek a professional that could help you understand various factors of how the addiction started and how it has taken over one’s life. There are biological factors such as genes that makes one vulnerable in developing addiction. There may be social factors such as abuse or poverty in which one uses substances to cope. And for others the experience of psychological trauma may result in one using substances to soothe or to numb themselves.

Regardless of the reason, recovery is possible.

Come and see a professional psychiatrist, psychologist or counsellor today for more information on how you can beat your addiction. At Promises Healthcare, we are committed to helping you through your journey to recovery. Discover a new life, away from addiction and find renewed hope. Please contact our clinic for inquiries and consultations.

This article was written by Andrew da Roza, Psychotherapist and addictions specialist, Promises Healthcare