The link between Anxiety and Alcohol Use; and Implications for Treatment and Early Intervention Especially In Youths
Alcohol. A beverage that many people enjoy drinking; be it for socialisation or as an escape from reality. However, it is also a beverage that can harm your health and adversely affect many lives. Indeed, alcohol abuse has become increasingly rampant, where it is one of the leading causes of disease and death, with 5.3% of all global deaths and over 200 diseases and injury conditions resulting from the harmful use of alcohol. Worryingly, it is also a phenomenon that has affected Singapore, with 9.6% of Singaporeans engaging in binge drinking (as of 2016) and an increasing number of Singaporean young adults battling Alcohol Use Disorders (AUD). As such, alcohol abuse has become a growing cause of concern.
There are many reasons why alcohol consumption is increasing. Alcohol consumption has been perpetuated by the media in recent years, with an increase in advertising and marketing of alcohol. For instance, in Australia, people are exposed to about nine alcohol televised advertisements every month. In turn, exposure to such advertisements causes alcohol consumption to be glorified and promoted, where people have unrealistic positive expectations towards alcohol, believing that it boosts one’s mood and invokes cheerfulness and confidence. Additionally, alcohol consumption has also increased due to peer pressure. Be it a work engagement or partying with friends, people often find it hard to say no to alcohol, as that rejection may cause disapproval among colleagues or friends. Thus, many people engage in risky drinking behaviour to socialise and develop their relationships.
However, a more significant reason behind alcohol consumption is feelings of anxiety or having anxiety disorders. People with anxiety disorders have 2 to 3 times the risk of having alcohol use disorders (Smith & Randall, 2012). Many people tend to use alcohol to reduce social anxiety, as they believe that alcohol is an excellent aid to speak up and gain more confidence around others. Similarly, people use alcohol as a form of self-medication to overcome anxiety symptoms and stress, relying on it as a coping mechanism. However, contrary to popular beliefs, alcohol exacerbates rather than alleviates anxiety symptoms. This worsened anxiety makes them drink more and have more alcohol-related problems, which causes further anxiety and stress.
Alcohol abuse also causes anxiety. Drinking alcohol builds a tolerance to de-stressing effects of alcohol. This creates a temporary sense of relaxation but later leads to feelings of depression and anxiety. This is because the prolonged use of alcohol can act as a stressor and activate the body’s stress response system, changing neurotransmitter levels in the brain and causing an increase in stress and anxiety. As such, alcohol can worsen anxiety symptoms.
Therefore, anxiety and alcohol abuse tend to fuel each other in a vicious feed-forward cycle of co-occurring addiction and anxiety, which is difficult to break out from. As such, integrated treatment for both anxiety and alcohol use should be readily available.
There have been existing parallel or subsequent attempts to treat both anxiety disorder and AUD (i.e. treatment for anxiety disorders first, followed by AUD). However, studies have found that parallel treatments have caused worse alcohol outcomes compared to just seeking one treatment. This is possible because the cognitive load of receiving two separate treatments may be confusing or overwhelming for people, causing them to feel anxious or turn back to drinking as a coping mechanism. As such, these type of treatments causes a “co-morbidity roundabout”, which is a metaphor of mental health problems resurfacing when attempting to tackle substance disorders (and vice versa), thus failing to break out from the vicious cycle of these co-morbid disorders. Therefore, it is clear that both anxiety disorder and AUD are inter-related issues, and an integrated treatment approach is vital to tackle both disorders.
Stapinski et. al. (2015) carried out an integrated treatment for comorbid social anxiety and AUD, where participants undergo both Cognitive Behavioural Therapy (CBT) and motivational interviewing. Moreover, it involves core components such as building coping skills, developing alternative reinforcers and preventing relapse. This provides participants with useful skills such as enhancing social support networks, correcting misconceptions towards the benefits of drinking, reducing avoidance of social situations and developing healthy coping skills to manage triggers for drinking or anxiety.
This study took place over ten 90-minute sessions, where 117 participants with both social anxiety and AUD took part in this study. 61 of the participants received integrated treatment (both AUD and social anxiety) and 56 of the participants received treatment for AUD only. Results showed that both treatments enabled a great reduction in alcohol use and dependency. However, participants that underwent the integrated treatment were observed to have a greater decrease in social anxiety symptoms and a greater increase in overall quality of life. More importantly, these results remained constant even after a 6-month follow-up. This means that integrated treatment has long term effects on overall functioning and quality of life.
While the above has proven that integrated treatment is indeed useful in overcoming social anxiety and AUD, the road to recovery is a long and arduous journey, where there are a lot of physical and mental challenges suffered by both the clients and their families. Hence, these issues could be more easily overcome or even avoided if there are early intervention and support to at-risk youths.
Over the years, the number of youths drinking alcohol has increased. According to the Avon Longitudinal Study of Parents and Children (2004), the number of youths that engage in binge drinking increase tremendously between the age of 18 and 21 (from 18% to 35% respectively). Furthermore, 18-year-olds who drank alcohol as a coping mechanism or who had anxiety disorders were 1.8-3.8 times more likely to drink. Both groups had a greater risk of transitioning from low-risk alcohol use at age 18 to high-risk alcohol use at age 21.
There are many motives that may drive youths to drink alcohol. A primary reason is that youths are at a phase where they are transitioning to adulthood. Adulthood brings more stress and anxiety due to changes such as new relationships; along with new responsibilities and challenges such as living in a dormitory and budgeting. Additionally, this phase of life also provides youth with more autonomy and drinking opportunities (e.g. clubbing, drinking games). With these drastic changes in life, youths often drink to enhance positive moods, socialise with others, conform to social groups, or as a coping mechanism to overcome stress or anxiety. This causes harms associated with alcohol to peak in early adulthood, emphasising the importance of early intervention to avoid these detrimental consequences.
An ongoing programme called “Inroads Study” (Stapinsky et. al., 2019) aims to provide early intervention to youths with anxiety disorders and AUD. It seeks to enhance anxiety coping skills and address coping-motivated drinking. Moreover, this programme is specially tailored to make it more relevant and appealing to youths. This includes making the programme available online, which is preferred by youths as it is more convenient, affordable and reduces stigma. Participants can freely access online therapy sessions and modules about tackling challenges often faced by youths. Thus, such interventions can address the interconnections between anxiety and alcohol use, as well as reach out successfully to youths in a relevant and appealing manner.
Prevention programmes are also forms of early intervention that may benefit younger youths (i.e. 13- or 14-year-olds) that have a ‘high-risk’ of developing substance disorders, even if they do not currently have a substance disorder. It is vital to identify early onset of problems faced by youths and nipping them in the bud, providing them with early support and teaching them relevant life skills. This prevents problems faced by youths from developing into more severe adulthood problems such as substance disorders, chronic mental health problems and delinquency.
One such prevention programme was organised by Edalati & Conrod (2019), who first identified at-risk youths through the Substance Use Risk Profile Scale; where those with higher levels of certain personality traits (e.g. sensation seeking and negative thinking) were at higher risk of abusing substances before the onset of use. Afterwards, these youths attended coping skills workshops, CBT and motivational interviewing. Results showed that the programme proved effective in reducing alcohol use, alcohol-related harms and emotional and behavioural problems (i.e. symptoms of anxiety and depression). This shows the importance of early intervention and prevention programmes.
In conclusion, it is apparent that there are interconnection and the longstanding link between anxiety and alcohol use, where this co-morbidity can cause huge effects on one’s physical and mental wellbeing. Thus, this raises the importance of integrated treatment, allowing both conditions to be resolved at the same time. Furthermore, early intervention is extremely vital to offer support to youths and prevent potential disorders from occurring. More importantly, all this shows that alcohol is not the answer to relieve stress and anxiety, and can only serve to exacerbate rather than resolve our problems. Thus, such action could be done to reduce excessive alcohol use in our society, such that harmful usage and effects of alcohol could be prevented.
Smith, J. P., & Randall, C. L. (2012). Anxiety and alcohol use disorders: Comorbidity and treatment considerations. Alcohol Research: Current Reviews, 34(4), 414–431.
Stapinski, L. A., Rapee, R. M., Sannibale, C., Teesson, M., Haber, P. S., & Baillie, A. J. (2015). The clinical and theoretical basis for integrated cognitive behavioral treatment of comorbid social anxiety and alcohol use disorders. Cognitive and Behavioral Practice, 22(4), 504–521.
Golding, J., & ALSPAC Study Team (2004). The Avon Longitudinal Study of Parents and Children (ALSPAC)–study design and collaborative opportunities. Eur J Endocrinol. 151, U119-U123.
Stapinski, L., Prior, K., Newton, N., Deady, M., Kelly, E., Lees, B., Teesson, M., & Baillie, A. (2019). Protocol for the Inroads Study: A Randomized Controlled Trial of an Internet-Delivered, Cognitive Behavioral Therapy-Based Early Intervention to Reduce Anxiety and Hazardous Alcohol Use Among Young People. Journal of Medical Internet Research, 8(4), 1-14.
Edalati, H., & Conrod, P. J. (2019). A Review of Personality-Targeted Interventions for Prevention of Substance Misuse and Related Harm in Community Samples of Adolescents. Frontiers in psychiatry, 9, 770.
Youths these days have a lot on their plate. Teenagers have to cope with the highly competitive education system, and the fresh graduates are worried about employment opportunities or career advancement. Coupled with the need to maintain good relationships with their friends and family, these individuals may be experiencing high levels of stress. Some people do thrive well under stress, but what happens when stress levels exceed the healthy range? For those who are unable to cope, chances are their mental wellbeing would take a toll.
With young people unable to attend school in person regularly or go into the workplace during the circuit breaker, they might have felt increasingly isolated due to the lack of face-to-face social interaction over this extended period of time. Furthermore, having to fight for their own space while at home with their family members may have caused some conflict and frustration for some. Undoubtedly, cabin fever may have also kicked in for some of them. Although circuit breaker measures have recently been eased, youths may not be able to adjust back to the norms as easily as one might expect. Reports have shown that it is expected that more youths will be prone to developing mental health issues such as depression due to the various implemented COVID 19 pandemic coping measures.
Depression is one of the world’s leading mental health disorders, and youths have become increasingly prone to it. Studies have shown that depression affects up to 18% of Singaporean youths. People with depression may turn to self-harm or experience thoughts of suicide. These are often methods they adopt in order to cope with their difficult emotions. According to the suicide prevention agency Samaritans of Singapore (SOS), suicide remains the leading cause of death among youths aged 10 to 29 in Singapore, and as of 2018, 94 of them had succumbed to suicide. In order to curb the rise of depression cases among youths, it is important that we are able to identify the early stages of depression. Doing so will allow them to seek treatment earlier and to help them get back onto their feet. Depression, if left untreated, will severely impact people’s lives in a negative light, causing personal, educational and familial difficulties.
Here are some of the most common symptoms of depression that you should look out for (not exhaustive):
- Extreme sadness and low mood
- Lack of interest in activities once enjoyed
- Lack of self-worth
- Increased lethargy
- Experiences sleep disturbances and loss of appetite
- Poor concentration and impaired memory
- Sense of hopelessness and helplessness
- Excessive self-criticism and self-blame
If you notice a friend or family member of yours showing such symptoms for long periods of time, perhaps it is time to seek help from a professional mental health expert.
But how can we first better support troubled youths? When it comes to dealing with depression, individuals with mild depressive conditions could adopt self-help strategies such as trying to maintain a balanced diet, to pick up on relaxation techniques, embark on daily gratitude journaling exercises (e.g. 3 things I can be thankful for today) and get some exercise in, even if it’s just a stroll around the estate or exercises from ATHLEAN-X™ or Athlean-XX for Women. Try encouraging them to live a healthy lifestyle and maybe create a ‘Daily Wellness Plan’ – a list of little and big things they can accomplish on a daily basis to comfort and keep their moods up. However, it is key to take note that even though their depression may be perceived to be mild from a third person’s point of view, we should never make assumptions as to what they truly feel on the inside. We should never, under any circumstance, tell them to “snap out of it”. It is very important for us to be patient and listen to what they have to say if they do approach and confide in you. Stay empathetic and show your concern for the individual. Acknowledge and respect their feelings and worries. Listen actively by using active listening skills. Encourage them to join mental health support groups like those conducted by PSALTCare – journeying with others that are going through similar struggles can encourage social healing.
On the other hand, for those coping with moderate to severe conditions, we might need to encourage them to seek a multidisciplinary approach to recovery like psychiatric help and look to taking medications, with supporting psychotherapy or counselling sessions and support groups. They might also be afraid of the stigma attached to seeing a Psychiatrist or what would transpire in that session. Try to assure them that there is nothing to be ashamed of. In fact, it is a lot more common in Singapore now, and a trip to the Psychiatrist is as straightforward as seeing your family doctor. Alternatively, these youths can book appointments for psychotherapy first. With appropriate treatment and support, it is entirely possible for them to move on and lead a more productive and happier life. Here’s a questionnaire that is widely used by Psychiatrists to help determine depression to help you with next steps decisions: www.mdcalc.com/phq-9-patient-health-questionnaire-9
If you or anyone you know are struggling and are unable to cope with the post-lockdown blues, we strongly encourage you to get professional help. Do not hesitate to contact us when necessary.
- Teen Mental Health: Depression (Accessed 22/05)
- CNA: Under pressure at home and in school, youths battle depression (Accessed 22/05)
- Photo by Yuris Alhumaydy on Unsplash
The COVID-19 pandemic has caused many usual activities to be disrupted – apart from most adults having to work from home, the majority of students are also left with no choice but to do home-based learning (HBL). This leaves them cooped up at home with less face-to-face social interaction with their peers and teachers, and most importantly, this may have heightened their stress levels with regards to their academic performances. Considering that some students will most likely have to bear with HBL for quite some time, they will need to ensure that they are keeping themselves mentally healthy. In any case, having to deal with burnout is certainly undesirable, and learning how to handle their stress is crucial.
Youths dealing with HBL often have many things to stress over – from struggling with technical issues to the lack of discipline over one’s assignments and time management. They may tend to procrastinate more, which is unsurprising considering that they may be studying from the comforts of their bed. For the more studious ones, HBL may pose a challenge since it may be difficult for them to receive immediate feedback and guidance from their teachers. With such factors contributing to their stress levels, these youths may be burnt out even before HBL ends. If you are one of these troubled students struggling with HBL and study stress, here are some tips to help you get through the difficult times and to help you cope better.
Firstly, consider if you are allocating time for exercise in your weekly routine. Are you getting the exercise you need after your online classes? It is a well-known fact that exercising and staying fit can do wonders for your mental acuity, and can help lift your spirits through the release of endorphins, which act as “feel-good hormones”. Setting aside time to keep active will certainly benefit you in more ways than one – both physically and mentally. In addition to exercise, it is an added bonus if you pay more attention to your diet. Eating more brain foods will help you concentrate and absorb information better, hence translating into greater productivity as well as improved quality of work.
Now that there isn’t a need to attend school physically (at least for some students), there is a high chance that you no longer pack and organise your study materials. Moreover, your study space is most likely cluttered with notes, stationery and various other personal belongings. Take this chance to tidy up your workspace whenever you can – be it once you are done for the day or before you start. Excessive clutter can cause unnecessary stress as well as the loss of productivity, especially if you have to spend additional time looking for your relevant study materials or other lost items. Needless to say, over time, this will have a negative impact on your grades. In order to eliminate such potential causes of stress, try to make a conscious effort to tidy your study area often. Having a minimalistic workspace with only the essential items will definitely reduce distractions and allow you to concentrate better. For those who share a space with other family members, cutting down on excessive clutter will also help to keep familial relationships positive, for they will no longer have to bear with an unorganised environment, possibly resulting in less frustration and conflict. Having said this, start tidying up and you will come to realise that it is worth the effort.
Are you someone who lacks self-discipline? Most students find themselves facing this problem, especially with many more sources of distraction while at home. Some may tend to procrastinate and end up not having sufficient time to complete their tasks. Their poor time management thus leads to heightened stress levels, particularly when deadlines are nearing. The best tip we can offer is to start off with a list of all the tasks you need to complete. Create your own calendar or a to-do list, and work backwards from all your deadlines. Allocate enough buffer time to ensure that you can complete your assignments before the due date. With this, you can prioritise your assignments with more ease, as well as to ensure that you do not leave out any important tasks. You may think that you can remember all of them, but as stress levels increase with poor time management, something is sure to slip your mind.
In Singapore, the education system is very competitive, as most people would know. Many students rely heavily on tuition to give them a head start, or to help them catch up with any content that they were unable to grasp. However, with the pandemic, tuition centres are shut down to minimise the spread of the virus, leaving the students on their own to cope with their studies. As such, these students could be increasingly stressed out, for fear of falling behind on their school work. If you can relate to these individuals, try forming an online support group with your fellow classmates. Conduct group study sessions and help each other out regarding areas for improvement. Brainstorming ideas while teaching others can help you to revise your concepts as well as to gain more insight into particular topics. In a sense, it is killing two birds with one stone.
Last but not least, unhealthy stress levels can cause anxiety issues for some. In such cases, these individuals are advised to seek therapy or the necessary treatment if things get too overwhelming. Speaking to a therapist can help you to get things off your chest. Studies have shown that verbalising your negative feelings can help make them less intense, and can thus help you cope better with your emotions. We hope that you understand that there is no shame in seeking therapy whenever you are feeling too overwhelmed by studies or other forms of stress. Do come to us whenever deemed necessary, and we will be here to help you along the way.
- Putting Feelings Into Words Produces Therapeutic Effects In The Brain (Accessed on 27/05)
- Photo by Victoria Heath on Unsplash
By Tan Su-Lynn, Educational Psychologist
Bullying can be manifested in many forms, and children and youth can be involved in many ways in it. However, with 1 in 4 children in Singapore reporting that they have experienced bullying a few times a month, bullying might be closer to home than you think.
Bullying is done with the intent to hurt and is repeated or persistent. Often, the target of bullying finds it difficult to stop it or stand up for himself / herself. This is different from peer conflicts or quarrels which typically involve incidents where children mutually hurt each other. As parents and caregivers, how do we support our children as they navigate the complexities of relationship-building, and what are some warning signs that indicate that they are involved in bullying?
Broadly, there are three different types of bullying
- Relational: When hurtful actions are made with the intention to shame a person and damage the forming of healthy relationships and friendships. This can take the form of leaving someone out of a group, teasing, name-calling, expressing negative thoughts or feelings about a person, and even intimidating them to do things against their will.
- Physical: When harm has been inflicted on a person or their belongings. This can take the form of hitting, punching, kicking, inappropriate touching and persistent damaging or stealing of belongings.
- Cyber-bullying: Occurs on the internet, through mobile phones, computers, video-game systems and other forms of technology. Both relational and physical bullying can occur on this platform. For example, digital technology can be used to gossip and spread rumours or hostile messages, or game accounts can be hacked and items stolen.
How do I identify if my child is involved in bullying?
Recognising these warning signs is the first step in stemming bullying.
Warning signs of being a target of bullying:
||Emotional and Behavioural signs|
Warning signs of engaging in bullying:
- gets into verbal or physical fights
- suddenly possesses unexplained extra money or new belongings
- often reacts aggressively towards others
- has friends who bully others
- may be excessively worried about their popularity and reputation
- can be competitive
- has received many disciplinary warnings and actions
- refuses to accept responsibility for their actions
- blames others for their problems
- experiences anxiety or depression
- has difficulty regulating his/her emotions and behaviour
What should I do if I think my child is involved in bullying?
It is important to talk with children who show signs of being bullied or bullying others. The safety and mental health of our children should remain an utmost concern. It’s painful to think of your child receiving or inflicting harm on other kids, but bullying is a serious issue for both the targeted and the aggressor. According to research, a vast majority of bullies have also been the targets of bullying, and less than 1% of primary school children are “true bullies” – those who were not bullied by their peers.
Bear these three C’s in mind when relating with your child: Communicate, Consult and Connect
If you hear from a teacher or another parent that your child involved in a bullying situation, the first thing you should do is talk to your child about the situation. Be direct about the issue, but make it clear that you are open to hearing your child’s side of the story. Stay calm and say something like, “Your teacher called to tell me that you were involved in some bullying. I’m really concerned about this, and we need to talk about it. Please tell me what happened.”Avoid prejudging the situation and reacting based on emotions. It can be tempting to immediately blame the other party, criticise parenting, or condemn the school system, but it is also worth taking time to look inward and reflect on whether your own actions may be influencing your child’s. Some children may be modelling their interpersonal style based on the behaviour they have observed. If so, it is important to start fostering a positive home environment, where members of the family treat one another with kindness and respect, creating a safe space for children to share their worries and failures.
Talking through the situation with your child can help you understand why the bullying is happening, and what steps need to be taken in order to stop it. For example, you may find that your child has incredibly low self-esteem and bullying helped him/her feel powerful and able to control something. He/she might prefer being known as ‘the worst kid in school’ and interacting with other children in the process, rather than not being noticed at all and having no friends. Or perhaps your child might accept being the target of bullying with the mistaken belief that such behaviours are acceptable between friends. Some children may not be able to articulate their feelings. This is especially true of children who are struggling with anxiety, trauma, or another mental health issue. If you are having trouble, consider consulting a child psychologist or psychiatrist who has a lot of experience evaluating kids’ behaviours. Your child might need a therapist’s help to work through underlying issues, investigate the root of the problem and guide you and your child in tackling the specific challenges that your child faces in his/her social interactions.
Ultimately, it is about building a close and lasting connection with your child. Connecting with your child about his/her day-to-day life will put you in a better position to recognise signs of bullying and trouble. Start with asking your child a few open-ended questions on a daily basis. For example, ask him/her to share about one really great thing that happened that day, and one not-so-great thing. It can be tough to get started, but children who are regularly encouraged to share details of their lives with their parents tend to be more comfortable with continuing to do so when they are in their adolescence. Listening to your child in a supportive, non-judgmental way helps them feel connected to your presence and love in their lives, and makes them more receptive to opening up to you about their problems as well as accepting the advice that you give to them. It is always better to handle challenging issues like bullying together so that your child will be able to walk out of the shadow of the bullying with confidence and courage.