J Am Board Fam Pract: first published as 10.3122/jabfm.4.1.47 on 1 January 1991. Downloaded from And Substance Use Disorders: A Primer For Primary Care Physicians

MimI Landry, David E. Smith, M.D., David McDuff, M.D., and Otis 1. Baughman III, M.D.

Abstract: Primary care physicians encounter many patients with primary and secondary anxiety and substance use problems. Some patients have a of both an anxiety and a . Symptoms may be overdiagnosed, underdiagnosed, and misdiagnosed. This article provides the primary care physician with an overview of the relation between psychoactive substance use disorders and anxiety symptoms. Also described are drug use patterns and diagnostic criteria for psychoactive substance use disorders. A model for understanding the role of anxiety symptoms during drug use is provided. (J Am Board Fam Pract 1991; 4:47-53.)

Primary care physicians, especially rural family liability, and dual or multiple diagnoses, physicians, often are the first practitioners to see all within the practical time constraints of pa­ patients who have maladaptive drug use or psy­ tient visits. chiatric problems. In particular, primary care Physicians and other professionals who focus physicians treat many patients who have anxiety their work on the treatment of have disorders, the most prevalent group of psychiat­ become aware of the complex interrelations ric conditions in the . I Indeed, among common psychiatric syndromes, espe­ physicians in family practice, general practice, cially the forms of anxiety; substance use and internal medicine, and osteopathy write two abuse, especially , illicit drugs, and pre­ thirds (66.8 percent) of all new prescriptions for scribed medications; and ordinary medical ill­ antianxiety or medications.2 They pre­ nesses. These increasingly common clinical scribe more frequently than psychi­ problems can coexist in the same patient, mimic atrists-who prescribe more antidepressants each other, and mask or exacerbate each other. than primary care physicians-however, psychi­ Modem clinicians, especially those in primary atrists typically provide a mental illness diagnosis care specialties, must become expert in the fine http://www.jabfm.org/ for these patients while primary care physicians points of recognition, the subtleties of diagnosis, typically do not.3 Concurrently, primary care the risks and benefits of prescribing psychoactive clinicians treat large numbers of patients with medications, and the art of obtaining effective substance use disorders, whose complaints often consultations and making appropriate referrals. are anxiety, , or depression, rather than This article focuses on the subtleties of diag­

substance use. In addition, medications, such as nosis and shows how concepts from on 29 September 2021 by guest. Protected copyright. the benwdiazepines, which can be particularly medicine can be integrated with current descrip­ useful and beneficial to one patient, may have tive and criterion-based psychiatric diagnosis (as adverse effects on another. in the Diagnostic and Statisticallvlanual of Mental Physicians need to be knowledgeable about Disorders [DSlvf-III-R)) in the primary care set­ differential treatment outcomes, medication ting. The care of ordinary medical patients can be improved by a clearer understanding of the meaning of symptoms and the ways by which From the Haight Ashbury Training and EduL'ation Project, prescribed or self-medication contributes to the San Francisco; Haight Ashbury Free Clinics, San Francisco; Di­ vision of Alcohol and Drug Abuse, Department of , alleviation or exacerbation of symptoms. University of Maryland School of Medicine, Baltimore; and the Family Medicine Residency Program, Spartanburg Regional Anxiety and Anxiety Disorders Medical Center, Spartanburg, SC. Address reprint requests to Haigbt A~hbury Training and Educdtion Project, 409 Clayton Anxiety disorders are the most common group Street, San FrandsL"O, CA 94117. of psychiatric problems (Robins, et al. reported

Anxiety and Disorders 47

.. ------~.-.-...- ...... J Am Board Fam Pract: first published as 10.3122/jabfm.4.1.47 on 1 January 1991. Downloaded from 8.3 percent of Americans experienced clinically ing, or cold clammy hands; (8) dry mouth; (9) significant anxiety symptoms in a 6-month pe­ dizziness or lightheadedness; (10) nausea, diar­ riod, but only 23 percent received some form of rhea, or other abdominal distress; (11) flushes treatment).! However, the physician's decision to (hot flashes) or chills; (12) frequent urination; treat or how to treat must consider the severity (13) trouble swallowing or "lump in throat." of the problem and the risk-benefit ratio of the • Vigilance and scanning: (14) feeling keyed up treatment selected. Symptoms of anxiety are a or on edge; (15) exaggerated startle response; part of the human experience, but more severe (16) difficulty concentrating or "mind going anxiety creates dysfunction, and treatment deci­ blank" because of anxiety; (17) trouble falling or sions should rest upon an accurate diagnosis. It staying asleep; (18) irritability.4 p 253 is clinically useful to separate anxiety symptoms into two groups: primary and secondary. Substance Use Disorders Primary anxiety includes what patients might Substance use disorders are common in the gen­ refer to as "nervousness." In one large study, 25 eral population and the primary care setting, but percent of Americans considered themselves they are frequently undiagnosed. It is estimated "nervous."! It also includes the symptoms that that between 16 and 18 percent of family prac­ are common elements of many psychiatric dis­ tice patients have a formal diagnosis of alcohol­ orders, as well as such specific anxiety disorders ism. 5-7 Understanding the nomenclature and as generalized , post-traumatic definitions of can provide an stress disorder, and panic. important diagnostic foothold. There are two Secrmdary anxiety includes symptoms that are particularly useful ways of describing the use of caused by some other primary problem, e.g., psychoactive drugs: drug use patterns and drug medical illness, medications, or drug abuse. The use disorders. physician should consider whether the patient has a neurological problem, endocrine disorder, Drug Use Patterns prescription or street drug problem, alcohol Drug use patterns provide data that can be use­ withdrawal, or is consuming high doses of caf­ ful to form a diagnostic impression related to feine, over-the-counter cold preparations, diet both psychiatric and substance use disorders.8,9 pills, or . These patterns of volume and frequency of drug It is also important to become familiar with use provide important but incomplete clinical the diagnostic criteria for the various anxiety dis­ descriptions. It is necessary also to understand http://www.jabfm.org/ orders (panic disorder with or without agora­ the distinctions among drug use, abuse, and ad­ phobia, without , so­ diction, especially as they apply to prescribed cial phobia, obsessive compulsive disorder, medications and prescription-other drug combi­ post-traumatic stress disorder, and generalized nations. The cornerstone for understanding the anxiety disorder). distinctions among use, abuse, and addiction is

The DSM-III-R, for example, describes the the concept of drug-related dysfunction. on 29 September 2021 by guest. Protected copyright. essential feature of generalized anxiety disorder Experimental use is short-term, nonpatterned (GAD) as being unrealistic or excessive anxiety trials of a drug in which the user is motivated and worry about two or more life circumstances chiefly by curiosity and a desire to experience for 6 months or longer, during which the patient the anticipated effect. Such use generally begins has been bothered by these concerns more days socially among friends. than not.4 A minimum of six of the following Social-recreational use occurs in social settings 18 symptoms would be exhibited: among friends or acquaintances who wish to share an experience perceived as acceptable and • Motor tension: (1) trembling, twitching, or pleasurable. The primary motivation is social, feeling shaky; (2) muscle tension, aches, or sore­ and use is voluntary. ness; (3) restlessness; (4) easy fatigability. Circumstantial-situational use' is a self-limited • Autonomic hyperactivity: (5) shortness of use of variable pattern, frequency, intensity, and breath or smothering sensations; (6) palpitations duration. Use is motivated by a perceived need or accelerated heart rate (); (7) sweat- to achieve a known drug effect in order to cope

48 JABFP Jan.-Feb.1991 Vol. 4 No.1 1 J Am Board Fam Pract: first published as 10.3122/jabfm.4.1.47 on 1 January 1991. Downloaded from with a specific condition or situation or to en­ current social, occupational, psychologic, or hance the enjoyment of a specific situation. physical problems caused or exacerbated by the Intensified use is long-term patterned use oc­ use of the [drug]." 6 p 169 Alternately, there can curring at least once a day. It is motivated by a be "recurrent use in situations in which use is perceived need or desire to obtain relief from a physically hazardous." As can be seen, drug persistent problem or stressful situation. Use abuse is defined as the use of a may be unrestrained (bingeing), but it is still mo­ to such an extent that it seriously inteiferes with tivated by a desire to obtain relief from a per­ health or occupational and social functioning. sistent problem or stressful situation. There mayor may not be tissue dependence or Compulsive use is frequent, intense, and of rel­ tolerance, but this is not a necessary criterion atively long duration, producing some degree of for diagnosis. dependence; i.e., the user cannot stop at will Substance addiction is a progressive, dysfunc­ without experiencing physiologic discomfort or tional, pathological process that typically in­ psychologic disruption. Again, binge patterns cludes three aspects: (1) compulsion to use or may be involved. reuse a drug, (2) loss of control because of the drug(s), and (3) continued use despite adverse Substance Use Disorders: De/initions consequences.9 Substance use is the nonproblematic and non­ The DSM-IIl-R describes the following nine dysfunctional use of a psychoactive substance criteria, of which three or more have been pres­ both within and outside a medical context. It in­ ent for a month or more to diagnose psychoac­ cludes therapeutically prescribed medications. It tive : can also describe patterns of use that are non­ medical in nature, e.g., occasional self-medica­ 1. Substance often taken in larger amounts or tion with prescribed, nonprescribed, licit, and over a longer period of time than the person illicit drugs. Some patients can successfully self­ intended medicate their own anxiety with prescription 2. A persistent desire or one or more unsuc­ medications that are stolen or borrowed. From cessful efforts to cut down or control sub­ a societal or legal perspective, this might be con­ stance use sidered drug abuse, but conventionally, it is 3. A great deal of time spent in activities nec­ called drug misuse. Diagnostically, this medical essary to get the substance, taking the sub­ mismanagement is not considered drug abuse. stance, or recovering from its effects http://www.jabfm.org/ The term substance use describes experimental 4. Frequent intoxication or withdrawal symp­ and situational drug use patterns (including illicit toms when expected to fulfill major role ob­ drug use), which do not cause dysfunction in the ligations at work, school, or home, or when person's medical, social, or psychological substance use is physically hazardous spheres. Such drug use may be personally re­ 5. Important social, occupational, or recrea­

pugnant to the physician, but unless the drug tional activities given up or reduced because on 29 September 2021 by guest. Protected copyright. use creates dysfunction, there is little or no basis of substance use for medical intervention or treatment. Substance 6. Continued substance use despite knowledge use is not therefore a substance use disorder, ir­ of having a persistent or recurrent social, respective of cultural definitions. Drug use can psychological, or physical problem that is be a signal that serious problems do exist in the caused or exacerbated by the use of the person's life, or it can be a relatively unimportant substance event. However, when faced with such drug use, 7. Marked tolerance: need for markedly in­ the primary care physician can play a valuable creased amounts of the substance in order role in drug education and prevention. to achieve intoxication or desired effect, or Substance abuse denotes the presence of dys­ markedly diminished effect with continued function related to the person's drug use. The use of the same amount DSM-III-R criteria for psychoactive substance 8. Characteristic withdrawal symptoms abuse hinge on the person's continued use of a 9. Substance often taken to relieve or avoid drug despite knowledge of "persistent or re- withdrawal symptoms

Anxiety and Substance Abuse Disorders 49 L J Am Board Fam Pract: first published as 10.3122/jabfm.4.1.47 on 1 January 1991. Downloaded from Criteria 1 and 2 deal with loss of control; cri­ Table 1. Issues That Contribute to Addiction liability.

terion 3 addresses time involvement; criteria 4 Pharmacological and 5 relate to social dysfunction; criterion 6 re­ The pharmacology of the drug lates to continued use despite adverse conse­ Absorption quences; and criteria 7, 8, and 9 relate to the Metabolism Lipid solubility development of tolerance and withdrawal. The critical point is that issues of tolerance, tissue Onset and duration of action dependence, and withdrawal are not necessary Amount and purity of drug Euphorigenic and reinforcing qualities lO for establishing a drug addiction diagnosis. Onset of action Substance dependence can be a confusing term Dependence-withdrawal qualities because it has multiple meanings. The American Environmental Society on Addiction Medicine (ASAM) de­ Total drug combinations scribes substance dependence as having two pos­ Set and setting of the drug use sible components: (1) , Drug experience versus naivete and (2) .ll Psychological de­ Duration of use User expectations pendence centers on the user's need for a drug to Social support network reach a level of functioning or feeling of well­ being. Because this term is particularly subjec­ Host susceptibility Genetic predisposition to addiction tive and almost impossible to quantify, it is of Family history of abuse-addiction limited usefulness in making a diagnosis. Personal history of abuse-addiction Physical dependence refers to tissue dependence, Physical and emotional health High psychic distress establishment of tolerance, and evidence of an Dual diagnosis of and drug abuse abstinence syndrome or withdrawal symptoms upon cessation of drug use. Drug amount and chronicity are important variables: the higher tended period of time despite the risk of depen­ the dosage and longer the period of consump­ dency. For example, patients with severe, disrup­ tion, the more likely the development of toler­ tive, and dysfunctional agoraphobia who cannot ance, dependence, and subsequent withdrawal leave their homes would benefit greatly from symptoms. Physical dependence and tolerance therapy, even when the potential are best understood as two of many possible for dependence exists. The benefit-risk ratio im­ consequences of chronic exposure to psychoac­ plies that it is more dysfunctional for the patient http://www.jabfm.org/ tive substances that can or cannot include addic­ not to engage in social and occupational activi­ tion or dysfunction. ties than the potential for dependence on the drug. The physician's decision to prescribe med­ Dependence on Prescribed Medications ications that have the potential for dependence Physicians whose patients have symptoms of al­ must take into account the severity and dys­

cohol withdrawal are confronted with a diagnos­ functionality of the psychopathology. If the anx­ on 29 September 2021 by guest. Protected copyright. tic red flag that alerts them that problems exist. iety disorder is disruptive, dependence can be an Similarly, when physicians are faced with pa­ acceptable side effect of treatment, especially tients who have developed physical dependence when the physician provides the patient with de­ and tolerance to a prescribed medication, such pendence education, techniques such as drug as a benzodiazepine, once again there are diag­ holidays, and careful dosage regulation in order nostic signals. However, tolerance and depen­ to reduce the dependence. This often requires dence upon a prescribed psychoactive drug are not extra time and more monitoring, but iatrogenic necessarily problematic. There are a number of dependence should be accepted in managing se­ issues that relate to addiction liability (Table 1). vere acute problems or after failure of other Certain patients, e.g., those with family or per­ treatments. sonal histories of alcohol or other drug-related dysfunctions, are at a higher risk for addiction. Diagnosis There are legitimate circumstances for pre­ \\'hen diagnosing a suspected anxiety dis­ scribing psychoactive medications for an ex- order, the physician's first responsibility is

50 }ABFP Jan.-Feb. 1991 Vol. 4 No.1 J Am Board Fam Pract: first published as 10.3122/jabfm.4.1.47 on 1 January 1991. Downloaded from to discriminate between primary psychiatric symptoms. Also, can mimic disorders and secondary causes. In relation to anxiety symptoms. The key is to obtain a com­ drug use and anxiety symptoms, drug use can plete drug history. Figure 1 is a decision tree mimic, initiate or exacerbate, and mask anxiety useful in the differential diagnosis between

Anxiety Symptoms: Irrational/Excessive Worry. Avoidance Behavior, Increased Arousal. No Psychotic Disorder

Evidence of Recent ___Yi_es __ • Or ~ Recent Substance Use ~ Recent Cessation of Psychoactive Drug Use Substance Use ~ No ~ ~

Anxiety - Unrelated to Acute TX of Severe Acute TX of CNS Substance Use Psychopathology Withdrawal ! L

Diagnose Substance Use If Symptoms Cease. Disorder Anxiety Is Secondary to Substance Use ~ !

Establish Drugfree Diagnose Type of Baseline Substance Use Disorder ~ ~

Differential Diagnosis of If Symptoms Persist. Treatment Goal: Organic Anxiety Not Suspect Dual Diagnosis Establish and Maintain Drug Related (Primary), of Anxiety Disorder and From Secondary Anxiety Substance Use Disorders (eg. Medical Problem) ! ! ! http://www.jabfm.org/

Secondary Anxiety: Differentiate Treatment Goal: Addiction Medicine - Endocrine Situational Establish and Maintain Consult or Referral - Neurological Problems From Organic Sobriety and Manage the - Nicotine Anxiety Not Drug Anxiety - Medical Related

! ! on 29 September 2021 by guest. Protected copyright.

Treat the Cause of the Primary Anxiety: Addiction Medicine Anxiety - Generalized Psychiatric Consult or - Agoraphobia Referral - Panic -PTSD

Medical Consult or Treat Anxiety Referral as Needed Stepwise: 1st: Non-Pharmacological 2nd: Non-Psychoactive Meds 3rd: Psychoactive Meds ~

Psychiatry Consult or Referral as Needed Figure 1. Differential diagnosis of anxiety and substance use.

Anxiety and Substance Abuse Disorders 51 J Am Board Fam Pract: first published as 10.3122/jabfm.4.1.47 on 1 January 1991. Downloaded from anxiety disorders and substance-use-related prevention of additional episodes and other sub­ anxiety symptoms. stance abuse disorders.

Drug Use Can Mimic Anxiety Symptmns Drug Use Can Mask Psychiatric Symptoms Psychoactive drugs are termed psychoactive be­ In addiction theory and practice, it is not gen­ cause they can alter a person's central nervous erally important to ask why a patient began to system (eNS) and thus alter mood. Therefore, drink or take drugs, but to determine what hap­ one who ingests a eNS depressant may have pened when the person engaged in this behavior. symptoms of depression, and one who ingests a . Some persons engage in substance use to self­ eNS may have symptoms of over­ medicate a pre-existing disorder. The classic ex­ stimulation or anxiety. In both, the amount, amples are those using - to dose, and duration of drug use are important, as blunt the effects of anxiety or to blunt well as the psychological stability of the person. depression. We believe that patients with pri­ For example, a person who consumes "crack" mary addictive have roughly the same or is prescribed Desoxyn TM, especially at rates of concomitant psychopathology as the higher doses or for extended periods of time, general population, once specific criteria have may have symptoms of mild to severe anxiety, been met. These include: (1) clearing of all psy­ perhaps escalating to psychotic features. The choactive drug acute effects and acute , person may claim to have no personal or family whether drug of choice or prescribed medica­ history of such problems, but if a careful drug tion; (2) clearing of chronic and secondary drug history is taken, there will be a temporal relation effects (e.g., disappearance of stimulant-induced between the drug ingestion and symptoms. It is insomnia and ); (3) clearing of situa­ irrelevant whether the drug is legal or illicit, pre­ tional emotional states that relate to identifica­ scribed or not. The important fact is that anxiety tion and early treatment (e.g., shame, embarrass­ symptoms may not represent an endogenous ment); (4) establishment of healthy eating, anxiety disorder but may be caused by a eNS sleeping, and hygiene habits. active drug. Psychiatric symptoms that are caus­ One hypothetical example of drug use that ally related to drug ingestion will fade over time masks an affective disorder is the businessman as the drug is eliminated from the body. Treat­ who experiences daytime anxiety and poor sleep ment ranges from supportive counseling to med­ onset. He uses a benzodiazepine in the evenings ical management, depending upon the severity in order to go to sleep, and during the daytime http://www.jabfm.org/ of the symptoms and the dosage of the drug he uses alcohol, which is more socially appro­ ingested. priate at business lunches and dinners. He de­ velops eNS tolerance to and dependence on the Drug Use Can Initiate or Exacerbate a Psychiatric alcohol and the benzodiazepine. When he is DIsorder detoxified, his symptoms of insomnia and anxi­

In many cases, drug use can prompt a psychiatric ety will reemerge and linger past the expected on 29 September 2021 by guest. Protected copyright. disorder or extend and exacerbate symptomatol­ withdrawal-related symptoms of insomnia and ogy. The use of drugs can initiate an episode of anxiety. a psychiatric disorder in a person who has never experienced one before. It can prompt the re­ Drug Withdrawal Can Mimic Psychiatric appearance of a latent, hidden, psychiatric Symptmns disorder or worsen an existing, currently symp­ Just as drug use can mimic psychiatric symptoms tomatic disorder. If drug use prompts the ap­ and disorders, so can drug withdrawal mimic pearance of a psychiatric problem that lingers psychiatric symptoms. Because patients often and becomes chronic, it must be treated. The will not consult clinicians during active drug use course of the psychiatric problem becomes more but, rather, during times of crisis and with­ important than the drug that initiated or ex­ drawal, it is important to differentiate between acerbated it. Once the psychiatric problem de­ drug withdrawal symptoms and psychiatric dis­ velops a life of its own, the initiating drug ex­ orders. Clearly, an accurate drug and psychiatric perience becomes important primarily in the history is crucial.

52 JABFP Jan.-Feb.1991 Vol. 4 No. 1 J Am Board Fam Pract: first published as 10.3122/jabfm.4.1.47 on 1 January 1991. Downloaded from Consider the patient who has symptoms of Conclusion depression, lethargy, suicidal tendencies, and Primary care physicians may have many patients agitation. A good drug history would show that with psychiatric symptoms in their medical prac­ the patient recently ended a month-long period tice. These symptoms, such as anxiety, can be of cocaine-benzodiazepine use and was expe­ reflective of endogenous psychiatric disorders, riencing cocaine-benzodiazepine withdrawal. psychoactive substance use disorders, or other Otherwise, the patient could easily be given a medical or environmental processes. It is im­ diagnosis of depression, agitation and suicidal portant to screen patients routinely for psychi­ features, or perhaps an agitated depression with atric and substance use disorders. A first step is suicidal ideations. obtaining a good drug and psychiatric history and understanding drug use patterns, substance use disorders, and the relations between drug Polydrug Use and Psychiatric Symptoms use and psychiatric symptoms. The above descriptions of drug-induced psychi­ atric symptoms relate to the use of a single drug, such as a cocaine addict displaying cocaine­ References induced anxiety with panic or a cocaine with­ 1. Robins LN, Helzer JE, Weissman MN, et aJ. drawal depression. The national trend, however, Lifetime of specific psychiatric disorders is the use of multiple drugs in combination (or in three sites. Arch Gen Psychiatry 1984; 41: 949-58. serially) rather than single drug use. 2. IMS National Prescription Audit; Therapeutic cate­ A common adult combination is alcohol­ gorey report, ten year trend, 1988. Ambler, PA: cocaine-, while adolescents use L\1S America, Ltd. alcohol-cocaine-marijuana combinations. Poly­ 3. Beardsley RS, Gardocki G], Larson DB, Hidalgo j. drug use further complicates the diagnostic pic­ Prescribing of psychotropic medication by primary care physicians and psychiatrists. Arch Gen Psychi­ ture. A frequently used triad is cocaine, alcohol, atry 1988; 45:1117-9. and a benzodiazepine. Cocaine is used as an 4. American Psychiatric Association. Diagnostic and "upper," while alcohol and the benzodiazepine statistical manual of mental disorders. 3rd ed. Re­ are used to self-medicate the side effects of co­ vised. Washington, D.C.: American Psychiatric As­ caine overstimulation, which can include anxiety, sociation, 1987. insomnia, and paranoia. \Vhile intoxicated with 5. Creek LV, Achrich RL, Scherger \VE. The use of

standardized screening tests in family http://www.jabfm.org/ cocaine, the person may have episodes of co­ practice. F am Pracr Res] 1982 j 2: 11-7. caine-induced anxiety with panic. However, as a 6. Hotch DF, Sherin KM, Harding PN, Zitter RE. result of a secondary dependence and tolerance Use of the self-administered Michigan Alcoholism on alcohol and a benzodiazepine, if a withdrawal Screening Test in a family practice center. J Fam is experienced, the patient would be expected to Pract 1983; 17:1021-6. have episodes of anxiety and insomnia. The clin­ 7. Leckman AL, Umland BE, Blay M. Prevalence of alcoholism in a family practice center. J Fam Pract ical picture may be similar but one represents a 1984; 17:867-70. on 29 September 2021 by guest. Protected copyright. drug-induced intoxication state and the other 8. National Commission on Marijuana and Drug represents a withdrawal state. Though symp­ Abuse. Drug use in America, problem and perspec­ toms are similar, the time course, prognosis, and tive. Washington, D.C.: U.S. Government Printing treatment might be different. In this case, the Office, 1973. 9. Smith DE, Landry MJ. Psychoactive substance -induced anxiety would be use disorders: Drugs and alcohol. In: Goldman brief, and the anxiety possibly managed with HH, ed. Review of general psychiatry. 2nd ed. supportive counseling or perhaps a one-time Norwalk, Connecticut: Appleton & Lange, dose of a benzodiazepine. However, the CNS 1988: 166-85. depressant-induced withdrawal anxiety and in­ 10. Landry M. Addiction diagnostic update: DSM-IlI­ somnia would have a longer time course and de­ R psychoactive substance use disorders. J Psychoac­ tive Drugs 1987; 19:379-81. mand more aggressive medical management, in­ II. American Medical Society on Alcoholism and Other cluding a formal sedative- detoxification Drug Dependencies. Review course syllabus. New protocol. York: American Medical Society, 1987 :2.

Anxiety and Substance Abuse Disorders 53