When A Comorbidity Isn’t “Comorbid” At All

When medical professionals speak of the burden of illness, we use the term “morbidity.”  This can refer either to the impact of an illness on a patient’s quality of life, or to the overall impact of a disease on a defined community.  We also speak of “co-morbidities,” which, as you might expect, are two concurrent conditions, both of which must be treated in order for a patient to experience optimal health.

Comorbidities can be entirely unrelated, as in the case of a tooth abscess and fecal incontinence (at least I hope those are unrelated!).  Alternatively, they can be intimately connected, like CHF and coronary artery disease.  They may also represent seemingly discrete phenomena which, upon closer inspection, might be related after all—at least in some patients—like schizophrenia and obesity, depression and HIV, or chronic fatigue syndrome and XMRV (oops, scratch that last one!).  The idea is that it’s most parsimonious to find the connections between and among these comorbidities (when they exist) and treat both disorders simultaneously in order to achieve the best outcomes for patients.

I was recently asked to write an article on the comorbidity of alcoholism and anxiety disorders, and how best to manage these conditions when they co-occur.  Being the good (and modest—ha!) researcher that I am, I scoured the literature and textbooks for clinical trials, and found several studies of treatment interventions for combined anxiety and alcoholism.  Some addressed the disorders sequentially, some in parallel, some in an integrated fashion.  I looked at drug trials and therapy trials, in a variety of settings and for various lengths of time.

I quickly found that there’s no “magic bullet” to treat anxiety and alcoholism.  No big surprise.  But when I started to think about how these conditions appear in the real world (in other words, not in a clinical trial), I began to understand why.

You see, there’s great overlap among most psychiatric diagnoses—think of “anxious depression” or “bipolar with psychotic features.”  As a result, psychiatrists in practice more often treat symptoms than diseases.  And nowhere is this more the case than in the diagnosis and treatment of addictions.

Addictions are incredibly complex phenomena.  While we like to think of addictions like alcoholism as “diseases,” I’m starting to think they really are not.  Instead, an addiction like alcoholism is a manifestation or an epiphenomenon of some underlying disorder, some underlying pain or deficiency, or some sense of helplessness or powerlessness (for a more elaborate description, see Lance Dodes’ book The Heart of Addiction).  In other words, people drink not because of a dopamine receptor mutation, or a deficiency in some “reward chemical,” or some “sensation-seeking” genotype, but because of anxiety, depression, or other painful emotional states.  They could just as easily be “addicted” to gambling, running, bike riding, cooking (and yes, sex) as ways of coping with these emotions.  Incidentally, what’s “problematic” differs from person to person and from substance to substance.  (And it is notable, for instance, that mainlining heroin = “bad” and running marathons = “good.”  Who made that rule?)

“But wait,” you might say, “there’s your comorbidity right there… you said that people drink because they’re anxious.”  Okay, so what is that “anxiety”?  Panic disorder?  Post-traumatic stress disorder?  Social phobia?  Yes, there are certainly some alcoholics with those “pre-existing conditions” who use alcohol as a way of coping with them, but they are a small minority.  (And even within that minority, I’m sure there are those whose drinking has been a remarkably helpful coping mechanism, despite the fact that it would be far more supportive of our treatment paradigm if they just took a pill that we prescribed to them.)

For the great majority of people, however, the use of alcohol (or another addictive behavior) is a way to deal with a vastly more complicated set of anxieties, deficiencies, and an inability to deal with the here and now in a more direct way.  And that’s not necessarily a bad thing.  In fact, it can be quite adaptive.

Unfortunately, when we psychiatrists hear that word “anxiety,” we immediately think of the anxiety disorders as written in the DSM-IV and think that all anxious alcoholics have a clear “dual diagnosis” which—if we diagnose correctly—can be treated according to some formula.  Instead, we ought to think about anxiety in a more diffuse and idiosyncratic way:  i.e., the cognitive, emotional, behavioral, and existential phenomena that uniquely affect each of our patients.  (I’m tempted to venture into psychodynamic territory and describe the tensions between unconscious drives and the patient’s ego, but I’m afraid that might be too quaint for the sensibilities of the 21st century mind.)

Thus, I predict that the rigorous, controlled (and expensive, and time-consuming) studies of medications and other interventions for “comorbid” anxiety disorders and alcoholism are doomed to fail.  This is because alcoholism and anxiety are not comorbid in the sense that black and white combine to form the stripes of a zebra.  Rather, they make various shades of grey.  Some greys are painful and everlasting, while others are easier to erase.  By simplifying them as black+white and treating them accordingly, we miss the point that people are what matter, and that the “grey areas” are key to understanding each patient’s anxieties, insecurities, and motivations—in other words, to figuring out how each patient is unique.

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14 Responses to When A Comorbidity Isn’t “Comorbid” At All

  1. Rob Lindeman says:

    I do believe you’re beginning to “get it”, doctor! Treating phenomenology instead of people is a hell of a bad way to practice medicine, particularly when at the end of the day you’ll be prescribing a psychoactive medication.

    As long as we have no idea at all as to the pathology and pathophysiology of mental illness, we treat these people with drugs at their peril, and ours.

    • stevebMD says:

      Rob,

      Thanks… but the post wasn’t so much about treating with drugs vs therapy, but about the phenomenology of addictive illness, especially when “comorbid” with something else. There is absolutely no reliable way to separate out the addiction from the anxiety disorder in any given patient, as they interact with (and feed off of) each other in unpredictable and idiosyncratic ways. Assuming that the two entities are distinct for the purposes of a clinical trial is, in my opinion, absurd.

  2. duanesherry says:

    Steve,

    On again, your post is insightful. I agree with much of what you have to say, however we part ways in a couple of areas:

    If we’re talking about human suffering, I think your assessments on (such things) as the connection between alcholism and anxiety make sense. But if we’re talking about science, I don’t think these issues make their way onto the table of discussion.

    Also, ‘black or white’…
    … But some things are black and white. If not, then why the zebra?

    The story of creation (seen metaphorically) is as much about separation as anything else… light from darkness, etc… This appears to bring order to the universe… not chaos…

    In other words, I think your profession, psychiatry has lost its way, and needs some leadership…. It needs some ‘black and white’…. It needs to have more order, and less chaos….

    If ‘brain disorders’ are scientific, then it needs to show us the science…. If these issues are human suffering, then it needs to exercise more empathy, more compassion, more understanding.

    Space Shuttle Atlantis takes off tomorrow. The best of science, and the best of humanity… The mission (like every one of them before) will be a series of ‘go’s or an ‘abort’… Scientists, engineers behind the scenes…. A team of dedicated people whose eyes and ears will be on the safety of that crew… A ‘team’ unlike any other….

    Also, a leader at Johnson in Houston, who can overide the President of the United States, with his ‘go’ or ‘abort’…. A ‘team’ with a ‘strong leader’….

    This is what is missing in your profession.
    Psychiatry needs not only a strong team, but a leader.

    It needs to figure out where its been, where it is today, and where it would like to go… And once you and your colleagues have figured those things out, you can let the rest of us know.

    We’ve paid for your research (with taxpayer dollars), and we’ve not seen much for our money… in the areas of science and humanity.

    Let us know what you come up with.
    We’re anxious to hear.

    Duane

  3. BehaveNet says:

    Unconscious and ego are concepts too quaint for the post modern mind if not the 21st century mind.

    Your thesis suffers from vague definition. How do you define “cope” for example? Also, addiction is not about why the addict uses the substance (or behavior) but HOW. Jack London recognized this when he wrote “John Barleycorn…”

    Why throw the baby out with the bath water? As long as we keep in mind the limitations of our primitive categories, what’s wrong with saying comorbid or coexisting? Some people “have” only one, many have quite a few. Sometimes that helps with planning interventions. We just have to remember there’s only one brain.

    Rob, we know quite a lot about the pathology, maybe even the pathophysiology, but we still don’t know the mechanism. Still, we have drugs like naltrexone and buprenorphine that work.

  4. duanesherry says:

    Dr. Balt,

    RE: Last comment on this post, and on this blog.

    I’ve done my best (for the past five years.. on several blogs, in numerours place) to point out safer and more effective options for the symptoms of “mental illness”.

    Much of what I’ve had to say has landed on deaf ears in the psychiatric community (professional mental health system workers).

    So, I’m not going to take part in this any longer…
    Psychiatry has been a failure.

    Other options?
    We haven’t begun to scratch the surface!

    The rest is up to your profession…

    However, should you and your colleagues choose instead to ignore the realities, it’s likely that you’ll be replaced… by peer-run respites, and integrative practioners (from a varity of arts and sciences).

    I appreciate your forum.
    I’ve done my best.
    I’m exhausted…

    Duane

  5. thealienist says:

    Steve,

    You have left out a lot of research about comorbidity. The substance use researchers have been looking into different types of comorbidity and the effects that these types have on treatment. We have Type A and Type B alcoholics and Early- and Late-Onset alcoholics. We have evidence that if you treat the anxious Early-Onset alcoholic with an SSRI to reduce anxiety, you can indeed reduce the anxiety but you do not change (and may worsen) the alcohol use. SSRI use in anxious Late-Onset Alcoholics is more successful for both problems. 5-HT3 blockers, however, seem to be helpful in the Early-Onset alcoholics.

    Certainly, we have a long way to go, but there are researchers out there who are looking at more meaningful ways to identify and address problems of comorbidity in substance use disorders.

  6. Gary says:

    When the host wrote “deal”, maybe he he meant “not deal”. I’ve always been struck by the obvious wrongness of statements such as:

    “… the use of alcohol (or another addictive behavior) is a way to
    deal with a vastly more complicated set of anxieties…”

    Notice that “deal” and “not deal” are opposites. Zyprexa is associated with weight loss, or Zyprexa is not associated with weight loss? Not a trivial error.

    Addiction is a strategy of avoidance, or “not dealing.” Addiction is procrastination. Postponing the inevitable. Of not dealing.

    • Jackie says:

      Sometimes avoidance is “dealing.”

      Now, I agree with what you are saying if the person is avoiding something (looking for a job, marriage counselling, e.g.) which is causing the anxiety. Then hitting the bottle would be “not dealing” with the underlying problem.

      But sometimes there is no underlying problem causing the anxiety. If hitting the bottle avoids that kind of anxiety, then it is “dealing.” Not the best way, and one that brings its own problems, but “dealing” nonetheless.

  7. stephany says:

    Another way to put it is “self-medicating” that’s typically how a patient’s doc would describe drinking away problems, then slap on a dx and offer a benzo instead!

    http://clinicaltrials.gov/ct2/show/NCT00352469?term=anxiety+alcoholism&rank=1

    There’s a trial for this discussion, Seroquel the antipsychotic for everyone! You can bet that’s the dual dx drug of choice given at psych wards where inpatient docs see a lot of dual dx patients, and many times, no therapists on board inpatient, so no one is there to help decipher what came first? the self-medicating w booze for anxiety etc or the anxiety? one thing concrete we know is the patient will be discharged on pharmaceuticals, many w a 90 day court order to take the meds.

    I’m not a doctor, but it sure doesn’t seem logical to put a patient on a drug regime to replace another vice, without serious psycho-therapy on board…. not to forget that using this study as example via antipsychotic Seroquel: it is an abusable med, often abused in prisons, via crushing, snorting.

    http://ajp.psychiatryonline.org/cgi/content/full/164/1/174

  8. Jackie says:

    “Re-thinking Addiction’s Roots, and Its Treatment” from today’s New York Times:

    http://www.nytimes.com/2011/07/11/health/11addictions.html

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