Changes in Anxiety among Abstinent Male Alcoholics*

Journal of Studies on Alcohol, Vol. 52, No. 1, 1991 Changes in Anxiety among Abstinent Male Alcoholics* SANDRA A. BROWN, PH.D., MICHAEL IRWIN, M.D.,* ^ND MARC A. SCHUCKIT, M.D.* Psychology Service, San Diego Veterans Affairs Medical Center & Department of Psychiatry, School of Medicine, University of California, San Diego ABSTRACT. Symptoms of anxiety are prevalent features of alcoholics seeking treatment. In the present study levels of state anxiety among male primary alcoholics (with no preexisting major psychiatric disorders) were examined 3 times per week during inpatientreatment for alcoholism and again at 3 months following treatment. The 171 male alcoholics also completed the trait scale of the State Trait Anxiety Inventory upon admission to an inpatient program and at 3 months following treatment. Results indicate that recently detoxified males experience multiple anxiety symptoms, with 40% reporting significantly elevated levels of state anxiety at admission (> 75th percentile). By the second week of treatment state anxiety scores typically returned to the normal range although symptoms continued to decrease significantly with each week of continued abstinence. Elevated levels of anxiety symptoms were more common among primary alcoholics with a history of panic episodes or generalized anxiety disorder symptoms. While abstainers and relapsers did not differ in level of anxiety observed during treatment, the relapsers report significantly higher state and trait anxiety scores at follow-up. (J. Stud. Alcohol 52: 55-61, 1991) YMPTOMS OF MOOD disturbance are common among people entering treatment for alcoholism. It is often difficult to discriminate between independent disorders and symptoms secondary to intoxication, toxicity, withdrawal and idiosyncratic reactions to the drug (Allen and Frances, 1986). Approximately 40% of recently detoxified primary alcoholic males display clinically sig- nificant levels of depressive symptoms upon treatment intake (Brown and Schuckit, 1988). While depressive symptomatology is often severe and can be accompanied by suicidal ideation, such symptoms tend to rapidly diminish with abstinence and seldom require active intervention. Similarly, the vast majority of male alcoholics report anxiety symptoms during drinking or withdrawal, including 80% with palpitations or shortness of breath in such situations (Schuckit et al., 1990). Using the State Trait Anxiety Inventory (STAI) (Spielberger, 1983), Roelofs and Dikkenberg (1988) found that level of anxiety varies with length of abstinence during the year following treatment. Reports of the incidence and severity of anxiety Received: July 25, 1988. Revision: June 30, 1989. *This research was supported by grants from the Department of Veterans Affairs Research Service and the National Institute on Alcohol Abuse and Alcoholism. *Drs. Irwin and Schuckit are affiliated with the Alcohol Research Center, San Diego VA Medical Center, and the Department of Psychiatry, School of Medicine, University of California, San Diego. Requests for reprints should be directed to Sandra A. Brown, Ph.D., Psychology Service (116B), Veterans Affairs Medical Center, San Diego, Calif. 92161. symptoms among alcoholics during the first few weeks of alcohol treatment vary markedly. However, such discrepancies are not surprising since anxiety may occur secondary to withdrawal, as well as a primary or minor feature of anxiety disorders, affective disorders, personality disorders, psychosis and organic disorders. The incidence of anxiety disorders that might require treatment among the alcoholic population has received increasing attention in the alcoholism research literature (e.g., Weissman et al., 1980). For example, Mullaney and Trippet (1979) reported that 33% of female alcoholics and 13% of male alcoholics met criteria for agoraphobia whereas 17% and 25%, respectively, could be classified as social phobias. Additionally, an elevated incidence of alcoholism (25-64%) has been reported among those with posttraumatic stress disorder (e.g., Egendorf, 1982; Sierles et al., 1983). The incidence of mood disturbance reported in alcohol dependent samples varies with measurement procedure, as well as differences in diagnostic criteria employed and length of the abstinence at the time of assessment (Brown and Schuckit, 1988). Considering the high level of withdrawal related anxiety, it is possible for anxiety disorders to be misdiagnosed (Schuckit et al., 1990). However, unlike major anxiety disorders, severe anxiety symptoms among primary alcoholics are likely to abate with time and in the absence of active intervention. The variability in the incidence and causes of anxiety symptoms as well as other mood dysfunction among alcoholics is complicated because many studied groups are heterogeneous with regard to primary diagnosis (Schuckit, 55

56 JOURNAL OF STUDIES ON ALCOHOL / JANUARY 1991 1985). For example, higher levels of panic disorder (5%) and generalized anxiety disorder (11%) have been reported for alcohol and narcotic addicts (Rounsavitte et at., 1980) than for primary alcoholics (1% and 4%, respectively) (Schuckit et at., 1990). In order to clarify the typical incidence, change and relation to outcome the present study examined anxiety symptoms among a group of carefully diagnosed male primary alcoholics throughout a 4-week inpatient alcoholism treatment program and at 3-month follow-up. The change in level of both state and trait anxiety symptoms with abstinence was examined. Also, anxiety symptoms were examined among those with features of secondary anxiety disorder symptoms. Subjects Method Male veterans entering the Alcoholism Treatment Program at the San Diego VA Medical Center were screened for participation through the Alcohol Research Center (ARC). One hundred and seventy-one men meeting DSM- III (American Psychiatric Association, 1980), criteria for alcohol dependence and alcoholism defined by RDC (Spitzer et al., 1978) agreed to participate in this study (98% of those eligible) and completed assessments during treatment and at 3-month follow-up. Veterans completed the Alcohol Research Center Interview (Schuckit et al., 1988), which is a structured clinical interview derived from the Schedule of Affective Disorders and Schizophrenia (Spitzer and Endicott, 1977), the Diagnostic Interview Schedule (Robins et al., 1985) and additional questions to determine DSM-III-R anxiety disorder symptoms (American Psychiatric Association, 1987). A resource person (family member, girlfriend or close friend, typically living with the patient) completed a comparable interview for the veteran. All interview information from the veteran and resource person as well as medical records were reviewed by a psychiatrist for diagnosis. In order to examine only veterans who fulfilled criteria for alcohol dependence before any other major psychiatric disorder had developed (i.e., primary alcoholism), 29% of the admissions were excluded from the present study. Of the original 241 consecutive admissions considered, 12% had an onset of antisocial personality disorder prior to major life problems from alcohol, 11% met criteria for other substance abuse before the onset of alcoholism and 6% had other primary psychiatric disorders including two individuals (1%) who met DSM-III-R criteria for panic disorder prior to the onset of alcoholism. The primary alcoholics, aged 22 to 74 years (mean [-SD] = 45.6-10.8) had completed an average of 13.0 years of education and were typically unemployed TABLE 1. Recent drug use of male primary alcoholics (N= 171) Median (range) Number reporting Number reporting number of use during use during week days since preceding month preceding treatment last use* Marijuana 26 6 14 (2-90) Barbiturates 2 0 38 (2-74) Amphetamines 5 I 20 (5-90) Cocaine 7 0 24 (7-90) Solvents 1 0 14 *Within last 3 months. (73.4%) at the time of entry into the Alcoholism Treatment Program. Forty-two percent of the population were divorced, 27% were married, 15% were separated, 15% were single and 2% were widowed. The population was predominantly white (81%) although blacks (12%), Hispanics (5%) and Native Americans (1%) were represented. The average age at which the criteria for alcoholism were first met was 34.6-11.7 years, and men reported an average of 16.4-10.9 drinks per day on an average of 25.2-7.6 days per month during the 3 months prior to entry into the Alcoholism Treatment Program. As a result of outpatient detoxication procedures, this sample had been abstinent an average of 9.35 --- 7.43 days prior to treatment. The primary alcoholic men in the present study typically had experience with other drugs (61.0%) with an average of 1.6-2.0 different drugs sampled during their lifetime. Twenty-four percent reported drug use during the 3 months prior to treatment with marijuana being the most commonly used drug (N = 35). The average length of time since last use of any drug other than alcohol was 33 days, and as Table 1 indicates very few men reported recent drug experience that might produce anxiety symptoms. Further, none of the individuals studied were taking psychotropic medication at the time of study. Men who had been prescribed medication during outpatient detoxication discontinued such medication at least 48 hours prior to study. Procedure Men entering the Alcohol Treatment Program were interviewed by ARC staff within 48 hours of admission using the Alcohol Research Center Interview (Schuckit et al., 1988); at least one resource person for each patient was interviewed as well. The ARC instrument was de- signed to assess history of alcohol and substance abuse for self and family, demographic and medical information, alcohol withdrawal symptoms, psychiatric diagnoses most relevant to alcoholics and occurrence of the onset of major life problems related to alcohol and drugs. For each par-

BROWN, IRWIN AND SCHUCKIT 57 ticipant a resource person was selected for interview who was currently or recently living with the veteran and who had knowledge of the participant's personal and family history. Resource person interviews were typically completed by wives, ex-wives, girlfriends, siblings or parents (87%). Interview data from the patient and resource person and medical records were independently reviewed by a psychiatristo determine primary and secondary diagnoses based on DSM-III alcohol dependence (American Psychiatric Association, 1980) and RDC alcoholism criteria (Spitzer et al., 1978). The State Trait Anxiety Inventory (STAI) (Spielberger, 1983) was used to assess severity of anxiety symptoms during treatment and at 3-month follow-up. The STAI is a 40-item self-report questionnaire comprised of two independent sections: the S-Anxiety scale that measures how individuals feel "right now" (e.g., I feel frightened; I feel nervous), and the T-Anxiety scale that refers to stable or persistent patterns of anxiety-proneness (e.g., I have disturbing thoughts; I worry too much). Higher state anxiety scale (S-Anxiety) scores are characterized by subjective feelings of nervousness, tension, worry and arousal of the autonomic nervous system. High T-Anxiety scores reflect the tendency to perceive stressful situations as dangerous or threatening and to respond with intense, anxious reactions. Factor analytic studies have confirmed the state and trait dimensions of the STAI (e.g., Spielberger et al., 1980; Vagg et al., 1980) among several nonalcoholic populations. T-Anxiety scale scores are relatively stable over time with test-retest reliability coefficients ranging from.71 to.86 for a 1-month period and from.65 to.77 for a 2- to 3-month time period. As expected, S-Anxiety scale scores fluctuate more over time; however, this scale has good internal consistency (median alpha coefficient of.93 for working adults, college students and military samples). Further, construct validity studies with this instrument indicate that the STAI is a good measure of anxiety symptoms across a variety of medical and neuropsychiatric populations (see Spielberger, 1983). The STAI was administered within 48 hours of admis- sion and the S-Anxiety scale was individually completed 3 times per week for the duration of the 4-week inpatient treatment program. The STAI was also completed at 3- month follow-up to assess anxiety symptoms in relation to drinking status and to determine whether self-report of anxiety-proneness (T-Anxiety) scale scores diminish with abstinence. As part of the ARC, information regarding the symptoms and occurrence of panic attacks as well as generalized anxiety disorder symptoms was obtained. Specifically, the ARC interview (Schuckit et al., 1988) is used to query the alcoholic and resource person regarding occurrence of DSM-III-R panic attack symptoms (e.g., shortness of breath; chest pain or discomfort; fear of going crazy or doing something uncontrolled), frequency of attacks and incidence of attacks during periods of drinking, drug use and abstinence. Similarly, questions regarding the experience of DSM-III-R generalized anxiety disorder symptoms (e.g., worry, motor tension, autonomic hyperactivity and vigilance and scanning), duration of symptoms and relation to alcohol and drug use are included in both alcoholic and resource person interviews. All information was reviewed by a psychiatristo determine generalized anxiety disorder and panic disorder diagnoses. Subjects were assessed at 3 months following treatment with the ARC follow-up interview (Schuckit et al., 1988), resource person interviews, medical chart review and blood draws to verify drinking outcome status. Interviews were conducted with 97% of the sample and outcome was determined by resource person interview or chart review in the remaining cases. The multiple criteria procedure based on percent change in gamma-glutamyltransferase (GGT), aspartate aminotransferase (SGOT) and alanine aminotransferase (SGPT), which was developed and cross-validated by Irwin and associates (Irwin et al., 1988), was employed to verify recent abstention. Results The mean weekly S-Anxiety scores were calculated for each participant. Figure 1 displays the S-Anxiety scores of primary male alcoholics over the 4-week inpatient period and at the 3-month follow-up point. S-Anxiety scores decreased significantly over the 4-week time period (F = 2,216/93, 1/170 df, p.001) with means of 39.02 ñ 11.45, 35.87 ñ 10.78, 33.58 ñ 10.57 and 32.72 ñ 11.61, respectively. Post hoc Newman-Kuels analyses indicate significant reductions (p.05) in S-Anxiety scores between week 1 and week 2, week 2 and week 3, and week 3 and week 4. Upon entry 40% (n = 68) obtained S-Anxiety scores above the 75% percentile for this age group (S-Anxiety- 44); however, by the second week of treatment mean S-Anxiety scores were within the normal range. At discharge only 12% of males obtained scores above the 75th percentlie. Of the 171 men assessed during treatment and at follow-up 41% (n = 70) returned to drinking within the 3-month follow-up period. Those alcoholics abstaining for the entire 3-month posttreatment period differ on anxiety measures from those who return to drinking after treatment only at the follow-up time point (F = 2.74, 1/150 df, p.001). Five percent (n = 5) of male alcoholics abstinent throughout the 3-month follow-up period obtained S-Anxiety scores above the 75th percentlie for this age group. Further, the outcome status (i.e., abstinent or relapsed) was not significantly different for those with discharge S-Anxiety scores above the 75 percentile compared to alcoholics with lower anxiety scores ( (: =.62, I df, n = 67, p =.56).

58 JOURNAL OF STUDIES ON ALCOHOL / JANUARY 1991 t5 "'"-.X x Abstained through... Drank within 3 months following treatment WEEK 1 WEEK 2 WEEK3 WEEK4 3 MONTIt FOLLOW-UP INPA+IENT 3-M( NTH * Significant group difference, p <.001. Figure 1. Mean S-Anxiety scores of male primary alcoholics during and following treatment: abstainers vs relapsers * Significant group difference, p <.01. Figure 2. Mean T-Anxiety scores of male primary alcoholics: abstainers vs relapsers While the S-Anxiety scores were expected to change over time, T-Anxiety scores were expected to reflect more stable characteristics. One-third (33.5%) of primary alcoholics obtained T-Anxiety scores at intake above the seventy-fifth percentile (T-Anxiety-> 40) regardless of drinking outcome status (mean = 45.38-11.89). As shown in Figure 2 the trait anxiety scores of alcoholics are significantly lower at 3-month follow-up (mean = 33.52-11.48) with abstaining alcoholics reporting significantly fewer trait anxiety characteristics than alcoholics who drink during the 3-month follow-up period (F = 1.86, 1/150 df, p <.01). As reported elsewhere (Schuckit et al., 1990), two (1%) of the 171 male alcoholics studied met DSM-III-R diagnostic criteria for panic disorder and 7 male alcoholics (4%) reported symptoms of generalized anxiety disorder after the onset of alcohol dependence. In addition, five other men had experienced at least one panic attack at some time during drinking or nondrinking periods. The demographi characteristics and drinking histories of the anxiety disorder symptom group (n = 7) and panic attack history subjects (n = 7) were comparable to other primary alcoholics. For example, the mean length of alcoholism for these groups was 35.1 years and 36.2 years, respectively, and groups were not significantly different in length of abstinence prior to treatment (F -- 0.42, 2/168 dr, p =.66). The STAI scores of men reporting a history of at least one panic episode and those with generalized anxiety disorder symptoms were each compared to alcoholics without such a history and are presented in Table 2. Male alcoholics with a history of panic episode(s) tend to report more state anxiety symptoms throughouthe 4 weeks of inpatient treatment than alcoholics without a history of panic attacks or anxiety disorder symptoms (mean STAI difference --6.80). However, alcoholics with a panic attack history obtained slightly lower state anxiety scores at follow-up than men without a significant anxiety symptom history. Alcoholics with a panic attack history also tend to report more trait anxiety symptoms at intake (mean = 50.44) compared to alcoholics with no history of such episodes (mean = 45.10); however, groups are comparable at follow-up (means = 34.25 and 33.47, respectively). The seven men evidencing symptoms of generalized anxiety disorder obtained a similar pattern of anxiety symptom severity and remission as those with a panic attack history. Alcoholics with secondary generalized anxiety disorder symptoms report more state anxiety symptoms throughouthe entire 4 week inpatient program (mean STAI difference = 10.07) but at follow-up obtain S-Anxiety scores (mean = 36.00) comparable to alcoholics without an anxiety disorder (mean = 31.11). Similarly, those alcoholics with generalized anxiety disorder

BROWN, IRWIN AND SCHUCKIT 59 TABLE 2. Mean (+ SD) State Trait Anxiety Inventory scores of male primary alcoholics during and following treatment in relation to anxiety disorder symptoms STATE ANXIETY No panic or History of Generalized generalized one or more anxiety anxiety panic disorder symptom attacks symptoms history (n=7) (n=7) (n= 157) Week I 45.70 _+ 11.98 49.11 -+ 6.05 38.65 +- 11.34 Week 2 40.89 ñ 7.25 44.92 ñ 12.49 35.59 ñ 10.89 Week 3 39.52 --- 8.12 42.11 ñ 14.43 33.25 ñ 10.61 Week 4 41.76-12.39 43.81 ñ 18.94 32.18 ñ 11.38 Three-month follow-up 26.63 ñ 5.10 36.00 ñ 13.16 31.11 ñ 13.25 TRAIT ANXIETY Week I 50.44 ñ 13.68 59.50 ñ 6.41 45.10 ñ 11.77 Three-month follow-up 34.25 ñ 5.90 41.67 ñ 11.13 33.47 ñ I 1.74 symptoms reported more trait anxiety during the first week of treatment than alcoholics without an anxiety disorder (means = 59.50 and 45.10, respectively) but reported more similar scores at follow-up (means = 41.67 and 33.47, respectively). Given the limited sample sizes, anxiety scores were subjected to tests of significant differences at only two time points: week 4 of inpatient treatment and 3-month follow-up. The S-anxiety scores of the panic attack group and generalized anxiety symptom group were higher than the primary alcoholics without such a history at week 4 of treatment (approximate F = 5.93, 2/159 df, p <.01) but S-anxiety and T-anxiety scores were not significantly different at follow-up. Histories of panic attacks, diagnosis of secondary panic disorder and symptoms of generalized anxiety disorder were not associated with poorer outcome following treatment. Specifically, one of the seven (14%) men who reported panic attacks, neither of the two panic disorder men and three of the seven (43%) generalized anxiety disorder men relapsed compared to 42% (n = 66) of the 157 male alcoholics without such anxiety symptom histories. Further, three of the 14 men with anxiety histories who drank during the follow-up period did so in a limited fashion ( --< 4 days per month) and one drank continuously (30 days per month). Additionally, the men with anxiety symptom histories who had the highest STAI scores did not drink in the 3 months following treatment. Thus, these three anxiety symptom categories were not associated with poorer 3-month drinking outcome in the male primary alcoholic population studied. Discussion Results of the present study indicate that among male primary alcoholics elevated levels of state and trait anxi- ety symptoms are common upon admission into an alcoholism treatment program and that anxiety states decrease rapidly during inpatient hospitalization. In the present study, the mean state anxiety scores of male alcoholics were within the normal range by the second week of treatment (2 weeks abstinent). Trait anxiety scores as measured by the State Trait Anxiety Inventory at admission are significantly above levels typical for men in the 40 to 60 year old age range, and while it appears that recently drinking male alcoholics view themselves as chronically prone to anxiety and worry, this perception changes dramatically with continued abstinence from alcohol. Thus, a portion of the T-Anxiety scores may reflect drinking state effects rather than personality characteristics. Further, the present findings suggesthat panic disorder and generalized anxiety disorder beginning after the onset of alcohol dependence may not place primary alcoholics at additional risk for relapse in the initial 3 months following treat- ment. Consistent with other studies of anxiety symptoms among alcoholics (e.g., Roelofs and Dikkenberg, 1987), a large portion of recently detoxified alcoholic men report elevations in anxiety symptoms and a perception that they are persistently anxious, troubled and worried. Thus, many alcoholics may present with anxiety disorder type symptoms but these symptoms most typically rapidly abate with inpatient hospitalization and abstinence. In contrasto previous reports indicating a high incidence of anxiety disorders among alcoholics (e.g., Bowen et al., 1984; Mullaney and Trippet, 1979), when only those anxiety symptoms that persist during periods of abstinence are considered among male primary alcoholics the incidence of secondary anxiety disorders is found to be relatively low. It may be that previous studies have made diagnoses during acute and subacute phases of withdrawal or have examined more heterogeneous alcoholic populations in which individuals with primary anxiety disorders or other drug dependence have subsequently developed secondary alcohol dependence. In the present study, state anxiety symptoms returned to normal levels within 2 to 3 weeks of abstinence for 88% of the population studied, although the remainder had high levels (-> 75 percentile) of state anxiety with 4 weeks of abstinence. Further only 7% of men remaining abstinent during the initial 3 months following treatment have elevated S-Anxiety scores. This pattern of anxiety symptom reduction suggests that diagnostic and intervention decisions regarding anxiety disorders should not be made prior to 3 weeks of abstinence and that male alcoholics may experience fewer anxiety symptoms than is typical for the general adult male population if they maintain abstinence for 3 months. The pattern of anxiety symptom reduction noted in the present study parallels the rate of remission of depressive symptoms of male primary alcoholics noted previously

60 JOURNAL OF STUDIES ON ALCOHOL / JANUARY 1991 (Brown and Schuckit, 1988). Of note, the subgroup of male primary alcoholics with a history of generalized anxiety disorder symptoms obtain an average of 10 points more on the state anxiety scale and 15 points more on the trait anxiety scale of the STAI at intake than other primary alcoholics. By the 3-month follow-up, STAI scores of alcoholics with a history of generalized anxiety disorder symptoms were no longer significantly different from the general alcoholic population. There are several possible reasons for the more limited incidence of anxiety symptoms and anxiety disorder symptoms reported in the present study relative to other investigations of alcoholics. Anxiety symptoms were repeatedly measured throughout 4 weeks of inpatient treatment and were found to quickly abate. Assessment of anxiety symptoms and anxiety disorders among alcoholics at only one time point, especially during the first 2 weeks of abstinence, may result in an overestimate of the incidence of both. It is also possible that a portion of the reduction in anxiety symptoms noted in this study reflects the effects of repeated self-report (Hesselbrock et al., 1983; Willenbring, 1986). However, since the trait anxiety measure also shows significant diminution when measured at only two time points that were 4 months apart it is unlikely that the reduction in state anxiety scores is solely a measurement artifact. Furthermore, other studies may have included secondary alcoholics with primary affective disorder, anxiety disorder or other drug dependence that may result in greater reports of anxiety symptoms and a very different pattern of anxiety symptom change over time. Thus, the pattern of rapid abatement of anxiety symptoms described in the present study strictly applies to primary alcoholics. Additionally, the present study included only males most typically in the middle to late middle age range. The incidence of anxiety symptoms and disorders appears to vary across sexes and age groups (Spielberger, 1983) and generalization to other populations should be made with caution. Finally, the possibility that anxiety symptoms remit solely or partly as a function of hospitalization cannot be ruled out. In the present study, a history of panic attacks and generalized anxiety symptoms (as distinct from an independent panic disorder or generalized anxiety disorder) was not associated with poorer drinking outcome even though these male alcoholics did not receive specific behavioral or pharmacologic intervention for anxiety symptoms or anxiety disorders. Of note, self-report state and trait anxiety symptom level during treatment was comparable for alcoholics who abstained and those who drank following treatment. However, relapse rates were higher for individuals with extreme anxiety scores at discharge. Thus, while negative affective states have been identified as common precursors to alcohol and other drug relapse (Marlart and Gordon, 1985), it is unclear whether among primary alcoholics anxiety symptoms or secondary anxiety disorders increase the vulnerability for relapse within the initial 3 months following treatment. In summary, the present study demonstrates that among male alcoholics with no preexisting major psychiatric disorder, anxiety symptoms are prevalent upon entry into treatment but decrease in severity within 2 weeks of treatment. Alcoholics with a history of panic episodes or generalized anxiety disorder symptoms tend to report more state and trait anxiety symptoms during treatment than other primary alcoholics; however, these groups do not appear to have a poorer prognosis or to have more anxiety symptoms at 3 months follow-up. The possibility that male alcoholics with elevated state anxiety scores at discharge may be at higher risk for early relapse merits additional study. References ALLEN, M.H. AND FRANCES, R.J. Varieties of psychopathology found in patients with addictive disorders: A review. In: MEYER, R.E. (Ed.) Psychopathology and Addictive Disorders, New York: Guilford Press, 1986, pp. 17-38. AMERICAN PSYCHIATRIC ASSOCIATION TASK FORCE ON NOMENCLATURE AND STATISTICS. Diagnostic and Statistical Manual of Mental Disorders (DSM-III), Washington, D.C., 1980. AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and Statistical Manual of Mental Disorders, (DSM-III-R), Washington, D.C., 1987. BOWEN, R.C., CIPYWNYK, D., D'ARcY, C. AND KEEGAN, D. Alcoholism, anxiety disorders, and agoraphobia. Alcsm. clin. exp. Res. 8: 48-50, 1984. BROWN, S.A. AND SCHUCKIT, M.A. Changes in depression among abstinent alcoholics. J. Stud. Alcohol 49: 412-417, 1988. EGENDORF, A. The post-war hell of Vietnam veterans: Recent research. Hosp. community Psychiat. 35: 901-907, 1982. HESSELBROCK, M.N., HESSELBROCK, V.M., TENNEN, H., MEYER, R.E. AND WORKMAN, K.L. Methodological considerations in the assessment of depression in alcoholics. J. cons. clin. Psychol. 51: 399-405, 1983. IRWIN, M., BAIRD, S., SMITH, T.L. AND SCHUCKIT, M. Use of laboratory tests to monitor heavy drinking by alcoholic men discharged from a treatment program. Amer. J. Psychiat. 145: 595-599, 1988. MARLATT, G.A. AND GORDON, J. Determinants of relapse: Implications for the maintenance of behavior change. In: DAVIDSON, P.O. AND DAVIDSON, S.M. (Eds.) Behavioral Medicine: Changing Health Lifestyles, Elmsford, N.Y.: Pergamon Press, Inc., 1980, pp. 410-452. MULLANEY, J.A. AND TRIPPET, C.J. Alcohol dependence and phobias: Clinical description and relevance. Brit. J. Psychiat. 135: 565-573, 1979. ROBINS, L.N., HELZER, J.E., CROUGHAN, J., WILLIAMS, J.B.W. AND SPITZER, R.L. NIMH Diagnostic Interview Schedule, Version IliA, Public Health Service ADDM-T-42-3 (4-85), Washington, D.C., 1985. ROELOFS, S. AND DIKKENBERG, G.M. Hyperventilation and anxiety: Alcohol withdrawal symptoms decreasing with prolonged abstinence. Alcohol 4: 215-220, 1987. ROUNSAVILLE, B.J., ROSENBERGER, P., WILBER, C., WEISSMAN, M.M., AND KLEBER, H.D. A comparison of the SADS/RDC and the DSM- III: Diagnosing drug abusers. J. nerv. ment. Dis. 168: 90-97, 1980. SCHUCKIT, M.A. The clinical implications of primary diagnostic groups among alcoholics. Arch. gen. Psychiat. 42: 1043-1049, 1985. SCHUCKIT, M.A., IRWIN, M. AND BROWN, S.A. The history of anxiety

BROWN, IRWIN AND SCHUCKIT 61 symptoms among 171 primary alcoholics. J. Stud. Alcohol 51: 34-41, 1990. SCHUCKIT, M.A., IRWIN, M., HOWARD, T., AND SMITH T. A structured diagnostic interview for identification of primary alcoholism: A preliminary evaluation. J. Stud. Alcohol 49: 93-99, 1988. SIERLES, F.S., ellen, J.J., MCFARLAND, R.E. AND TAYLOR, M.A. Posttraumatic stress disorder in concurrent psychiatric illness: A preliminary report. Amer. J. Psychiat. 140: 1177-1179, 1983. SPIELBERGER, C.D. State-Trait Anxiety Inventory, Palo Alto, Calif.: Consulting Psychologists Press, Inc., 1983. SPIELBERGER, C.D., VAGG, P.R., BARKER, L.R., DONHAM, O.W. AND WESTBERRY, L.G. The factor structure of the State Trait Anxiety Inventory. In: SARASON, I.G. AND SPIELBERGER, C.D. (Eds.) Stress and Anxiety, Vol. 7, New York: Hemisphere Pub., 1980. SPITZER, R.L. AND ENDICOTT, J. Schedule for Affective Disorders and Schizophrenia, New York: New York State Psychiatric Institute, 1977. SPITZER, R.L., ENDICOTT, J. ^ND ROBINS, E. Research Diagnostic Criteria: Rationale and reliability. Arch. gen. Psychiat. 35: 773-782, 1978. VAGG, P.R., SPIELBERGER, C.D. AND O'HEARN, T.P. Is the State-Trait Anxiety Inventory multidimensional.'? Pers. individ. Diff. 1: 207-214, 1980. WEISSM^N, M.M., MYERS, J.K. ^ND H^RDING, P.S. Prevalence and psychiatric heterogeneity of alcoholism in a United States urban community. J. Stud. Alcohol 41: 672-681, 1980. WILLENBRING, M.L. Measurement of depression in alcoholics. J. Stud. Alcohol 47: 367-372, 1986.