Comorbid Social Anxiety and Alcohol Dependence
A. Alcohol use disorders complicate psychiatric disorders
b. Problematc drinking: lifetime diagnosis of alcohol abuse, alcohol dependence of ‘hazardous alcohol use’
c. Hazardous alcohol use: WHO definition – one of the following:
i) 5 or more drinks per day at least 3 days per week
ii) 8 or more drinks per day at least one day per week
iii) 12 or more drinks per day at least one day per month
2. Alcohol abuse: largest predictor of poor social anxiety disorder treatment outcomes (Versiani et al., 1997)
3. Clinical drug trials of mood and anxiety disorders exclude alcohol use disorders
B. Psychiatric disorders complicate alcohol use disorders
1. Co-occurring major depression associated with increased risk of alcohol relapse (Greenfield et al., 1998)
2. Anxiety symptoms can interfere with adherence to alcohol treatment
a. Alcohol treatments include group participation
b. Co-occurring social anxiety disorder: fear group participation
c. Anxiety symptoms may make individuals less likely to seek treatment for alcoholism and less likely to participate fully in group modality including self help groups.
4. Why social anxiety disorder and alcohol dependence are a useful model of alcoholism with psychiatric comorbidity
(1) 22.3% with Social Anxiety financially dependent (on welfare or disability payments)
(2) 10.6% with no disorder
(2) Thus alcoholics may marry persons with social anxiety, children at high risk for both
3.“Drinking to cope”
(c) Women with Social Anxiety may be less likely to use ETOH as coping mechanism in social situations
reduces general tension (Tran et al., 1997)
4. “Drinking to cope
5. Switch Driver Seat (Kushner et al., 1990)
b) MAOI: Monoamine oxidase inhibitor. Serotonin and norepinephrine are monoamines. Monamine oxidase is a housekeeper enzyme which chews up monoama=ine. MAOI’s have been shown to effective antidepressants and anxiolytics. Not used too much today because of dietary restrictions (all psychiatry residents should use an MAOI before finishing training or they won’t use it after training) eg: Nardil, Parnate
d) GABAergic anticonvulsants include gabapentin (Neurontin) and pregabalin (shown effective in studies but not on the market in USA).
a) CBT is similar here as described above under Social Anxiety treatment: focus is on changing drinking behavior
b) MET conceptualizes the therapist as a coach, helping the client progress along the stages of change (precontemplation to contemplation to action to maintainance)
c) TSF is a therapy modeled from the 12 Steps of Alcoholics Anonymous (AA), therapist helps the client work through Steps 1 through 4, encourages attendance at AA meetings outside of therapy time
a) disulfuram (Antabuse): causes build up of a toxic metabolite of alcohol (acetaldehyde) by blocking the enzyme acetaldehyde dehydrogenase. If someone on this drug has alcohol, they will have a bad reaction and feel sick. Placebo controlled studies have not supported it’s efficacy other than in some special populations where medication intake is supervised.
b) naltrexone (Rivea): blocks opiate receptors and is thought to decrease alcohol craving and to make drinking less reinforcing: decreases number of drinking days and number of drinks per drinking day. Some placebo controlled studies have largely supported its efficacy in conjunction with a psychosocial intervention. However, some studies have been negative. May be selectively efficacious in certain subpopulations of alcoholics.
c) ondansetron (Zofran): Has FDA indication as antiemetic in chemotherapy patients. One group has found it efficacious in decreasing alcohol use at 1/100th the dose used as an antiemetic.
d) topiramate (Topomax): FDA indication as anticonvulsant. One group has shown efficacy in alcoholism.
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