Comorbid Social Anxiety and Alcohol Dependence


I.  Alcohol use disorders and psychiatric disorders complicate each other


                        A. Alcohol use disorders complicate psychiatric disorders

1. Problematic alcohol use related to higher rates of mood and anxiety disorders (Sareen et al., 2004)

a. Two epidemiologic surveys associate ‘problematic drinking’ with mood and anxiety 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.


C. What we will be talking about

1. What is Social Anxiety?

2. What is Alcohol Dependence?

3. Social Anxiety and Alcohol Dependence in the same individual


4. Why social anxiety disorder and alcohol dependence are a useful model of alcoholism with psychiatric comorbidity

a. Are they related?
b. Can Social Anxiety induce Alcohol Dependence?
c. Can Alcohol Dependence induce Social Anxiety?

d. Treatment of Co-occurring Social Anxiety and Alcohol Dependence

6. Conclusions


I.                   Diagnosis and Epidemiology

A.    Social Anxiety

1.      Diagnosis (American Psychiatric Association, 1994)

a)      Hallmark: fear of scrutiny: people fear they are being watched and judged harshly by others when in certain situations:

(1)   Specific – e.g., Public Speaking – feel very nervous in public speaking situations, not overly concerned in other situations
(2)   Generalized – feel very nervous in several different social situations eg eating in public, speaking to someone in authority, participating in small groups
(a)    More severe (Stein et al., 2000)
(b)   What this talk is mainly about

b)      Either avoids uncomfortable situations or endures severe discomfort in the situation

c)      Avoidance can lead to interference in different spheres: Turner et al interviewed 21 subjects seeking treatment for social anxiety disorder (Turner et al., 1992)

(1)   Education: 85% reported the disorder impaired academic performance
(2)   Work: 92% endorsed occupational impairment
(3)   Social: 70% said social anxiety impaired their social life

2.      Epidemiology

a)      Lifetime prevalence depends on how disorder defined (how interference is measured): approximately 2-13% (Kessler et al., 1998; Schneier et al., 1992)

b)      Demographics (Davidson et al., 1993; Stein et al., 2000)

(1)   Women:men =3:2
(2)   More likely to be financially dependent
(a)    One community sample (Schneier et al., 1992):

(1)   22.3% with Social Anxiety financially dependent (on welfare or disability payments)

(2)   10.6% with no disorder

c)      Age of onset typically in the mid-teens (Kessler et al., 1998; Schneier et al., 1992)

(1)   In one community study (ECA) 90% onset before age 25 (Schneier et al., 1992):

B.     Alcohol Dependence

1.      Diagnosis (American Psychiatric Association, 1994)

a)      Continued use despite having problems (3 or more of the following occurring in same 12 months):

(1)   Tolerance
(2)   Withdrawal
(3)   Substance taken in larger amounts than intended
(4)   Persistent unsuccessful attempts to cut down or control substance use
(5)   A great deal of time spent getting, using, or recovering from substance
(6)   Important activities given up or reduced to continue use
(7)   Continued use despite psychological or physical problem

2.       Epidemiology

a)      Lifetime Prevalence 20% in men, 8% in women (Kessler et al., 1997)

b)      Demographics (the average alcoholic looks like us) One large study of nearly 2000 alcoholics: (Schuckit et al., 1997b)

(1)   Education: average 12.6 + 2.25 years
(2)   Race: 76.4% Black, 15.4% White, 8.2% Hispanic
(3)   40.3% Married
(4)   Almost 2/3 were abstinent 3+ months
(5)   Average Alcoholic: educated, married and don’t drink every day

c)      Age of Onset:

(1)   Diagnosis first in mid 20’s to early 30’s (Schuckit et al., 1998)
(2)   By age 31, 50% of those who will develop alcohol dependence, already have (Schuckit, 2000)


II.                Social Anxiety and Alcohol Dependence in the same individual

A.    Are these two related?

1.      Anecdotal Studies

a)      Drinking co-occurs with nervousness(Kiefer et al., 2002; Schuckit and Hesselbrock, 1994; Schuckit et al., 1990)

b)      Anxiety symptoms vs. anxiety disorder: some studies observed anxiety symptoms, then erroneously concluded re disorder (when it wasn’t evaluated)(Schuckit and Hesselbrock, 1994):

c)      Alcohol withdrawal causes anxiety symptoms (Brown et al., 1991; De Soto et al., 1985; Schuckit and Hesselbrock, 1994)

2.      Assortative mating

(1)   Psychiatric impairment increases risk of choosing psychiatrically impaired mate (Schuckit et al., 1995)

(2) Thus alcoholics may marry persons with social anxiety, children at high risk for both


3.“Drinking to cope”

B.     Social Anxiety induced Alcohol Dependence

1.      Age of Onset

a)      Social Anxiety typically begins in the teens (Schneier et al., 1992)

b)      Alcohol dependence typically begins in the 20’s

c)      So, social anxiety most likely to precede alcohol dependence

2.      Tension Reduction

a)      ETOH works both from actual pharmacologic effect and from belief that ETOH has been ingested (de Boer et al., 1993) 

(1)   Alcohol Expectancy: defined as that component of ETOH’s effect due to beliefs.  eg. Two people: both may have same pharmaceutical response to drink.  But, psychological experience of the drink may be influenced by what each BELIEVES alcohol will do for them.
(2)   Gender related expectancies (Corcoran and Michels, 1998)
(a)    Men more likely to expect ETOH to make them more ‘one of the guys’: may be more likely to drink, or may drink more, in a social group
(b)   Women more likely to expect ETOH to make them look like a ‘troubled woman’: may be less likely to problem drink in social group

(c) Women with Social Anxiety may be less likely to use ETOH as coping mechanism in social situations

b)      Alcoholics may be more likely to expect ETOH to reduce tension (Young and Oei, 1993): “problem drinkers” more likely to report positive effects from drinking than non-problem drinkers

c)      Alcohol use reduces social anxiety more than it

         reduces general tension (Tran et al., 1997)

d)     People with social anxiety expect tension reduction significantly more than others

e)      They may, then, be more likely to drink in social situations

3.      Tension reduction theory

a)      Reframes self medication theory

(1)   Tension reduction: “I can’t socialize because of my anxiety.  Alcohol helps me socialize by decreasing my anxiety.  I’ll have a drink so I can socialize”
(2)   Self Medication: “I can’t socialize because I have a disorder and alcohol is the medication which treats my disorder.”

b)      More behavioral in its concept

c)      Conflicting findings regarding whether or not alcohol actually reduces tension (Abrams et al., 2001; Himle et al., 1999)

(1)   Study is not easy to do
(2)   Have to measure tension reduction after a real alcohol beverage and after a ‘sham’ alcohol beverage (smells and looks the same)


4. “Drinking to cope


5. Switch Driver Seat (Kushner et al., 1990)

d)     Early on, ETOH may attenuate anxiety (Social Anxiety Drives ETOH use)

e)      Later in disease ETOH may cause anxiety (Alcohol Dependence Drives Social Anxiety)

C.     Alcohol Induced Social Anxiety

1.      Alcohol withdrawal causes anxiety (Allan, 1995; De Soto et al., 1985; Schuckit and Hesselbrock, 1994; Schuckit et al., 1990; Schuckit et al., 1997a)

2.      Anxiety improves several weeks after cessation of alcohol (Brown et al., 1991; Schuckit et al., 1990)

3.      After control for withdrawal and prolonged withdrawal, anxiety disorders not really more prevalent in alcohol dependent individuals than in general population (Schuckit and Hesselbrock, 1994)

a)      Social anxiety in general population ranges from 2-13%


b)      In Alcohol Dependent individuals, after controlling for withdrawal syndrome: 9%


III.             Treatment

A.    Social Anxiety

1.      Psychotherapy: Cognitive behavioral therapy (CBT) effective  (Heimberg, 2001)

a)      Thoughts, feelings and behaviors are a cycle (thoughts lead to feelings which lead to behaviors which lead to thoughts etc)

b)       CBT helps client interrupt the cycle by identifying and restructuring problematic thought patterns and by encouraging more adaptive behaviors

c) If thoughts and/or behaviors are changed, feelings (like anxiety) will also change




2.      Medication: SSRI’s, MAOI’s, benzodiazepines, GABAergic anticonvulsants (Connor et al., 1998; Heimberg, 2001; Pande et al., 1999; Schneier, 2001; Stein et al., 2001; Stein et al., 2002)

a)      Examples of SSRI’s : fluoxetine (Prozac), sertraline (Zoloft) paroxetine (Paxil), citalopram (Celexa), es-citalopram (Lexapro)


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


c) Benzodiazepines shown effective in social phobia include alprazolam (Xanax) and clonazepam (Klonopin)


d) GABAergic anticonvulsants include gabapentin (Neurontin) and pregabalin (shown effective in studies but not on the market in USA).


B.     Alcohol Dependence (Anton et al., 1999)

1.      Psychotherapy: CBT, Motivational Enhancement Therapy (MET), Twelve Step Facilitation Therapy (TSF) (Fuller and Hiller-Sturmhofel, 1999)

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

2.      Medication: disulfuram, naltrexone, ondansetron, topiramate (Anton et al., 1999; Johnson et al., 2003; Johnson et al., 2000; O'Malley et al., 1992; Volpicelli et al., 1992)


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.

C.     Comorbid Social Anxiety and Alcohol Dependence

1.      What we know: Not many studies have been done

a)      Psychotherapy (Randall et al., 2001b; Thevos et al., 2000)

(1)   Women may do better with Cognitive Behavioral Therapy than Twelve Step Facilitation (Thevos et al., 2000)
(2)   If CBT for alcohol dependence is enhanced to specifically address Social Anxiety, outcomes are not improved. (Randall et al., 2001b)


b)      Medication (Randall et al., 2001a)

(1)   Some medications for Social Anxiety can not be used for alcoholism
(a)    Benzodiazepines (addictive)
(b)   MAOIs (dietary restraints: red wine, beer)
(2)   Paroxetine may help subjects with Social Anxiety and Alcohol use (Randall et al., 2001a).  These subjects did not have alcohol abuse or alcohol dependence necessarily but did say they used alcohol to cope with their Social Anxiety.
(3)   Short term vs long term medication treatment: no data

2.      Don’t know if order matters

a)      Treat Social Anxiety first

b)      Treat Alcohol Dependence first

c)      Treat both simultaneously


IV.             Conclusions

A.    Relationship between Social Anxiety and Alcohol Dependence is complex

B.     May be a unique population of Alcohol Dependent individuals which preferentially respond to specific pharmaceutical intervention



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