Alcoholics with and without social phobia: a comparison of substance use and psychiatric variables

Measuring the neglected anxiety disorder: validation of the social anxiety spectrum-short version (SHY-SV) questionnaire

BACKGROUND

In the recent years, a growing body of literature stressed the importance of a dimensional perspective on mental disorders. In particular, since its conceptualization, one of the main concerns in the field of Social Anxiety Disorder (SAD) has been the definition of a diagnostic threshold, leading to the suggestion that SAD may be more properly classified as a spectrum of severity rather than a discrete disorder based on subjectively determined threshold. The purpose of the current research is to evaluate the psychometric qualities of the Social Anxiety Spectrum - Short Version (SHY-SV), a novel questionnaire designed to measure the complete range of social anxiety symptoms, from overt manifestations to subthreshold ones.

METHODS

42 subjects with a clinical diagnosis of social anxiety disorder (SAD) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 43 subjects with a clinical diagnosis of Obsessive-Compulsive Disorder (OCD) and 60 individuals without current or lifetime mental disorders (HC) were recruited from the Psychiatric Clinic of the University of Pisa. Subjects were assessed with the SCID-5, Liebowitz Social Anxiety Scale (LSAS) and the SHY-SV.

RESULTS

SHY-SV showed strong internal consistency, and both the total and domain scores had great test-retest reliability. The Pearson's coefficients for the SHY-SV domain scores ranged from 0.391 to 0.933, and they were positively and significantly correlated with one another (p 0.001). All the SHY-SV domain scores were highly correlated with the SHY-SV total score. Results from of the correlation coefficients between SHY-SV and alternative measures of SAD were all significant and positive. Significant differences among diagnostic groups on both SAD-SV domains and total scores were found. SAD-SV total score increased significantly and progressively from HCs, to the OCD up to the SAD group which showed the highest values.

CONCLUSION

The SHY-SV demonstrated significant convergent validity with other dimensional SAD measures, great internal consistency, and test-retest reliability. With an increasing score gradient from healthy controls to patients with OCD to those with SAD, the questionnaire performed differently in each of the three diagnostic categories.

The Mediating Effects of Self-Esteem and Harm Avoidance on the Association between Social Anxiety Symptoms and Adult Attention Deficit Hyperactivity Disorder Symptom Severity in Turkish Inpatients with Alcohol Use Disorder

Objective: The first objective of this research was to examine the association of the symptom severity of social anxiety with the adult attention deficit hyperactivity disorder (ADHD) symptom severity in Turkish patients with alcohol use disorder (AUD). The second objective was to examine if harm avoidance and self-esteem mediated this relationship.

Method: This cross-sectional analysis was performed among 151 inpatients with AUD at the Bakirkoy/AMATEM, a treatment center for substance use disorder, in Istanbul. Patients were examined with the Liebowitz Social Anxiety Scale (LSAS), the Adult ADHD Self-Report Scale (ASRS), the Rosenberg Self-Esteem Scale (SES), and the temperament dimension of Harm Avoidance (HA). Using SPSS-20 software, the data was analyzed using Pearson correlations, multivariate analysis of covariance (MANCOVA), and multiple linear regressions.

Results: The scales scores were mildly correlated with each other. The low self-esteem and high HA were related with the inattentive (IN) dimension of ADHD, whereas low self-esteem solely predicted hyperactivity/impulsivity (HI) dimension of ADHD in MANCOVA. In the linear regression analysis, the severity of social anxiety, particularly avoidance dimension, was associated with the symptom severity of ADHD. In the second step of the analysis, together with the avoidance dimension of social anxiety, self-esteem was associated with the symptom severity of ADHD. However, in the third step, after including HA as an independent variable in the analysis, the avoidance dimension of social anxiety was no longer associated with the severity of adult ADHD symptoms, whereas self-esteem together with HA (particularly “anticipatory worry and pessimism” [HA-1], and “asthenia and fatigability” [HA-4]) predicted.

Conclusion: Findings of the present study shows that although the symptom severity of social anxiety is associated with the severity of ADHD symptoms among inpatients with AUD, among dimensions of social anxiety, the avoidance dimension plays a main role in this relationship. Also, while the self-esteem partially mediates this relationship, HA seems to have a full mediator effect on this relationship.

Protective behavioral strategies underutilization mediates effect of a brief motivational intervention among socially anxious undergraduate drinkers

Social anxiety (SA) is implicated in problematic undergraduate drinking. Brief motivational interventions (BMIs) reduce problematic undergraduate drinking. However, not all students benefit. Identification of vulnerable subgroups is an important next step. The current study examined the role of SA and protective behavioral strategies (PBS) on BMI outcomes. We reanalyzed a subset of data (53.3%; N = 120; 62.5% male) from a randomized trial in which heavy drinking undergraduates were randomized to a BMI or control. SA, past-month typical drinks, peak drinks, weekly quantity, alcohol problems, and PBS were assessed at baseline and 6 weeks. Main effects and interaction among the intervention condition (BMI vs. control) and SA group (low vs. high) were tested on alcohol outcomes and PBS. High SA undergraduates reported greater baseline drinking, more alcohol problems, and lower PBS. Post-BMI, high SA drinkers continued to report greater peak drinks, typical drinks, alcohol problems, and lower PBS use, controlling for baseline use. Among the BMI condition, parallel multiple mediation analyses revealed the PBS subscale Manner of Drinking uniquely mediated the relationship between SA and heavier post-BMI drinking. The PBS Manner of Drinking and Serious Harm Reduction subscales jointly mediated the relationship between SA and greater post-BMI alcohol problems. BMIs may need to be refined to improve outcomes for socially anxious drinkers. Increasing PBS utilization post-BMI may help improve BMI efficacy in this vulnerable group. Clinical implications are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Assessment of anxiety and depression among substance use disorder patients: a case-control study

Background

Several evidences from epidemiologic and treatment studies indicate that anxiety disorders, depression, and substance use disorders commonly co-occur, and the interaction is multifaceted and variable. Epidemiological studies and investigations within clinical substance abuse populations have found an association between anxiety disorders, depression, and substance use disorders.

Results

The mean age was 28.1 ± 6.5 years. The majority belonged to the moderate socioeconomic status (52%). Substance use disorder (SUD) patients expressed higher levels of anxiety and depression in comparison to the control group. Most of the study group (97%) expressed different levels of anxiety. Eighty percent of them expressed high and moderate anxiety levels, and 20% of caregivers were having mild anxiety levels. Ninety-three percent of the substance users expressed different levels of depression, either mild 12%, moderate 9%, or severe 72%. The Drug Use Disorder Identification Test scores were positively correlated with anxiety (r = 0.256 and p = 0.010) and depression (r = 0.330 and p = 0.001). Moreover, it was found that anxiety and depression are positively correlated with each other’s (r = 0.630 and p = 0.001).

Conclusion

Substance use disorders are associated with high levels of anxiety and depression. More specifically, it is associated with severe depression and anxiety. There is an obvious association between the presence of anxiety and depression on the one hand and the severity of drug-related problems on the other hand. Depression and anxiety are commonly present together in patients with SUDs.

Context-specific drinking and social anxiety: The roles of anticipatory anxiety and post-event processing

Individuals with clinically elevated social anxiety are especially vulnerable to alcohol-related problems, despite not drinking more than those with less anxiety. It is therefore important to identify contexts in which socially anxious persons drink more to inform intervention efforts. This study tested whether social anxiety was related to greater drinking before, during, or after a social event and whether such drinking was related to the psychosocial factors anticipatory anxiety or post-event processing (PEP; review of the social event). Among past-month drinkers, those with clinically elevated or higher social anxiety (HSA; n = 212) reported more anticipatory anxiety, more pre-event drinking to manage anxiety, and PEP than those with normative or lower social anxiety (LSA; n = 365). There was a significant indirect effect of social anxiety on pre-drinking via anticipatory anxiety. Social anxiety was related to more drinking during the event indirectly via the serial effects of anticipatory anxiety and pre-drinking. Unexpectedly, PEP did not mediate or moderate the relation between social anxiety and post-event drinking. In sum, anticipatory anxiety was related to more drinking before, during, and after a social event and HSA drinkers were especially vulnerable to drinking more to manage this anxiety, which increased drinking before and during the event. This effect was specific to anticipatory anxiety and not evident for another social anxiety-specific risk factor, PEP. Thus, anticipatory anxiety may be an important therapeutic target for drinkers generally and may be especially important among HSA drinkers.

Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges

Comorbid disorders are highly prevalent in patients with social anxiety disorder, occurring in as many as 90% of patients. The presence of comorbidity may affect the course of the disease in several ways such as comorbidity in patients with social anxiety disorder (SAD) is related to earlier treatment-seeking behavior, increased symptom severity, treatment resistance and decreased functioning. Moreover, comorbidities cause significant difficulties in nosology and diagnosis, and may cause treatment challenges. In this review, major psychiatric comorbidities that can be encountered over the course of SAD as well as comorbidity associated diagnostic and therapeutic challenges will be discussed.

The Relationship Between Social Anxiety and Alcohol and Marijuana Use Outcomes Among Concurrent Users: A Motivational Model of Substance Use

BACKGROUND

College students with more social anxiety symptoms are particularly vulnerable to problematic alcohol and marijuana use given their susceptibility for elevated anxiety symptoms in social settings combined with the normative nature of substance use. Existing research has established substance use as coping motivated for these students when examining alcohol and marijuana use problems separately. The next step is to determine whether students with more social anxiety who use both substances do so for similar or different reasons. The current study tested a comprehensive (i.e., all variables in the same model) motivational model of alcohol/marijuana use in a sample of college students from 10 universities across the United States who endorsed both past-month alcohol and marijuana use.

METHODS

College students were recruited through psychology department participant pools and completed an online survey assessing mental health symptoms, substance use motives, and substances use behaviors. Current sample comprised concurrent alcohol/marijuana users (n = 2,034), 29.6% of whom endorsed clinically indicated levels of social anxiety and nearly one-fourth exceeded the cutoff for hazardous drinking (23.2%) and hazardous marijuana use (21.9%).

RESULTS

Across both substances, coping motives significantly mediated the positive relationship between social anxiety symptoms and substance use problems. Unique to alcohol, conformity motives mediated the association between social anxiety symptoms and alcohol-related problems.

CONCLUSIONS

Taken together, students with more social anxiety who are focused on anxiety management may use either alcohol or marijuana; however, these students may experience more alcohol-related problems when drinking to fit in with peers.

Comorbid social anxiety disorder in patients with alcohol use disorder: A systematic review

INTRODUCTION

Lifetime prevalence of social anxiety disorder (SAD) among patients with alcohol dependence is around 11%. However, no systematic review has assessed the effect of comorbid SAD on the clinical outcomes of patients with alcohol use disorder (AUD).

OBJECTIVES

We aimed to compare clinical outcomes, such as alcohol relapse, suicide attempts, treatment response, readmissions, psychiatric comorbidities, and treatment compliance between patients with AUD and comorbid SAD versus patients with AUD without SAD.

METHODS

We carried out a systematic review by searching PubMed for articles published between January 1, 1960 and May 6, 2018. Inclusion criteria were met if a study reported a dichotomous sample of adult patients with AUD and SAD compared to patients with AUD without SAD. Review articles and preclinical studies were excluded. From the eligible studies, we extracted outcomes of interest, such as alcohol relapse, suicidal thoughts, suicide plan and attempts, treatment response, readmissions, psychiatric comorbidities, and treatment compliance.

RESULTS

Patients with both AUD and SAD have a higher prevalence of psychiatric comorbidities, mainly major depressive disorder (MDD), and depressive symptoms. In addition, they have poor treatment compliance. Conversely, the impact of comorbid SAD on alcohol relapse is controversial and current studies have yielded mixed results. Only one study assessed the impact of comorbid SAD on treatment response and showed no association. Furthermore, one study assessed suicidality and found higher rates of suicidal thoughts, suicide plans and attempts in patients with AUD and SAD.

CONCLUSION

The present systematic review shows that it is important to screen for other psychiatric comorbidities (especially MDD), suicidality, and improve treatment adherence in patients with AUD and comorbid SAD. Future prospective studies should clarify the impact of comorbid SAD.

The effects of social anxiety on alcohol and cigarette use across adolescence: Results from a longitudinal twin study in Finland

Conflicting reports exist on the direction of the relationship between social anxiety (SA) and alcohol/cigarette use (AU/CU) and alcohol/nicotine dependence (AD/ND), with both positive and negative associations reported. A prospective, longitudinal sample of Finnish twins (n = 1,906) was used to test potential explanations for these discrepancies. Specifically, this study used peer, parent, and teacher ratings of SA, and a clinical interview screening item for social anxiety disorder (SAD-Sc) to examine associations between SA and AU/CU and AD/ND from early adolescence into young adulthood. Peer-rated SA was negatively associated with AU, CU, and AD from age 14 through age 22, implying a protective effect (β = -0.01 to -.03). Teacher- and parent-rated SA associations were in the same directions but weaker or nonsignificant, indicating that aspects of SA that are recognizable by peers may be most relevant to AU/CU. Self-reported SAD-Sc was also negatively associated with AU, but positively associated with AD symptoms in young adulthood (β = 0.38). Our findings partially support the existence of different associations between SA and AU versus AD, but only in the context of SAD-Sc rather than trait SA. Neither trait SA nor SAD-Sc significantly predicted ND symptoms, although SAD-Sc was associated with both cigarette abstinence and daily smoking. These findings suggest that adolescent SA is modestly associated with lower AU/CU, although there may be some individuals with more severe SA who develop alcohol problems later in life. There was little evidence of a common underlying liability contributing to both SA and alcohol/cigarette use. (PsycINFO Database Record

Social anxiety symptoms in alcohol-dependent outpatients: prevalence, severity and predictors

ABSTRACT Objectives High rates of comorbidity between social anxiety disorder (SAD) and alcohol use disorders have been reported, but the predictors of this comorbidity are poorly known and most studies involve primary SAD samples. The aims were to estimate the prevalence and severity of SAD symptoms among alcohol-dependent patients and to investigate sociodemographic and clinical factors associated with SAD comorbidity, including suicidal behaviors. Methods A cross-sectional study with 53 adults who were in treatment for alcohol dependence at a Brazilian public university outpatient service. Assessment instruments Social Phobia Inventory (SPIN), Short Alcohol Dependence Data and Beck Depression Inventory. Bivariate analyses between the categorical outcome (Probable SAD: SPIN ≥ 19) and explanatory variables were conducted. Correlates of SPIN total and subscales scores (dimensional outcomes) were also investigated. Results The diagnosis and treatment of alcohol dependence occurred, on average, 30 years after the onset of alcohol use and 39.6% of the 53 patients (37 men and 16 women) reported alleviation of social anxiety symptoms with alcohol use. Twenty-four (45.3%) patients presented probable SAD. These patients differed from non-SAD alcohol-dependent individuals by having lower income and higher frequency of depression, suicidal ideation, suicide plans and attempts. The SPIN subscales mostly associated with suicidal behaviors were social inadequacy and social inferiority. Conclusions SAD symptoms are common among help-seeking alcohol-dependent individuals and should be directly investigated and treated, since depression and suicidality are associated with this comorbidity. Prospective studies are needed to assess the impact of SAD treatment on the clinical course of alcohol dependence.

A biopsychosocial model of social anxiety and substance use

Emerging prospective work suggests that individuals with social anxiety disorder (SAD) may be at particular risk for developing substance use disorders (SUD). Yet, little is known about why this may be so. Most research has utilized existing theories of substance use (e.g. tension reduction-based theories) to understand SAD-SUD relations. However, these theories do not address why individuals with social anxiety, in particular, experience such high rates of substance-related problems. A possible explanation may lie in the nature of social anxiety itself, which is characterized not only by chronically elevated negative affective states, but by low positive affect, fear of scrutiny, and social avoidance. These aspects of social anxiety may work in concert to place these especially vulnerable individuals at risk for SUD. The current paper presents a biopsychosocial model of SAD-SUD comorbidity that focuses on several specific facets of social anxiety that may be especially related to SUD risk. The utility of this model is evaluated via a review of the literature on the relations between SAD and substance-related behaviors.

Severity of anxiety in mental health versus addiction treatment settings when social anxiety and substance abuse are comorbid

There is increasing interest in the co-occurrence of social anxiety and addiction. Each investigation has a specific vantage point, e.g., the effect social anxiety has in a population with addiction or that of addiction in a population with social anxiety, which could create unique findings. Among comorbid individuals, is social anxiety more severe in people seeking treatment for anxiety, as compared to those seeking treatment for addiction? This report compares social anxiety severity between subjects in two studies--one involving socially anxious individuals (n=38) seeking treatment for addictions; the other (n=41) subjects with social anxiety and an alcohol use disorder, seeking treatment for social anxiety. Baseline severity scores on the Liebowitz Social Anxiety Scale for social anxiety were compared between the groups. No significant differences were found. For both groups, social anxiety was largely in the severe range. The results suggest that clinicians should attend to social anxiety symptom severity in patients with co-occurring social anxiety and addiction, regardless of the condition for which treatment is sought.

The impact of comorbid cannabis use disorders on the clinical presentation of social anxiety disorder

Previous research has examined the relationship between social anxiety disorder (SAD) and substance use disorders. Cannabis use disorders (CUDs) are becoming increasingly problematic within the population of individuals with SAD, yet the nature of this comorbidity remains largely unexamined. The aim of the current study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to examine differences between outpatients with SAD with versus without comorbid CUDs. The current study included 873 outpatients with a current diagnosis of SAD. Patients with SAD and comorbid CUDs (n = 173) were then compared to those with SAD without CUDs (n = 700) on demographic and clinical characteristics. Compared to patients without the comorbidity, patients with comorbid SAD and CUDs were more likely to have a lifetime diagnosis of PTSD and specific phobia and lifetime substance use disorders (including alcohol). SAD patients with comorbid CUDs were also more likely to report better physical health, and fewer limitations related to their physical health. These analyses remained significant after controlling for gender, the presence of other substance use disorders, mood disorders, and other anxiety disorders. Findings of this study suggest that there may be a unique relationship between SAD and CUDs that can potentially impact the clinical presentation of individuals with SAD. Future research is needed to examine the impact of this comorbidity in other patient populations.

The Role of Social Anxiety in a Brief Alcohol Intervention for Heavy-Drinking College Students

The Brief Alcohol Screening and Intervention for College Students (BASICS) reduces alcohol use and alcohol-related problems among undergraduates, yet variability in outcomes exists. Identifying individual difference variables related to outcomes could inform efforts to improve treatment protocols. The current study evaluated the role of social anxiety during BASICS. High socially anxious (HSA; n = 26) and low socially anxious (LSA; n = 44) heavy-drinking undergraduates were randomly assigned to BASICS (n = 38) or an assessment-only control (n = 32). HSA patients reported higher baseline alcohol consumption (typical drinks, weekly quantity, and frequency). BASICS significantly decreased weekly alcohol consumption and alcohol-related problems relative to the control group. Social anxiety moderated outcomes such that in the BASICS condition; HSA patients reported heavier typical drinks at posttest, even after controlling for referral status, baseline typical drinks, and trait anxiety. This was not the case in the control group. HSA patients may benefit from social anxiety-specific interventions during BASICS.

Putting Thoughts Into Context: Alcohol Expectancies, Social Anxiety, and Hazardous Drinking

Alcohol outcome expectancies (AOE), or beliefs about the effects of drinking, are believed to moderate the association between social anxiety and hazardous alcohol use. AOE can also vary depending on the drinking context. The current study tested whether AOE specific to three drinking contexts would moderate the association between social anxiety and hazardous use among undergraduates (N = 377; 70% women; Mage = 21.0). Results showed that AOE about convivial contexts (e.g., at a party), but not AOE about coping (e.g., when sad) or intimate (e.g., on a date) contexts, moderated the association between social anxiety and hazardous drinking. Specifically, social anxiety and hazardous drinking were related positively for those endorsing higher positive or lower negative AOE about convivial settings, and associated negatively for those reporting low positive or high negative AOE in these contexts. Thus, socially anxious young adults who endorse high positive or low negative AOE about convivial drinking contexts could be at elevated risk for alcohol-related problems.

Attention to social threat as a vulnerability to the development of comorbid social anxiety disorder and alcohol use disorders: an avoidance-coping cognitive model

Despite the frequent comorbidity of social anxiety disorder and alcohol use disorders, no theoretical model currently exists to explain the specific mechanisms underlying the comorbidity between these two disorders. An integration of existing theoretical models and empirical evidence across the social anxiety and alcohol use literatures is presented as the Avoidance-Coping Cognitive Model, which proposes that socially anxious individuals may be particularly vulnerable to the anxiolytic effects of alcohol through reductions in attention biases to social threat. The disproportionate reduction in anxiety may then make alcohol an attractive method of avoidance coping. Gaps in the empirical literature are reviewed in light of this model as future directions are suggested.

Effect of anxiety on treatment presentation and outcome: results from the Marijuana Treatment Project

Despite emerging evidence of the efficacy of psychotherapies for marijuana dependence, variability in outcome exists. This study examined the role of anxiety on treatment involvement and outcome. Four questions were examined: (1) Is greater anxiety associated with greater impairment at baseline? (2) Is baseline anxiety related to greater marijuana use and problems following treatment? (3) Does adding cognitive-behavioral therapy (CBT) to motivation enhancement therapy (MET) reduce anxiety relative to MET alone; (4) Are reductions in anxiety associated with better outcomes? The sample comprised 450 marijuana-dependent patients in the Marijuana Treatment Project. Marijuana use and anxiety were measured at pretreatment and 4- and 9-month follow-ups. At baseline, anxiety was linked to more marijuana-related problems. CBT was associated with less anxiety at follow-up compared to MET alone. Reductions in anxiety were related to less marijuana use. In fact, reduction in anxiety from baseline to 4-month follow-up was associated with less marijuana use at 9 months, but reduction in marijuana use did not predict subsequent anxiety. Data suggest that anxiety is an important variable that deserves further attention in marijuana-dependence treatment.

Social anxiety disorder and alcohol use disorder co-morbidity in the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND

To assess the prevalence and clinical impact of co-morbid social anxiety disorder (SAD) and alcohol use disorders (AUD, i.e. alcohol abuse and alcohol dependence) in a nationally representative sample of adults in the United States.

METHOD

Data came from a large representative sample of the US population. Face-to-face interviews of 43093 adults residing in households were conducted during 2001-2002. Diagnoses of mood, anxiety, alcohol and drug use disorders and personality disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule - DSM-IV version.

RESULTS

Lifetime prevalence of co-morbid AUD and SAD in the general population was 2.4%. SAD was associated with significantly increased rates of alcohol dependence [odds ratio (OR) 2.8] and alcohol abuse (OR 1.2). Among respondents with alcohol dependence, SAD was associated with significantly more mood, anxiety, psychotic and personality disorders. Among respondents with SAD, alcohol dependence and abuse were most strongly associated with more substance use disorders, pathological gambling and antisocial personality disorders. SAD occurred before alcohol dependence in 79.7% of co-morbid cases, but co-morbidity status did not influence age of onset for either disorder. Co-morbid SAD was associated with increased severity of alcohol dependence and abuse. Respondents with co-morbid SAD and alcohol dependence or abuse reported low rates of treatment-seeking.

CONCLUSIONS

Co-morbid lifetime AUD and SAD is a prevalent dual diagnosis, associated with substantial rates of additional co-morbidity, but remaining largely untreated. Future research should clarify the etiology of this co-morbid presentation to better identify effective means of intervention.

Social anxiety impacts willingness to participate in addiction treatment

Individuals with social anxiety have difficulty participating in group settings. Although it makes intuitive sense that social anxiety could present a challenge in addiction treatment settings, which often involve small groups and encouragement to participate in self-help groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), to our knowledge no study has yet assessed the impact of shyness on the treatment experience. Assessment surveys were given to 110 individuals seeking intensive outpatient substance abuse treatment at three community treatment programs. Established cut-offs for presence of clinically-significant social anxiety indicated a prevalence of 37%. Controlling for depression and worry, social anxiety was a unique predictor of endorsement that shyness interfered with willingness to talk to a therapist, speak up in group therapy, attend AA/NA, and ask somebody to be a sponsor. Socially anxious substance abusers were 4-8 times more likely to endorse that shyness interfered with addiction treatment activities. These findings have clinical and research implications.

Selbstmedikation und Sozialphobie

Zusammenfassung. Hintergrund: Der Fragebogen „Trinken wegen sozialer Angst” (TWSA; Wagner, Stangier, Heidenreich & Schneider, 2004 ) erfasst das Motiv, Alkohol zur Reduktion sozialer Angst einzusetzen. Das Instrument wurde bisher nur bei Alkoholabhängigen untersucht. Hier sollen Reliabilität und konvergente Validität in einer sozialphobischen sowie einer gesunden Stichprobe geprüft werden. Methode: 120 Patienten mit Sozialphobie und 120 Gesunde bearbeiteten den TWSA. Zur Überprüfung der Konstruktvalidität wurden Maße zur Psychopathologie, die Alkoholwirkungserwartungen und die Höhe des Alkoholkonsums erfasst. Ergebnisse: Der TWSA hat eine gute Reliabilität (Cronbachs α = .96). Es zeigen sich bedeutsame Korrelationen mit Maßen zur sozialen Angst. Ebenfalls ergeben sich Zusammenhänge zu Alkoholwirksamkeitserwartungen sowie zur konsumierten Alkoholmenge. Teilnehmer mit Sozialphobie erzielten höhere Werte als Gesunde. Diskussion: Die Ergebnisse belegen, dass der TWSA auch bei Patienten mit Sozialphobie und gesunden Personen reliabel und valide eingesetzt werden kann. Die für Patienten mit Sozialphobie erhöhten Werte unterstreichen die Notwendigkeit der Diagnostik komorbider substanzbezogener Störungen.

Social anxiety and dissociation among male patients with alcohol dependency

The aim of this study was to investigate the relationship between social anxiety and dissociation among male patients with alcohol dependency. Participants were 176 male patients consecutively admitted to an alcohol dependency treatment unit. The Liebowitz Social Anxiety Scale, the Dissociative Experiences Scale, the Beck Depression Inventory, the Spielberger State and Trait Anxiety Inventory, the Michigan Alcoholism Screening Test, and the Symptom Checklist-90-Revised were administered to all participants. The dissociative (N=58, 33.0%) group had significantly higher social anxiety scores than the non-dissociative participants. Patients with a history of suicide attempt or childhood abuse had elevated social anxiety scores compared to those without. In multivariate analysis, dissociative taxon membership predicted both of the two social anxiety subscale scores consisting of fear/anxiety and avoidance in a highly significant level while trait anxiety was a significant covariant for these subscales. Among dissociative symptoms, only depersonalization and amnesia/fugue were predictors of social anxiety. Dissociation and social anxiety are interrelated among alcohol-dependent men. This relationship may have implications for prevention and treatment of alcohol dependency among men with a childhood trauma history in particular.

Social anxiety disorder as a risk factor for alcohol use disorders: a prospective examination of parental and peer influences

Elucidation of mechanisms underlying the high rates of alcohol use disorder (AUD) remains a pressing clinical and research concern. Despite data indicating that social anxiety disorder (SAD) may be a psychological vulnerability that increases AUD risk, no known prospective research has examined underlying mechanisms. Given the nature of SAD, social support and peer alcohol use may be implicated. The present study set out to clarify the SAD-AUD link in several ways using a prospective dataset comprised of 1803 (47% female) young adults at T1, 1431 of whom were assessed again approximately 3 years later. First, stringent criteria were used to directly test whether SAD was a risk for AUD. Second, we examined whether social support and peer alcohol use moderated the prospective SAD-AUD link. Structured diagnostic interviews were conducted to assess DSM-IV Axis I disorders, negative life events, social support, and peer alcohol use. Among men, Time 1 (T1) SAD was not significantly related to Time 2 (T2) AUD. Yet, among women, T1 SAD was related to T2 AUD. Further, T1 SAD was the only internalizing disorder to significantly predict T2 AUD after controlling for relevant variables (e.g., T1 depression, other anxiety, alcohol and marijuana use disorders). The SAD-AUD relation demonstrated directional specificity. Family cohesion and adverse family relations significantly moderated this relation. Findings highlight the important role of SAD and familial support in the onset of AUD among women.

Understanding social anxiety as a risk for alcohol use disorders: fear of scrutiny, not social interaction fears, prospectively predicts alcohol use disorders

Increasing evidence indicates that social anxiety may be a premorbid risk factor for alcohol use disorders (AUD). The aim of this study was to replicate and extend previous work examining whether social anxiety is a risk factor for AUD by evaluating both the temporal antecedence and non-spuriousness of this relationship. We also examined whether social anxiety first-order factors (social interaction anxiety, observation anxieties) served as specific predictors of AUD. A non-referred sample of 404 psychologically healthy young adults (i.e. free from current or past Axis I psychopathology) was prospectively followed over approximately two years. Social anxiety (but not depression or trait anxiety) at baseline significantly predicted subsequent AUD onset. The relationship between social anxiety and AUD remained even after controlling for relevant variables (gender, depression, trait anxiety). Further, social anxiety first-order factors differentially predicted AUD onset, such that observation anxieties (but not social interaction anxiety) were prospectively linked to AUD onset. This study provides further support that social anxiety (and fear of scrutiny specifically) appears to serve as an important and potentially specific AUD-related variable that deserves serious attention as a potential vulnerability factor.

Treating Comorbid Social Anxiety and Alcohol Use Disorders: Combining Motivation Enhancement Therapy With Cognitive-Behavioral Therapy

Social anxiety disorder (SAD) and alcohol use disorders (AUD) co-occur at particularly high rates, resulting in greater impairment than either disorder alone. Thus, the development of effective treatments for patients with SAD and comorbid AUD is an important clinical and research aim. Yet little work has examined treatments for SAD with comorbid AUD. Given the efficacy of motivation enhancement therapy (MET) for AUD and cognitive-behavioral therapy (CBT) for SAD, combining MET with CBT may decrease symptoms of both AUD and SAD. The present case study outlines the successful use of combined MET-CBT to treat a 33-year-old man with a long history of generalized SAD with AUD. Following 19 sessions of MET-CBT, the patient was considered in remission for both disorders, with notable decreases in social anxiety and alcohol-related problems (with continued gains at 6-month follow-up). Although these data are preliminary, they indicate that the combination of MET and CBT may be a viable approach to the treatment for patients with SAD and comorbid AUD.

Specificity of social anxiety disorder as a risk factor for alcohol and cannabis dependence

Social anxiety disorder (SAD) is highly comorbid with alcohol use disorders (AUDs) and cannabis dependence. However, the temporal sequencing of these disorders has not been extensively studied to determine whether SAD serves as a specific risk factor for problematic substance use. The present study examined these relationships after controlling for theoretically-relevant variables (e.g., gender, other Axis I pathology) in a longitudinal cohort over approximately 14 years. The sample was drawn from participants in the Oregon Adolescent Depression Project. After excluding those with substance use disorders at baseline, SAD at study entry was associated with 6.5 greater odds of cannabis dependence (but not abuse) and 4.5 greater odds of alcohol dependence (but not abuse) at follow-up after controlling for relevant variables (e.g., gender, depression, conduct disorder). The relationship between SAD and alcohol and cannabis dependence remained even after controlling for other anxiety disorders. Other anxiety disorders and mood disorders were not associated with subsequent cannabis or alcohol use disorder after controlling for relevant variables. Among the internalizing disorders, SAD appears to serve as a unique risk factor for the subsequent onset of cannabis and alcohol dependence.

Social phobia in an outpatient alcohol and drug treatment sample

OBJECTIVE

To examine characteristics of patients with social phobia (SP) in alcohol and drug treatment settings and to identify features distinguishing this group from patients with and without other psychiatric conditions.

METHOD

A random sample of 105 patients completing an initial assessment at two outpatient alcohol and drug treatment services were assessed and agreed to a 9 month follow-up interview, completed by n=102 (97%). At baseline the Composite International Diagnostic Interview (CIDI) was administered. Current diagnoses at baseline were used to separate the sample into those with SP (n=33), other current psychiatric disorders (OPD, n=40), and those with no current psychiatric diagnosis other than a substance use disorder (NPD, n=29). The novel methodology used in this study compared the SP group first to the NPD group to see if SP was associated with a different presentation, and then compared the SP group to the OPD group to see if any identified differences were associated with SP per se or psychopathology generally. The three groups were compared on demographic, current clinical, and past treatment utilization variables at baseline, while follow-up data were used to compare the groups on treatment outcome and treatment utilization.

RESULTS

The SP group did not differ from either group in a systematic way. What differences did emerge tended to show a difference between OPD and NPD, with SP intermediate between the two, or that SP and OPD together were different from NPD.

CONCLUSIONS

Despite the relatively small sample size, these findings suggest that in substance use disorder treatment settings, patients with coexisting SP do not represent a distinctly high-needs or at-risk group in the broader context of patient populations, for which coexisting psychiatric diagnoses are the norm rather than the exception.

Implications of comorbid alcohol dependence among individuals with social anxiety disorder

BACKGROUND

Social anxiety disorder (SAD) is highly comorbid with alcohol use disorders (AUD) yet the nature of this comorbidity remains unclear. To better understand these associations, we first examined whether SAD was related to AUD above and beyond relevant covariates. Second, we examined the psychosocial impairment associated with the comorbidity of SAD and AUD versus SAD without AUD. Third, the temporal sequencing of SAD and AUD among comorbid individuals was examined.

METHODS

Participants included 5,877 (50% females) adults from the National Comorbidity Survey.

RESULTS

As predicted, SAD was related to alcohol dependence (not abuse) after controlling for relevant conditions, indicating that SAD is linked to more severe alcohol impairment and that this link is not better accounted for by other pathology. Results also supported the hypothesis that the addition of alcohol dependence to SAD resulted in greater impairment across a variety of domains relative to SAD without alcohol dependence (e.g., greater rates of health care utilization, other psychiatric diagnoses, health problems, and greater interpersonal stress). Additionally, for the majority of comorbid individuals, SAD onset predated alcohol dependence onset, suggesting SAD increases vulnerability for misusing alcohol.

CONCLUSIONS

Together, these data lend support for the contention that SAD may serve as a risk for alcohol dependence and indicate that the co-occurrence of these two conditions may result in greater personal and public health care costs.

Does co-occurring social phobia interfere with alcoholism treatment adherence and relapse?

This study investigates the impact of social phobia on adherence to and outcomes 6 months following standard alcohol treatment and Alcoholics Anonymous (AA) group meetings among alcohol-dependent patients with and without social phobia. In a cohort study, 300 detoxified alcohol-dependent individuals in Porto Alegre, Brazil, were interviewed during, as well as 3 and 6 months after hospital detoxification. At both follow-up points, treatment adherence was low and relapse rates were high among patients with and without social phobia, and no significant differences were seen between the two groups of patients in relapse, adherence to AA, or adherence to psychotherapy. Findings from this sample suggest that although alcohol-dependent patients with social phobia showed a tendency for less adherence at AA and felt less integrated with their AA group, social phobia comorbidity was not a significant risk factor for alcohol use relapse or for nonadherence to AA or psychotherapy.

Coexisting psychiatric disorders in a New Zealand outpatient alcohol and other drug clinical population

OBJECTIVE

To describe the extent of psychiatric disorder and mental health service utilization in a representative outpatient alcohol and other drug (AOD) treatment sample in New Zealand.

METHOD

A total of 105 patients were randomly recruited from two outpatient AOD treatment services in New Zealand and completed a diagnostic interview within the first 2 months of treatment. Axis I psychiatric diagnoses were made using the computerized Composite International Diagnostic Interview (CIDI-Auto), and were supplemented by the South Oaks Gambling Scale (SOGS) and the conduct disorder and antisocial personality disorder section of the Diagnostic Interview for Genetic Studies (DIGS).

RESULTS

Seventy-four per cent of the sample had a current non-substance or gambling axis I disorder, with a lifetime rate of 90%. The most commonly diagnosed of these coexisting psychiatric disorders were major depressive episode (34%), social phobia (31%) and posttraumatic stress disorder (31%). Past contact with mental health services was common, while contact at the time of baseline assessment was uncommon.

CONCLUSIONS

Coexisting psychiatric disorder was the rule and not the exception in this sample. AOD patients are clearly part of the larger population of mental health patients. AOD services need to be capable of comprehensive assessment and treatment planning, which includes coexisting psychiatric disorders, and should work toward better integration with other mental health services.

Substance-dependent patients with and without social anxiety disorder: occurrence and clinical differences. A study of a consecutive sample of alcohol-dependent and poly-substance-dependent patients treated in two counties in Norway

AIMS

(1) To identify clinically important differences between patients with and without social anxiety disorder (SAD) among alcohol-dependent and poly-substance-dependent patients. (2) To explore if primary SAD is a predictor of alcohol-dependency or poly-substance dependency when controlling for other Axes I and II disorders.

METHODS

A consecutive sample of in- and outpatient alcohol-dependent (N = 146) and poly-substance-dependent patients (N = 114) from public treatment programmes in two catchment areas was assessed by personal interview, the Composite International Diagnostic Interview and the Millon Clinical Multiaxial Inventory.

RESULTS

The frequency of current SAD was 42%; SAD was significantly more frequent among poly-substance-dependent patients (51%) than among alcohol-dependent patients (34%). Patients with SAD do not represent a distinct clinical subgroup, but the occurrence of SAD is combined with the occurrence of other anxiety disorders, affective disorders and personality disorders in both substance groups. The analysis showed a trend towards primary SAD as a predictor for developing poly-substance dependency.

CONCLUSIONS

Patients with SAD in both substance groups exhibited more comorbid Axis I and II disorders. They may need specific psychiatric treatment for such disorders in addition to treatment for SAD. Treatment of primary SAD could be a target for preventing poly-substance dependency in young populations.

The relationship between social anxiety disorder and alcohol use disorders: A critical review

Epidemiological studies have demonstrated a significant co-morbidity between social anxiety disorder (SAD) and alcohol use disorders (AUDs). Despite the fact that many studies have demonstrated strong relationships between SAD and AUD diagnoses, there has been much inconsistency in demonstrating causality or even directionality of the relationship between social anxiety and alcohol-related variables. For example, some studies have showed a positive relationship between social anxiety and alcohol-related variables, while others have shown a negative relationship or no relationship whatsoever. In an attempt to better understand the relationship between social anxiety and alcohol, some researchers have explored potential moderating variables such as gender or alcohol expectancies. The present review reports on what has been found with regard to explaining the high co-morbidity between social anxiety and alcohol problems, in both clinical and non-clinical socially anxious individuals. With a better understanding of this complex relationship, treatment programs will be able to better target specific individuals for treatment and potentially improve the efficacy of the treatments currently available for individuals with co-morbid SAD and AUD.

A Critical Look at Dual-Focused Cognitive-Behavioral Treatments for Comorbid Substance Use and Psychiatric Disorders: Strengths, Limitations, and Future Directions

Several large-scale studies examining outcome predictors across various substance use treatments indicate a need to focus on psychiatric comorbidity as a very important predictor of poorer SUD treatment involvement and outcome. We have previously argued that current cognitive-behavioral treatments (CBT) approaches to SUD treatment do not focus on the necessary content in treatment in order to effectively address specific forms of psychiatric comorbidity, and thus only provide clients with generic coping strategies for managing psychiatric illness (as would be achieved in other SUD treatment approaches; Conrod et al., 2000). Furthermore, following our review of the literature on dual-focused CBT treatment programs for concurrent disorders in this article, we argue that combining CBT-oriented SUD treatments with specific CBT treatments for psychiatric disorders is not as straightforward as one would think. Rather, it requires very careful consideration of the functional relationship between specific disorders, patient reactions to specific treatment components, and certain barriers to treatment in order to achieve an integrated dual-diagnosis focus in treatment that is meaningful and to which clients can adhere.

Prevalence of social phobia in a clinical sample of drug dependent patients

INTRODUCTION

Social phobia is among the most frequent psychiatric disorders and can be classified into two subtypes, nongeneralized and generalized. Whereas it significantly worsens the morbidity of comorbid substance abuse disorders, and it often is associated with reduced treatment responses, there is still lacking data on its prevalence in clinical populations of drug abusing patients.

METHODS

The study sample consisted of 75 inpatients and 75 outpatients meeting DSM-IV criteria for drug dependence. Symptoms of social phobia were assessed with the French-language version of the Liebowitz Social Anxiety Scale (LSAS).

RESULTS

Prevalence rate were 20% for the generalized subtype and 42.6% for the nongeneralized subtype. Gender difference emerged in the severity of fear, women reporting significantly greater fear relating to performance situations than men.

CONCLUSIONS

An important proportion of patients with substance dependence present a comorbid generalized or nongeneralized social phobia. Early recognition of social phobia and adequate interventions is warranted for these patients in order to improve their treatment response with regard to quality of life and relapse prevention.

“Trinken wegen sozialer Angst“ und “Soziale Angst wegen Trinken“:

Zusammenfassung. Theoretischer Hintergrund: Zur Erfassung von Aspekten sozialer Ängste bei Alkoholabhängigkeit wurden die beiden Fragebögen “Trinken wegen sozialer Angst“ (TWSA) und “Soziale Angst wegen Trinken“ (SAWT) entwickelt. TWSA erfasst Trinken zur Reduzierung von sozialen Ängsten. SAWT misst alkoholinduzierte soziale Ängste. Fragestellung: Es wurden die Reliabilität, faktorielle Validität und Konstruktvalidität überprüft. Methode: Psychometrische Analysen wurden an zwei Stichproben (n = 116 und n = 205) von alkoholabhängigen Patienten durchgeführt. Ergebnisse: Cronbachs a von TWSA ist .97 und von SAWT .95. Die Ergebnisse zweier Hauptkomponentenanalysen stützen die faktorielle Validität der Fragebögen, und die Korrelationen zu anderen Maßen sprechen für ihre Konstruktvalidität. Schlussfolgerungen: Die Ergebnisse ergeben erste Hinweis dafür, daß Alkoholkonsum zur “Selbstmedikation“ sozialer Ängste durch den TWSA und alkoholinduzierte soziale Ängste durch den SAWT reliabel und valide erfasst werden können.

Paroxetine for social anxiety and alcohol use in dual-diagnosed patients

The objective of this study was to compare the efficacy and tolerability of paroxetine to matched placebo in adults with co-occurring social anxiety disorder and alcohol use disorder. Outcome measures included standardized indices of social anxiety and alcohol use. Fifteen individuals meeting DSM-IV criteria for both social anxiety disorder and alcohol use disorder were randomized to treatment. Paroxetine (n = 6) or placebo (n = 9) was given in a double-blind format for 8 weeks using a flexible dosing schedule. Dosing began at 20 mg/d and increased to a target dose of 60 mg/d. There was a significant effect of treatment group on social anxiety symptoms, where patients treated with paroxetine improved more than those treated with placebo on both the Clinical Global Index (CGI) and the Liebowitz Social Anxiety Scale (Ps < or = 0.05). On alcohol use, there was not a significant effect of treatment on quantity/frequency measures of drinking, but there was for the CGI ratings (50% paroxetine patients versus 11% placebo patients were improvers on drinking, P < or = 0.05). This pilot study suggests that paroxetine is an effective treatment for social anxiety disorder in individuals with comorbid alcohol problems, and positive treatment effects can be seen in as little as 8 weeks. Further study is warranted to investigate its utility in helping affected individuals reduce alcohol use.