Elsevier

Clinical Psychology Review

Volume 25, Issue 6, September 2005, Pages 734-760
Clinical Psychology Review

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

https://doi.org/10.1016/j.cpr.2005.05.004Get rights and content

Abstract

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.

Section snippets

Social anxiety disorder and alcohol use disorders

SAD, referred to as social phobia in the Diagnostic and Statistical Manual of Mental Disorders-4th Edition-Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000), is characterized by an intense and importunate fear of being regarded and subsequently judged negatively by others. The individual believes that he/she will act inappropriately or that his/her physiological symptoms of anxiety, such as sweating or heart palpitations, will be obvious to those around him/her and thus

Prevalence of co-occurrence

Despite the fact that the construct of SAD was only introduced in the 1970s (Marks, 1970), there has been an increasing degree of evidence demonstrating a strong relationship between SAD and AUD (Kessler et al., 1994, Ross et al., 1988, Schneier et al., 1992, Schneier et al., 1989). A variety of research methods have been employed to examine the relationship between SAD and AUDs, including epidemiological studies of co-morbidity rates in clinical and general population samples, investigation of

Theoretical models to explain the co-morbidity

There have been a number of cognitive, behavioral, and psychosocial models that have been applied to explaining the relationship between SAD and AUD. Given the data showing SAD to be temporally antecedent to AUD development in co-morbid cases (Kushner et al., 1990), most of these models have worked on the assumption that SAD causes the AUD. Given alcohol's known anxiolytic properties, it is typically argued that socially anxious individuals drink to alleviate their physiological and

Testing the models

Despite all of the evidence demonstrating a strong relationship between the diagnoses of SAD and AUD, attempts to understand why this relationship exists have been less fruitful. Surprisingly, despite the growing amount of research in the area, much about the relationship between SAD and AUD is still unclear; even the direction of the relationship between social anxiety and alcohol-related variables has been inconsistently demonstrated in research examining the overlap of specific symptoms of

Potential moderating variables

Recently, there has been a trend towards exploring possible moderator variables to help explain why some socially phobic individuals abuse alcohol, while others may avoid excessive consumption of alcohol (Cooper, Russell, Skinner, Frone, & Mudar, 1992). Moderator variables are those that influence the strength and/or the direction of the relationship between the independent and dependent variables (Baron & Kenny, 1986). These can be differentiated from mediator variables, which attempt to

Other variables interacting with expectancy

In an attempt to further understand how alcohol expectancies affect the development of co-morbid SAD–AUD, some researchers have begun examining how so-called third variables (e.g., situational factors, gender) might interact with alcohol expectancies. The ultimate goal of such studies has been to further clarify why those with social anxiety are more likely to develop AUD, compared to those without social anxiety, and to better specify which individuals with SAD are most likely to develop

Limitations of the TRT, SRD, and SMH Models

Although we have discussed the strengths of the TRT, SRD, and SMH models (and adaptations of these including expectancy-based models) in accounting for the high co-morbidity between SAD and AUD, these models do not consider several facts that are important in considering the complex relationship between SAD and AUD. First, all three models have the same treatment implication-namely, treat the SAD (since it is causally related to the AUD) and the AUD should also resolve since there would be no

Treatment of co-morbid social anxiety and alcohol use disorders

Despite the high co-morbidity rates between SAD and AUD, little research has examined the most effective treatment approach for these individuals be it a psychosocial approach, a pharmacological approach, or some combination of these treatment approaches (Herbert, 1995, Thevos et al., 2000). Further, treatment for AUD and SAD, as well as other co-morbid non-AUD diagnoses in general, tend to be completed separately (i.e., by different treatment providers at different times), with a lack of

Conclusions and future directions

It has only been in the last decade or so that researchers have begun to seriously explore not only which variables contribute to the high co-morbidity between SAD and AUD, but also to examine which treatments are most effective in treating these complicated patients. The current models for explaining the relationship, including the TRT, SRD, and SMH, although quite promising explanations when considered together, also have several serious shortcomings, including failing to explicitly take

Acknowledgement

The first author is supported through a doctoral studentship from the Nova Scotia Health Research Foundation. The second author is supported through an Investigator Award from the Canadian Institutes of Health Research.

The authors would like to thank Allison Eisner for her research assistance.

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