The relationship between social anxiety disorder and alcohol use disorders: A critical review
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.
References (101)
- et al.
The pharmacologic and expectancy effects of alcohol on social anxiety in individuals with social phobia
Drug and Alcohol Dependence
(2001) - et al.
The moderating effects of tension-reduction alcohol outcome expectancies on placebo responding in individuals with social phobia
Addictive Behaviors
(2004) - et al.
Shyness, alcohol expectancies, and alcohol use: Discovery of a suppressor effect
Journal of Research in Personality
(1992) - et al.
Shyness, alcohol expectancies, and drinking behavior: Replication and extension of a suppressor effect
Personality and Individual Differences
(1997) - et al.
Social anxiety and drinking in college students: A social cognitive theory analysis
Clinical Psychology Review
(1999) - et al.
Self-medication in social phobia: A review of the alcohol literature
Addictive Behaviors
(2003) - et al.
Investigations of causal pathways between PTSD and drug use disorders
Addictive Behaviors
(1998) - et al.
Incorporating social anxiety into a model of college problematic drinking
Addictive Behaviors
(2005) An overview of the current status of social phobia
Applied and Preventive Psychology
(1995)- et al.
Alcohol and caffeine use by social phobics: An initial inquiry into drinking patterns and behavior
Behaviour Research and Therapy
(1995)
The relationship between anxiety disorders and alcohol use disorders: A review of major perspectives and findings
Clinical Psychology Review
Co-morbidity of alcohol and anxiety disorders among college students: Effects of gender and family history of alcoholism
Addictive Behaviors
The impact of interactional impediments on social anxiety and self-presentation
Journal of Experimental Social Psychology
Alcohol expectancies and social deficits relating to problem drinking among college students
Addictive Behaviors
Alcohol detoxification and social anxiety symptoms: A preliminary study of the impact of mirtazapine administration
Journal of Affective Disorders
The context-specific positive alcohol outcome expectancies of university women
Addictive Behaviors
Development and validation of measures of social phobia scrutiny fear and social interaction anxiety
Behaviour Research and Therapy
Alcohol abuse in social phobia
Journal of Anxiety Disorders
Cognitive behavioral therapy delays relapse in female socially phobic alcoholics
Addictive Behaviors
Self-administration of alcohol before and after a public speaking challenge by individuals with social phobia
Psychology of Addictive Behaviors
Effects of alcohol on social anxiety in women: Cognitive versus physiological processes
Journal of Abnormal Psychology
Diagnostic and statistical manual of mental disorders
Consensus statement on social anxiety disorder from the international consensus group on depression and anxiety
Journal of Clinical Psychiatry
The moderator–mediator variables distinction in social psychological research: Conceptual, strategic, and statistical considerations
Journal of Personality and Social Psychology
Shy children, phobic adults: Nature and treatment of social phobia
Identifying young adult substance abusers: The Rutgers Collegiate Substance Abuse Screening Test
Journal of Studies on Alcohol
Expectations of reinforcement from alcohol: Their domain and relation to drinking patterns
Journal of Consulting and Clinical Psychology
Considering co-morbidity in social phobia
Social Psychiatry and Psychiatric Epidemiology
The revised cheek and buss shyness scale
Alcohol-related expectancies versus demographic/background variables in the prediction of adolescent drinking
Journal of Consulting and Clinical Psychology
The development of alcohol-related expectancies in adolescents: Separating pharmacological from social learning influences
Journal of Consulting and Clinical Psychology
Preferences for ethanol and diazepam in anxious individuals: An evaluation of the self-medication hypothesis
Psychopharmacology
The effects of alcohol on conflict behavior in the albino rat
Quarterly Journal of Studies on Alcohol
Reinforcement theory and the dynamics of alcoholism
Quarterly Journal of Studies on Alcohol
Motivations for alcohol use among adolescents: Development and validation of a four-factor model
Psychological Assessment
Stress and alcohol use: Moderating effects of gender, coping, and alcohol expectancies
Journal of Abnormal Psychology
Risk of heavy drinking and alcohol use disorders in social phobia: A prospective analysis
American Journal of Psychiatry
Pharmacotherapy of social anxiety disorder
Journal of Clinical Psychiatry
The epidemiology of social phobia: Findings from the Duke Epidemiological Catchment Area Study
Psychological Medicine
Advancing the expectancy concept via the interplay between theory and research
Alcoholism, Clinical and Experimental Research
Social anxiety and alcohol use: Evaluation of the moderating and mediating effects of alcohol expectancies
Journal of Anxiety Disorders
Risk for alcoholism: A comparison between two different groups of sons of alcoholics on cardiovascular reactivity and sensitivity to alcohol
Alcoholism, Clinical and Experimental Research
Emotional processing of fear: Exposure to corrective information
Psychological Bulletin
Alcohol expectancy theory: The application of cognitive neuroscience
Alcohol and tension reduction
Alcohol expectancies and drinking behavior in adults with social anxiety disorder and dysthymia
Cognitive Therapy and Research
Cited by (212)
Risk estimation in relation to anxiety and depression for low probability negative events
2024, Behaviour Research and TherapySocial anxiety and alcohol consumption: The role of social context
2023, Addictive BehaviorsDevelopment and Initial Pilot Testing of a fully integrated treatment for comorbid social anxiety disorder and alcohol use disorder in a community-based SUD clinic setting
2022, Behaviour Research and TherapyCitation Excerpt :Current models in understanding SAD and AUD comorbidity suggest that once both problems are present, they serve to mutually maintain and exacerbate one another (Stewart & Conrod, 2008). Efforts to develop and evaluate treatments targeting individuals with SAD and AUD comorbidity have been surprisingly limited (see Morris et al., 2005; for a review). Early research in this area unsuccessfully attempted to treat comorbid SAD and AUD using parallel cognitive behavioral therapy (CBT) protocols (Randall et al., 2001).