Anthony H. Ecker

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.

Antecedents and consequences of cannabis use among racially diverse cannabis users: An analysis from Ecological Momentary Assessment

BACKGROUND Cannabis remains the most commonly used illicit substance and use rates are rising. Notably, the prevalence of cannabis use disorders (CUD) nearly equals that of other illicit substance use disorders combined. Thus, the present study aimed to identify cognitive, affective, and situational predictors and consequences of ad-lib cannabis use in a racially diverse sample. METHODS The sample consisted of 93 current cannabis users (34.4% female; 57.1% non-Hispanic Caucasian), 87.1% of whom evinced a current CUD. Ecological Momentary Assessment was used to collect frequent ratings of cannabis withdrawal, craving, affect, cannabis use motives, and peer cannabis use over two weeks. Mixed effects linear models examined within- and between-day correlates and consequences of cannabis use. RESULTS Withdrawal and craving were higher on cannabis use days than non-use days. Withdrawal, craving, and positive and negative affect were higher immediately prior to cannabis use compared to non-use episodes. Withdrawal and craving were higher among those who subsequently used cannabis than those who did not. Cannabis use resulted in less subsequent withdrawal, craving, and negative affect. Enhancement and coping motives were the most common reasons cited for use. Withdrawal and negative affect were related to using cannabis for coping motives and social motives. Participants were most likely to use cannabis if others were using, and withdrawal and craving were greater in social situations when others were using. CONCLUSIONS Data support the contention that cannabis withdrawal and craving and affect and peer use play important roles in the maintenance of cannabis use.

Cannabis use during a voluntary quit attempt: An analysis from ecological momentary assessment

BACKGROUND There is little research that has sought to identify factors related to quit success and failure among cannabis users. The current study examined affective, cognitive, and situational factors related to cannabis use among current cannabis users undergoing a voluntary, self-guided quit attempt. METHOD The sample consisted of 30 (33% female) current cannabis users, 84% of whom evinced a current cannabis use disorder. Ecological momentary assessment was used to collect multiple daily ratings of cannabis withdrawal, negative affect, peer cannabis use, reasons for use, and successful coping strategies over two weeks. RESULTS Findings from generalized linear models indicated that cannabis withdrawal and positive and negative affect were significantly higher during cannabis use than non-use episodes. Additionally, when negative and positive affect were entered simultaneously, negative affect, but not positive affect, remained significantly related to use. Participants were significantly more likely to use in social situations than when alone. When participants were in social situations, they were significantly more likely to use if others were using. Participants tended to use more behavioral than cognitive strategies to abstain from cannabis. The most common reason for use was to cope with negative affect. CONCLUSIONS Overall, these novel findings indicate that cannabis withdrawal, affect (especially negative affect), and peer use play important roles in cannabis use among self-quitters.

College drinking problems and social anxiety: the importance of drinking context

Social anxiety more than quadruples the risk of developing an alcohol use disorder, yet it is inconsistently linked to heavy alcohol use. Elucidation of the relation between social anxiety and alcohol use is an important next step in treating and preventing risky drinking. College students routinely face potentially anxiety-provoking social situations (e.g., meeting new people) and socially anxious undergraduates are especially vulnerable to alcohol-related impairment. Drinking to cope with social anxiety is thought to reinforce alcohol use, yet research on coping-motivated drinking among socially anxious students has yielded inconsistent findings. Further, undergraduate drinking varies by drinking context, yet the role of context in drinking behaviors among socially anxious individuals remains unclear. The current study sought to examine the relationship of social anxiety and drinking quantity in specific drinking contexts among undergraduates (N = 611). We also evaluated whether relevant drinking contexts mediated the relationship between social anxiety and alcohol-related problems. Clinically elevated social anxiety was related to heavier consumption in negative emotion (e.g., feeling sad or angry) and personal/intimate (e.g., before sexual intercourse) contexts, but not social/convivial contexts (e.g., parties, bars). Quantity of alcohol consumed in negative emotion and personal/intimate contexts mediated the relationship between social anxiety and drinking problem severity. Drinking in personal/intimate contexts demonstrated a unique mediational role. Findings suggest that heavy drinking in particular contexts (especially personal/intimate and negative emotion) may play an important role in drinking problems among socially anxious individuals.

Cannabis use vulnerability among socially anxious users: cannabis craving during a social interaction.

Socially anxious individuals appear especially vulnerable to cannabis-related problems. However, the nature of the social anxiety-cannabis relation remains unclear. The present study examined the timing and specificity of cannabis craving in response to a social anxiety induction task among 82 (71% female) cannabis users randomly assigned to either a social interaction or reading task. Participants completed ratings of substance (cannabis, alcohol, cigarette) craving at baseline (prior to being informed of task assignment), before, during, and after task. The Time × Condition interaction was significant such that cannabis craving increased from before to during the task among participants in the social interaction condition, but not among those in the reading condition. This effect was specific to cannabis craving and was not observed for craving for alcohol or cigarettes. Data suggest that increases in state social anxiety may play a role in cannabis use behaviors.

Solitary cannabis use frequency mediates the relationship between social anxiety and cannabis use and related problems.

BACKGROUND AND OBJECTIVES Individuals with elevated social anxiety are seven times more likely to meet criteria for cannabis use disorders, yet social anxiety is unrelated to more frequent cannabis use. The lack of relation to cannabis use frequency may be at least partially due to lack of attention to cannabis use context. It may be that socially anxious persons engage in frequent solitary cannabis use, perhaps using before social situations in the hope that being intoxicated during the social event will help them feel less anxious. In fact, using cannabis alone has been associated with experiencing more cannabis-related problems in prior work. METHODS The current study sought to identify whether solitary cannabis use frequency mediated the relationship between social anxiety and cannabis-related problems among 276 current cannabis using undergraduates who completed an online survey of putative predictors of substance use. RESULTS Social anxiety was robustly related to more frequent solitary (but not social) cannabis use and solitary cannabis use frequency uniquely mediated the relation of social anxiety to cannabis use and related problems. DISCUSSION AND CONCLUSIONS Frequent solitary use appears to play an important role in the experience of cannabis-related problems among socially anxious persons. SCIENTIFIC SIGNIFICANCE Intervention strategies may benefit from targeting frequent solitary cannabis use, particularly among at-risk users such as those with elevated social anxiety.

Psychometric properties of a valuations scale for the Marijuana Effect Expectancies Questionnaire.

Given that marijuana remains the most commonly used illicit substance, identification of the role of potentially malleable cognitive factors in marijuana-related behaviors remains an important goal. The Marijuana Effect Expectancies Questionnaire (MEEQ; Schafer & Brown, 1991) assesses marijuana effect expectancies that are differentially related to marijuana use and use-related problems. Evaluation of the desirability of marijuana effect expectancies may provide additional information regarding cognitions related to marijuana use behaviors. The present study examined the psychometric properties of the Marijuana Effect Expectancy Questionnaire-Valuations Scale (MEEQ-V) which was developed for this study to assess the desirability of marijuana effect expectancies. The sample was comprised of 925 (73.0% female) undergraduate participants, 41.9% of whom endorsed lifetime marijuana use and 24.7% of whom reported current (past three-month) use. The MEEQ-V scales demonstrated adequate internal consistency. Most (but not all) MEEQ-V scales were correlated with their corresponding MEEQ scale. There was some support for convergent validity. MEEQ-V scales were differentially related to frequency of marijuana use and use-related problems. Most MEEQ-V scales were related to frequency of marijuana use above and beyond variance attributable to corresponding MEEQ scales. Results suggest that assessment of desirability of marijuanas effects could provide unique and important information about cognitions related to marijuana use behaviors.

Cannabis craving in response to laboratory-induced social stress among racially diverse cannabis users: The impact of social anxiety disorder

Social anxiety disorder appears to be a risk factor for cannabis-related problems. Although it is presumed that increases in cannabis craving during elevated social anxiety reflect an intent to cope with greater negative affectivity, it is unclear whether increases in physiological arousal during social stress are related to cannabis craving, especially among those with social anxiety disorder. Similarly, no studies have assessed motivational reasons for cannabis use during elevated social stress. Thus, the current study tested whether increases in state social anxiety (measured subjectively and via physiological arousal) were related to greater cannabis craving among 126 current cannabis users (88.9% with cannabis use disorder, 31.7% with social anxiety disorder, 54.0% non-Hispanic Caucasian) randomly assigned to either a social interaction or reading task. As predicted, cannabis users in the social interaction condition reported greater cannabis craving than those in the reading condition. This effect was particularly evident among those with social anxiety disorder. Although physiological arousal did not moderate the relationship between condition and craving, coping motives were the most common reasons cited for wanting to use cannabis and were reported more among those in the social interaction task. These experimental results uniquely add to a growing literature suggesting the importance of elevated state social anxiety (especially among those with social anxiety disorder) in cannabis use vulnerability processes.

Integrated Cognitive Behavioral Therapy for Comorbid Cannabis Use and Anxiety Disorders

Cannabis use disorders (CUDs) co-occur with anxiety disorders at high rates, presumably because some individuals with anxiety disorders may rely on cannabis to manage anxiety. Motivation enhancement therapy (MET) combined with cognitive-behavioral therapy (CBT) is an efficacious intervention for CUD, yet outcomes are worse for patients with elevated anxiety. The integration of MET-CBT with False Safety Behavior Elimination Treatment (FSET) may be useful with anxious CUD patients, as the use of cannabis to manage anxiety can be targeted as a false safety behavior. Here, we describe the integrated treatment and the successful use of it among two patients—one with CUD and comorbid social anxiety disorder (SAD) and one with CUD and comorbid SAD and generalized anxiety disorder. Data support the feasibility of this integrated treatment as a viable approach to the treatment of CUD and comorbid anxiety disorders. Future controlled trials are now warranted to further evaluate the intervention.

Distress Tolerance Among Students Referred for Treatment Following Violation of Campus Cannabis Use Policy Relations to Use, Problems, and Motivation

Students referred to treatment after violating campus drug policies represent a high-risk group. Identification of factors related to these students’ cannabis use could inform prevention and treatment efforts. Distress tolerance (DT) is negatively related to substance-related behaviors and may be related to high-risk cannabis use vulnerability factors that can impact treatment outcome. Thus, the current study tested whether DT was related to cannabis use frequency, cannabis-related problems, and motivation to change cannabis use among 88 students referred for treatment after violating campus cannabis policies. DT was robustly, negatively related to cannabis use and related problems. DT was also significantly, negatively correlated with coping, conformity, and expansion motives. DT was directly and indirectly related to cannabis problems via coping (not conformity or expansion) motives. Motives did not mediate the relation of DT to cannabis use frequency. DT may be an important target in treatment with students who violate campus cannabis policies.