Maureen H. Carrigan

Self-medication in social phobia: A review of the alcohol literature☆

It is well documented that many individuals endorse the belief that alcohol reduces social anxiety. Individuals with social phobia, therefore, might be expected to use alcohol as a coping strategy in an attempt at self-medication. The purpose of the present paper was to review the published literature on the relationship between alcohol use and social phobia to test the self-medication hypothesis (SMH). Support for one aspect of the SMH was found; individuals with social phobia use alcohol to reduce anxiety. Support for the second premise, that alcohol actually reduces social anxiety, was less conclusive.

Drinking to Cope in Socially Anxious Individuals: A Controlled Study

BACKGROUND Several hypotheses exist to account for the higher than normal rate of alcoholism in individuals with high trait anxiety (or anxiety disorders). Most of these suggest that the practice of drinking alcohol to reduce anxiety leads to an increased risk of alcoholism in vulnerable individuals. The first assumption of the hypothesis is that anxious individuals use alcohol to cope with their anxiety. Few studies have examined this issue systematically, and none have used a nonanxious matched control group. METHODS Twenty-three individuals with high social anxiety and 23 nonsocially anxious matched controls were included in the study. Groups were similar on demographic variables and alcohol use. All participants were queried regarding the use of alcohol to cope, the practice of avoiding social situations if alcohol was not available, and the degree of relief attained by alcohol. Participants also were asked about using alcohol in 11 specific situations. RESULTS The socially anxious group was significantly more likely than controls to report using alcohol to feel more comfortable in social situations and to avoid social situations if alcohol was unavailable. They also reported a greater degree of relief of anxiety from alcohol. Exploratory analyses revealed that socially anxious individuals reported using alcohol more to cope with social interactions than with social performance situations. CONCLUSIONS Individuals high in social anxiety deliberately drink alcohol to cope with their social fears. They report that alcohol is moderately effective at reducing their anxiety, which is seemingly sufficient to allow them to endure social situations. The data support the first assumption of the self-medication hypothesis-that alcohol is used to reduce social discomfort in socially anxious individuals; however, the study was not designed to address the veracity of the self-medication hypothesis as a whole. Results can help guide future studies that examine the relationship between social anxiety and alcohol.

Acute and protracted cocaine abstinence in an outpatient population: a prospective study of mood, sleep and withdrawal symptoms.

This study addresses unresolved questions about cocaine withdrawal by prospectively assessing monitored cocaine abstinence over 28 days in a sample of 24 male and female cocaine-dependent outpatients. Based on results from urine drug screens and self-reported substance use, it is likely that these patients were abstinent from cocaine during the assessment period. Abstinence-related symptoms were monitored at 2, 5, 10, 14, 21, and 28 days following last cocaine use. For patients who were known to relapse, assessments began again after the last day of cocaine use. Consistent with findings from inpatient studies of cocaine abstinence, linear improvements in negative affect, low cocaine craving, and increases in cognitive skills were reported over the 28 days. Also consistent with inpatient studies of cocaine withdrawal, a phasic withdrawal syndrome was not observed in this outpatient sample. Unlike inpatient studies, no disturbances in sleep were reported.

Alcohol Outcome Expectancies and Drinking to Cope with Social Situations

Repeated use of alcohol as a coping strategy to reduce anxiety or discomfort increases ones risk of developing alcohol dependence. Previous studies have found alcohol outcome expectancies (AOE) strongly predict drinking behavior, in general, and also are related to drinking to cope. The purpose of the current study was to examine AOE that may be related to drinking to cope with discomfort in social situations. It was hypothesized that positive AOE, especially related to assertion and tension reduction, would be most associated with drinking to cope with social situations. Fifty-six community volunteers from a larger study on attentional bias and drinking to cope were divided into high (n=36) and low (n=20) drinking to cope groups following completion of a questionnaire battery. Findings indicated AOE were well able to classify drinking to cope status, with 91% of cases correctly classified. As hypothesized, assertion and tension reduction AOE uniquely contributed to the discriminant function in classifying drinking to cope groups. These findings have implications for the prevention and treatment of alcohol use disorders and suggest that AOE should be further investigated as potential moderators of the relationship between social anxiety and alcohol use disorders.

Attentional bias and drinking to cope with social anxiety.

This study investigated the sensitivity of the emotional Stroop test for identifying individuals who reported drinking to cope with social fears. Community volunteers completed a modified Stroop task during which social threat, alcohol-related, and control words were presented. High scores on drinking-to-cope measures were hypothesized to be associated with longer response latencies to both social threat and alcohol-related words. Consistent with previous studies, alcohol dependence was correlated with latencies for alcohol-related words, and level of social anxiety was correlated with response latency to social threat words. As expected, drinking-to-cope measures predicted response latency to alcohol-related and social threat words. These results suggest that the emotional Stroop test is useful in studying the relationship between social anxiety and alcohol consumption.

Exposure to negative affect cues and urge to smoke.

While much of the cue exposure literature for cigarette smoking has focused on external cues, little has been done in the area of exposing participants to internal cues, such as negative affect (NA), despite the important role of such cues in maintaining smoking behavior. Smokers were exposed to an NA mood induction to induce an urge to smoke and then exposed to NA cues over several trials in an attempt to decrease this urge. Participants (N = 32) were undergraduate smokers assigned to either the exposure or control group for the mood induction procedure, which occurred over 8 trials. All participants viewed NA images and listened to NA music at Trial 1. The exposure group continued to view NA images and listened to NA music, and the control group viewed neutral images and listened to neutral music for 6 subsequent trials lasting about 5 min each. Both groups were exposed to NA images and NA music at Trial 8. NA and urge to smoke ratings were assessed at the end of each trial; heart rate was measured continuously. Results indicated that the mood induction procedure induced NA and urge to smoke, but the extinction procedure did not decrease urge over trials. Heart rate data were not associated with self-report data. In conclusion, the mood induction procedure in the present study appears to be an efficient way to induce urge to smoke. However, further research is necessary to determine why urge to smoke seems to be resistant to extinction.

Treatment of Co-Occurring Alcoholism and Social Anxiety Disorder

Social anxiety disorder, also called social phobia, was recognized as a distinct anxiety disorder in 1980 (American Psychiatric Association [APA], 1980). The prevalence of 13% in the general population (11% in males and 15% in females), makes it the most prevalent anxiety disorder in the United States (Kessler et al., 1994). As such, there has been a rapidly growing interest in this ‘‘neglected’’ anxiety disorder (Liebowitz, Gorman, Fyer, & Klein, 1985). The cardinal feature of social anxiety disorder is extreme fear of scrutiny and negative evaluation by others in social interactions or social performance situations (American Psychiatric Association, 1994). These fears typically begin in early adolescence (Ballenger et al., 1998). In one epidemiologic survey, more than 90% of those who developed social anxiety disorder did so by the time they were 25 (Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992). If social situations are encountered and endured rather than avoided, they are done so with extreme discomfort. Social phobia is more debilitating than shyness (Chavira, Stein, & Malcarne, 2002), and it does not spontaneously remit (Bruce et al., 2005). The chronicity of the disorder results in significant underachievement and underperformance, lower levels of satisfaction with life, and a generally higher level of functional disability than individuals without social anxiety disorder (Simon et al., 2002; Quilty, Van Ameringen, Mancini, Oakman, & Farvolden, 2003). It is well known from anecdotal reports in treatment-seeking (Chambless, Cherney, Caputo, R Schneier,Martin, Liebowitz, Gorman, & Fyer, 1989) and non-treatment-seeking samples (Thomas, Randall, &Carrigan, 2003) that socially anxious individuals intentionally use alcohol to self-medicate their social fears. The self-medication hypothesis (Khantzian, 1997), the tension reduction hypothesis (Conger, 1956), and the stress-response-dampening hypothesis (Sher & Levenson, 1982) all predict that repeated use of alcohol to

Treatment of Social Anxiety with Paroxetine: Mediation of Changes in Anxiety and Depression Symptoms

Investigation of relationship patterns between co-occurring symptoms has greatly improved the efficacy of psychiatric care. Depression and anxiety often present together, and identification of primary vs secondary psychiatric symptoms has implications for treatment. Previous psychotherapy research investigating the relationship between social anxiety and depression, across social anxiety treatment, found that severity of social anxiety accounted for most of the change in depression severity across time. Conversely, severity of depression accounted for little variation in severity of social anxiety. The current investigation was conducted to extend these findings by examining this mediational relationship in a pharmacologic trial comparing paroxetine (n = 20) and placebo (n = 22). Social anxiety and depression severity were assessed weekly for 16 weeks. Consistent with the previous study, results indicated that social anxiety severity mediated most of the variance in depression severity, with little variance accounted for by a test of the reverse mediation. Surprisingly, this same pattern was also found in the placebo group. These findings suggest that this pattern of mediational relationships may be fundamental to social anxiety, rather than specific to treatment modality or secondary comorbidity.

The relationship between depression level and smoking motives in college smokers

While the link between cigarette smoking and depression symptomatology has been well established, more research is needed to determine how smoking motives are related to depression levels in smokers. Specifically, smoking motives related to the friendship-like attachment to smoking (i.e., affiliative attachment) may play an important role in individuals reporting depressive symptomatology. The present study examined the relationship between three smoking motives and depression levels in a sample of 79 mildly nicotine-dependent, college student cigarette smokers. A hierarchical multiple regression analysis was conducted with depression as the dependent variable and gender and cigarettes per day as the independent variables (Step 1), positive and negative reinforcement motives (Step 2), and affiliative attachment motives (Step 3). Results of regression analyses indicated that affiliative attachment motives explained significant variance in participant depression level above and beyond that explained by positive and negative reinforcement motives. These findings suggest that smokers with elevated depression should be assessed for social functioning and affiliative attachment smoking motives, and future research should be conducted to determine if individuals with high levels of affiliative attachment may benefit from smoking cessation treatment programs with an enhanced social support component.

Social anxiety and alcohol use: The role of alcohol expectancies about social outcomes

Abstract Though social anxiety disorder and alcohol use disorders commonly co-occur, the mechanisms involved in social anxiety and hazardous drinking among college students are not well understood. The current study contributes to the emerging literature on social anxiety and college drinking as the first known study to test how positive (e.g. “I would feel at ease in social situations”) and negative (e.g. “I would make a fool out of myself”) alcohol outcome expectancies (AOE) specific to social situations (social AOE) impact the association between social anxiety and hazardous alcohol use among 718 undergraduates (61% women; Mage = 19.50, SD = 1.45; 85% White). Results supported the mediation, but not the moderation models. There were positive indirect effects of social anxiety through positive social AOE and negative indirect effects of social anxiety through negative social AOE on both hazardous drinking outcomes (i.e. alcohol consumption and alcohol problems). Findings suggest that there could be competing pathways for increasing (positive social AOE) and decreasing (negative AOE) risk for hazardous alcohol use in socially anxious college students.