Social Anxiety Disorder and Alcoholism Sarah W. Book MD Medical University of South Carolina.

Social Anxiety Disorder and Alcoholism

Sarah W. Book MD

Medical University of South Carolina

©2004 Alcohol Medical Scholars Program

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Why is it important?

Effective Alcoholism pharmacologic treatments have been elusive Mixed reviews for naltrexone (Revia) Small number of studies support

ondansetron (Zofran) and topiramate (Topamax)

Disulfuram (Antabuse) used despite minimal support in the literature


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Why is it Important?

Heterogeneity of “Alcohol Dependence” Type I Alcoholic

Depression or anxiety Later onset

Type II Alcoholic Earlier onset Family history of alcoholism Antisocial personality disorder


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Why is it Important?

Alcoholics with Social Anxiety

Unique example of Type I alcoholic Homogeneous group of alcoholics May respond differentially to specific

treatments


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What we will be talking about

What is Social Anxiety? What is Alcohol Dependence? Social Anxiety and Alcohol Dependence

in the same individual Are they related? Can Social Anxiety induce Alcohol use? Can Alcohol Dependence induce Social

Anxiety?


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What we will be talking about

Treatment of Co-Occuring Social Anxiety and Alcohol Dependence

Conclusions


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Diagnosis of Social Anxiety

Hallmark: Fear of scrutiny Specific Generalized

More severe than Specific What this talk is mainly about

Avoids situations or endures them


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Social Anxiety Disorder

Interferes in normal life

85% report impaired academic performance 92% endorse occupational impairment 70% said it impaired their social life

Turner et al 1992


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Epidemiology of Social Anxiety Disorder

Lifetime prevalence ~10% Women:Men=3:2 More likely to be financially dependent 22% with Social Anxiety on welfare or

disability 11% with no disorder


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Natural History of Social Anxiety Disorder

Age of onset in mid-teens

90% of those with Social Anxiety had onset prior to age 25

ECA Data


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Alcohol Dependence

Tolerance Withdrawal Substance taken in larger amounts then intended Persistent unsuccessful attempts to cut down or control

substance use A great deal of time spent getting, using, or recovering from

substance Important activities given up or reduced to continue use Continued use despite psychological or physical problem


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Epidemiology of Alcohol Dependence

Lifetime prevalence 20% in men, 8% in women

Education: > High School Married Frequently Abstain from Alcohol

Schuckit et al 1997


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What Does an Alcoholic Look Like?

Average Alcoholic:

Educated Married Doesn’t drink every day


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Natural History of Alcohol Dependence

Age of onset mid 20’s to early 30’s

By age 31, 50% of those who will develop alcohol dependence already have (Schuckit, 2000)


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Social Anxiety & Alcohol Dep. in the Same Individual

Are these two related? Anecdotal Studies

Drinking co-occurs with nervousness Anxiety symptoms or anxiety disorder? Alcohol withdrawal causes anxiety symptoms

Assortative mating Psychiatric impairment increases risk of choosing

psychiatrically impaired spouse This alcoholics may marry persons with social anxiety and

children at higher risk for both


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Social Anxiety and Alcohol

Age of Onset Social anxiety: mid teens Alcohol dependence: mid 20’s Social Anxiety likely to precede alcohol

dependence


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Social Anxiety & Alcohol Use

Tension Reduction How does alcohol reduce anxiety?

Pharmacological effect Belief that alcohol has been ingested

Alcohol Expectancy Define: that component of ETOH effect which is

due to belief.


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Expectancies may be gender related Men: ETOH makes me one of the guys Women: ETOH makes me look like a

‘troubled woman’ Women with social anxiety may be less

likely to use ETOH as a coping mechanism in social situations

Corcoran and Michels 1998


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Alcoholics may be more likely to have positive expectancies

Alcohol does reduce social anxiety (maybe more than general tension)

People with social anxiety may be more likely to have positive expectancies AND may be more likely to drink in social situations


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Early on: Anxiety drives ETOH use Later on: ETOH use exacerbates or

causes anxiety

Kushner et al, 1990


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Alcohol Induced Anxiety

Alcohol withdrawal causes anxiety Anxiety improves several weeks after

cessation of drinking After we control for withdrawal and

prolonged withdrawal, anxiety disorders are no more prevalent than in the general population (Schuckit and Hesselbrock 1994)


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Alcohol Induced Anxiety

Social Anxiety Disorder affects 2-13% of general population

In one group of alcoholics, after controlling for alcohol withdrawal, 9% met criteria for Social Anxiety Disorder

This is not different than the general population


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Treatment of Social Anxiety

Psychotherapy Cognitive Behavioral Therapy (CBT) shown

to be effective (Heimberg, 2001) Thoughts, feelings, and behaviors are a cycle Goal of CBT: restructure problematic thought

patterns and encourage more adaptive behaviors

If thoughts and behaviors change, feelings (e.g. anxiety) will also change


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Treatment of Social Anxiety

Medication SSRI’s: fluoxetine (Prozac), sertraline

(Zoloft), paroxetine (Paxil), citalopram (Celexa), es-citalopram (Lexapro)

MAOI’s Benzodiazepines: alprazolam (Xanax), and

clonazepam (Klonopin) GABAergic anticonvulsants: gabapentin

(Neurontin)


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Treatment of Alcohol Dependence

Psychotherapy CBT, Motivational Enhancement Therapy

(MET) and Twelve Step Facilitation (TSF) Focus of CBT: change drinking behavior MET: conceptualizes the therapist as a

coach, helping the client along the “stages of change”


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Psychotherapy (cont) Twelve Step Facilitation (TSF)

Modeled after 12 Steps of Alcoholics Anonymous (AA)

Therapist helps client work through steps 1-4 Encourages AA attendance outside of therapy

time


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Medications

disulfuram (Antabuse) naltrexone (Revia) ondansetron (Zofran) topiramate (Topamax)


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Treatment of Comorbid Social Anxiety and Alcoholism

What We Know - not very much Psychotherapy

Women may do better with CBT than TSF Enhancing CBT treatment for Alcoholism to

address Social Anxiety did not improve outcomes

Randall et al 2001


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Some medications useful for Social Anxiety may not be safe for Alcohol Dependence Benzodiazepines MAOIs


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Paroxetine more effective than placebo in one pilot study

Subjects had Social Anxiety and Alcohol Abuse or Alcohol Dependence

N=15 Treatment 8 weeks

Randall et al 2001


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Treatment of Social Anxiety and Alcoholism

Does order matter? Treat anxiety first? Treat alcoholism first? Treat both simultaneously

Maybe treat social anxiety with SSRI and alcoholism with topiramate (gaba-ergic anticonvulsant, shown effective for alcohol dependence, may be effective for anxiety)


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Conclusions

Relationship between Social Anxiety and Alcoholism is complex

May be a unique population of Alcoholics which responds preferentially to specific pharmacologic intervention

Social Anxiety Disorder and Alcoholism Sarah W. Book MD Medical University of South Carolina.

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