Anxiety sensitivity, controllability, and experiential avoidance and their relation to drug of choice and addiction severity in a residential sample of substance-abusing veteransā
Introduction
It is generally recognized that substance abuse and withdrawal are associated with a wide range of positive and negative psychophysiological effects that contribute, in part, to appetitive and aversive motivational systems and affective states (Wise, 1988). Moreover, substance abusers generally have a poor tolerance for unpleasant bodily states and negative affect that results from their ongoing abuse of controlled substances and cycles of withdrawal Araujo et al., 1996, Lacks & Leonard, 1986. Indeed, relapsed alcoholics often identify negative somatic and emotional states as causal factors in relapse Carpenter & Hasin, 1999, O'Brien et al., 1984, Tiffany & Drobes, 1990āa finding that has been confirmed in laboratory-based studies (e.g., Cooney et al., 1997, Litt et al., 2000). For example, Cooney et al. (1997) found that negative affect enhanced the effects of alcohol cue presentation on the elicitation of alcohol urges and prediction of time to relapse. Other studies have also shown that high dispositional self-awareness and the experience of predominantly negative emotional events is associated with increased risk of relapse following a detoxification program (Hull, Young, & Jouriles, 1986). Yet, the precise nature of affective motivational states in persons who abuse controlled substances is not well understood.
Recent efforts to describe the role of interoceptive sensitivity and negative affect in substance abuse populations have adopted several constructs from the anxiety literature such as anxiety sensitivity (Stewart, Samoluk, & MacDonald, 1999). Anxiety sensitivity is generally conceptualized as a tendency to respond fearfully to the occurrence of symptoms of anxiety and is believed to augment the experience of fear and negative affect in a positive spiral Peterson & Reiss, 1992, Reiss, 1991. Indeed, several studies have shown that anxiety sensitivity, as assessed using the Anxiety Sensitivity Index (Reiss, Peterson, Gursky, & McNally, 1986), is a salient cognitive risk factor in the etiology and maintenance of anxiety disorders, particularly panic disorder (e.g., Cox et al., 1996, Taylor et al., 1992). Not only is anxiety sensitivity a prominent feature of several models of anxiety symptomatology Reiss, 1991, Reiss, 1997, Zinbarg et al., 1997, but it is often associated with other psychological factors such as negative emotionality (Lillienfeld, 1997) and depression (Taylor, Koch, Woody, & McLean, 1996). In all, anxiety sensitivity represents a relatively stable trait-like psychological factor that reliably discriminates clinical and nonclinical manifestations of fear and panic.
Interest in anxiety sensitivity in the context of substance abuse derives from the view that abuse of some controlled substances (e.g., alcohol, benzodiazepines) largely functions to attenuate arousal, fear, negative affect, or even the tendency to catastrophize about arousal sensations. The motivation to abuse controlled substances, particularly those that attenuate arousal and negative affect (e.g., alcohol), may be driven, in part, by fear of anxiety-related symptoms and efforts to avoid or minimize their occurrence and recurrence McNally, 1996, Stewart et al., 1999. In other words, the removal of the behavioral components of anxiety sensitivity (e.g., fear of one's own fearful responding) negatively reinforces drug consumption. For example, individuals who meet diagnostic criteria for alcohol abuse or dependence typically score significantly higher than average on the Anxiety Sensitivity Index compared to nonclinical norms (e.g., Karp, 1993). Other studies have shown that highly anxiety-sensitive females are at increased risk for becoming dependent on anxiolytic substances (e.g., Conrod, Pihl, Stewart, & Dongier, 2000), and that anxiety sensitivity is predictive of frequency of drug and alcohol abuse (DeHaas, Calamari, & Bair, in press).
Although preliminary, some studies also suggest that differences in anxiety sensitivity are associated with drug choice (i.e., preference for alcohol over stimulants and other controlled substances) among males seeking treatment for substance abuse (Norton et al., 1997). Similar relations between drug of choice and anxiety sensitivity have been reported in nonclinical populations (e.g., Stewart, Karp, Pihl, & Peterson, 1997). For instance, Stewart, Karp et al., (1997) and Stewart, Taylor, and Baker (1997) found that young adults scoring high on the Anxiety Sensitivity Index report drinking more often to cope with negative affect compared to lowly anxiety-sensitive controls (see also Stewart, Zvolensky, & Eifert, 2001); a finding that has been demonstrated in a sample of high AS women who were shown to drink significantly more than low AS women when given access to alcohol in an experimental setting (Stewart & Zeitlin, 1995). Indeed, one of the more robust findings in this literature to date is the consistent relations found between high anxiety sensitivity scores and frequency of alcohol consumption to cope with negative affect (Stewart, Peterson, & Pihl, 1995).
Far less robust are reported relations among substance abuse, drug of choice, anxiety sensitivity, and other individual difference factors (Cox, 1987). One reason for the inconsistency in relating drug of choice with personality domains may be due, in part, to other nonspecific factors that often figure prominently in substance abuse more generally (Stewart et al., 1999). Aside from assessment of interoceptive sensitivity (e.g., anxiety sensitivity), other relevant domains that may contribute to understanding individual difference factors in substance abuse include, but are not limited to (a) functional impairments related to the cycle of addiction (i.e., addiction severity), (b) drug of choice, (c) substance use history, (d) perceptions of control, (e) the tendency to either avoid or accept unpleasant private events (i.e., negative thoughts, feelings, emotional responses), and (f) the more general presence of symptoms of negative affect (e.g., depression, anxiety; see Cox, 1987). Each of these domains taps theoretically and practically relevant predispositions that may offer additional information related to use and abuse of controlled substances. In addition, such information may be relevant to assessment and treatment interventions that target behaviors more broadly related to substance abuse over and above examination of drug choice and behaviors related to use of controlled substances specifically.
The present study of predominantly male veterans enrolled in a 28-day residential substance abuse treatment program attempts to replicate and expand upon the findings of Norton et al. (1997) and those of others in addressing multifaceted psychological risk factors (e.g., anxiety sensitivity, perceived control, nonacceptance/avoidance) that have been implicated in substance abuse and how such factors relate to drug of choice, extent of diagnostic comorbidity, and addiction severity. Specifically, we address (a) the extent to which heightened anxiety sensitivity accounts for drug of choice (i.e., preference for depressants over stimulants), (b) whether psychological risk factors (e.g., bodily fears, perceived controllability, experiential avoidance) correlate with, or interact to affect, drug of choice, (c) how such risk factors are related to functional impairment resulting from a pattern of addiction, and (d) the extent of relation between the assessed psychological risk factors, substance preference, and diagnostic comorbidity. In addition, we examined whether (a) drug of choice varies reliably between persons with a primary substance abuse diagnosis only versus those participants comorbid for at least one other psychological condition, and (b) whether psychological and addiction-related indices differ as a function of diagnostic status and treatment. Such domains, in turn, may be conceptualized more broadly as functionally related to specific motivational factors (e.g., tension reduction, Levenson, Sher, Grossman, Newman, & Newlin, 1980) that constitute a psychological risk for substance abuse.
Section snippets
Participants
Ninety male and four female (age; M=44.0; S.D.=8.40) veterans who applied for admission to the residential/inpatient substance abuse treatment program at the G.V. (Sonny) Montgomery Veterans Affairs Medical Center, Jackson, MS, participated in this study. Of the sample, 26.6% was Caucasian, 72.3% African American, and 1.1% fell into the Other racial category (e.g., Native American). Approximately one-third (36.2%) of the sample had completed high school, whereas 52.2% had college or advanced
Results
Mean anxiety sensitivity scores (M=33.0; S.D.=13.8) for the present sample were over one standard deviation above those for nonclinical men and women (17.8 and 18.8, respectively; Peterson & Reiss, 1992) and were within clinical ranges for anxious individuals (22.4 for anxious college students, 36.4 for patients diagnosed with panic disorder, and 38.4 for patients diagnosed with PTSD; Peterson & Reiss, 1992).
Consistent with Norton et al.'s (1997) approach, participants were divided in high,
Discussion
The central aim of the present study was to replicate and extend the findings of Norton et al. (1997) and others showing a relation between anxiety sensitivity, drug of choice, and abuse of controlled substances in a large sample of inpatients with substance abuse problems. Contrary to expectation, we were unable to show any reliable relation between anxiety sensitivity and drug of choice, nor support for the view that highly anxiety-sensitive individuals use alcohol or other controlled
Acknowledgements
This research was supported by the Veterans Integrated Service Network 16 Mental Illness Research and Education Clinical Center. The second author acknowledges the support of the South Central VA Health Care Network Mental Illness Research Education and Clinical Centers (MIRECC) in completion of this project. Preparation of this manuscript was also supported, in part, by a grant (No. 1RO1MH6010701) from the National Institute of Mental Health to John P. Forsyth.
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Portions of this article were presented (1999, November) at the annual meeting of the Association for Advancement of Behavior Therapy, Toronto, Canada.