Social anxiety and problematic cannabis use: Evaluating the moderating role of stress reactivity and perceived coping
Introduction
Social anxiety is associated with cannabis dependence (Agosti, Nunes, & Levin, 2002; Lindquist, Lindsay, & White, 1979; Lynskey et al., 2002). Findings from the national comorbidity study (NCS) indicate that although there is a 4.2% lifetime prevalence rate for cannabis dependence in the general population, among individuals with social anxiety disorder (SAD) the prevalence rate of cannabis dependence is 29.0% (Agosti et al., 2002). Interestingly, problematic cannabis use and SAD appear to share a specific relationship since, in the NCS sample, the rate of cannabis dependence was highest in SAD relative to any other anxiety disorder. For example, those with SAD show cannabis dependence rates more than twice that of generalized anxiety disorder (GAD) and panic disorder (PD).
Although frequently considered to be relatively benign, the high rates of co-occurrence cannabis use disorders (CUD) such as cannabis dependence among individuals with SAD is noteworthy because cannabis use is associated with a variety of substantial problems. Long-term cannabis use is associated with legal problems and alcohol and tobacco use (Reilly, Didcott, Swift, & Hall, 1998). Driving under the influence of cannabis results in significantly impaired driving performance (Ramaekers, Robbe, & O’Hanlon, 2000) and a recent review concludes that recent cannabis use increase automobile crash risk (Ramaekers, Berghaus, van Laar, & Drummer, 2004). Additionally, smoking cannabis has been found to have a larger effect on respiratory function than smoking tobacco (Bloom, Kaltenborn, Paoletti, Camilli, & Lebowitz, 1987; Sherrill, Krzyzanowski, Bloom, & Lebowitz, 1991), including cellular changes that may serve as a risk factor for cancer (Fligiel et al., 1997; Sarafian, Magallanes, Shau, Tashkin, & Roth, 1999). Discontinuation of cannabis is associated with withdrawal effects such as restlessness, sleep disturbance, and appetite change (Wiesbeck et al., 1996).
Despite the link between SAD and CUD and the important public health consequences associated with these conditions, there is a paucity of research examining the etiology and maintenance of these co-occurring disorders. Apart from epidemiological accounts, we are aware of only one study investigating the nature of the association between social anxiety and cannabis use (Oyefeso, 1991). This report found that daily cannabis users demonstrated significantly higher scores of social anxiety than individuals who use cannabis less regularly. It is quite clear therefore that the mechanisms underlying the co-occurrence of these two conditions remain largely unexplored.
One explanation for the high levels of co-occurrence of these conditions is tension reduction (Conger, 1956). According to tension-reduction models, individuals use substances to decrease negative affect. There has been considerable interest in understanding the relationship between negative affective states, including anxiety and substance use. Due to the distress inherent to anxiety disorders, it follows that anxious individuals would be at higher risk for substance use as a means to provide relief.
There is support for a tension-reduction model among cannabis users. The literature suggests that stress is a risk factor for substance use and relapse (Sinha, 2001). For example, cannabis users report increased use during times of distress (Kaplan, Martin, Johnson, & Robbins, 1986). Cannabis users report relaxation or relief from tension to be the most common reason for and the most common effect from cannabis use (Hathaway, 2003; Reilly et al., 1998). The expectation that cannabis will reduce tension has been associated with cannabis use among non-clinical undergraduates (Schafer & Brown, 1991) and cannabis users report they use to marijuana to cope with stress and anxiety (Hathaway, 2003; Ogborne, Smart, Weber, & Birchmore-Timney, 2000).
No known studies have examined the utility of a tension-reduction model of cannabis use among individuals with social anxiety. Yet research involving alcohol use provides some support for a tension-reduction model accounting for substance abuse among these individuals. Higher levels of social anxiety are associated with greater tension-reduction alcohol outcome expectancies (Ham, Hope, White, & Rivers, 2002; Kidorf & Lang, 1999; O’Hare, 1990). In addition, higher levels of social anxiety are associated with greater consumption of alcohol in response to experimental anxiety-provoking situation (Kidorf & Lang, 1999). Interestingly, socially anxious individuals do not appear to be more physically reactive to stressors relative to non-socially anxious individuals despite the fact that socially anxious individuals perceive themselves to be more physically reactive (Edelmann & Baker, 2002). Thus, the “tension” component of this model appears to be more influenced by exaggerated perceptions regarding stress reactivity versus actual physical reactivity.
A tension-reduction account of the association between SAD and substance use disorders suggests that substance use, which later evolves into substance abuse, acts as a maladaptive tension-reduction coping strategy. That is, tension, partly created by SAD, is coped with through the use of illicit substances. Obviously, individual differences in coping exist along with a range of adaptive and maladaptive coping strategies. Thus, coping strategies can be thought to moderate the relationship between SAD and substance abuse problems. Individuals with better coping strategies are less likely to resort to maladaptive coping and those with limited coping resources are more likely to utilize illicit substances. This is consistent with some of the literature on coping in SAD. For example, individuals with SAD plus comorbid alcohol use disorders (AUD) report less problem-focused coping than socially anxious individuals without AUD in alcohol-specific situations (Tran & Haaga, 2002). Thus, patients with SAD possessing poorer coping may be particularly vulnerable to abusing substances such as cannabis as well.
The current study examined whether the association between symptoms of SAD and CUD is moderated by perceived coping and physical reactivity to anxiety-provoking stimuli. As previous research has found gender (Siqueira, Diab, Bodian, & Rolnitzky, 2001) and alcohol use (Agosti et al., 2002; Bonn-Miller, Zvolensky, Leen-Feldner, Feldner, & Yartz, 2005) to be associated with cannabis use, gender and AUD symptoms were included as covariates to ensure they were not responsible for any observed effects. Consistent with prior work in the alcohol and social anxiety literatures, it was hypothesized that perceived coping to the stressor would moderate the relationship between SAD and CUD symptoms. Physical reactivity to the stressor was not expected to moderate this relationship. It was also hypothesized that this moderational effect of perceived coping would be diagnostically specific to SAD symptoms.
Section snippets
Participants
Participants were 123 (73 female) undergraduates at a large state university in Tallahassee, FL. Participants were recruited through advertisement fliers posted in various locations around campus (including the Student Counseling Center) asking for participants for a 2.5 h paid study ($25) of physiological responses and psychological functioning. Potential participants were screened by telephone to determine eligibility. Participants were at least 18 years of age and exclusion criteria included
Sample
Thirty-five participants (30.7%) endorsed some symptoms of CUD and 51 (45.9%) endorsed some symptoms of AUD. The numbers of participants endorsing symptoms of anxiety disorders are as follows: specific phobia symptoms (, 45.0%), SAD symptoms (, 19.1%), post-traumatic stress disorder symptoms (, 15.1%), obsessive compulsive disorder symptoms (, 5.8%), PD symptoms (, 5.4%), and generalized anxiety disorder symptoms ( 5.6%).
Zero-order relations among anxiety and cannabis symptoms
Zero-order correlations were computed to provide an
Discussion
The present study serves as the first known investigation of potential moderators of the relationship between SAD and CUD symptomatology. Our data support previous findings suggesting that SAD symptoms are associated with CUD symptoms (Agosti et al., 2002; Lindquist et al., 1979; Lynskey et al., 2002) as well as data signifying that this relationship appears to be specific to SAD symptoms (Agosti et al., 2002). It is particularly noteworthy that in the present study the association between SAD
References (44)
- et al.
Qualitative dimensions of worry in DSM-III-R generalized anxiety disorder subjects and nonanxious controls
Behaviour Research and Therapy
(1989) - et al.
Tracheobronchial histopathology in habitual smokers of cocaine, marijuana, and/or tobacco
Chest
(1997) - et al.
Anxiety sensitivity and drug abuse in individuals seeking treatment for substance abuse
Behaviour Research and Therapy
(1997) Alcohol expectancies and social anxiety in male and female undergraduates
Addictive Behaviors
(1990)- et al.
Dose related risk of motor vehicle crashes after cannabis use
Drug Alcohol Depend
(2004) - et al.
Avoidance-oriented coping as a predictor of panic-related distress: A test using biological challenge
Journal of Anxiety Disorders
(2004) - et al.
Anxiety sensitivity and self-reported reasons for drug use
Journal of Substance Abuse
(1997) A community survey of adverse effects of cannabis use
Drug and Alcohol Dependence
(1996)- et al.
Preliminary tests of a cognitive model of generalized anxiety disorder
Behaviour Research and Therapy
(1999) - et al.
Rates of psychiatric comorbidity among US Residents with lifetime cannabis dependence
American Journal of Drug and Alcohol Abuse
(2002)
The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations
Journal of Perosnality and Social Psychology
Respiratory effects of non-tobacco cigarettes
British Medical Journal
Marijuana use among daily tobacco smokers: Relationship to anxiety-related factors
Journal of Psychopathology and Behavioral Assessment
Applied multiple regression/correlation analysis for the behavioral sciences
Reinforcement theory and the dynamics of alcoholism
Quarterly Journal of Studies on Alcohol
Self-reported and actual physiological responses in social phobia
British Journal of Clinical Psychology
Structured clinical interview for Axis I DSM-IV disorders—patient edition (SCID-I/P, version 2.0)
An analysis of coping in a middle-aged community sample
Journal of Health and Social Behavior
If it changes it must be a process: Study of emotion and coping during three stages of a college examination
Journal of Personality and Social Psychology
Alcohol expectancies and drinking behavior in adults with social anxiety disorder and dysthymia
Cognitive Therapy and Research
Cannabis effects and dependency concerns in long-term frequent users: A missing piece of the public health puzzle
Addiction Research and Theory
Post-hoc probing of significant moderational and mediational effects in studies of pediatric populations
Journal of Pediatric Psychology
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