The relationship between cannabis use disorders and social anxiety disorder in the National Epidemiological Study of Alcohol and Related Conditions (NESARC)

https://doi.org/10.1016/j.drugalcdep.2011.12.023Get rights and content

Abstract

Background

Cannabis use disorders (CUD) are highly comorbid with social anxiety disorder (SAD), and SAD may be a risk factor for cannabis dependence. This study explored these relationships in several ways. First, we examined whether SAD was more likely to be related to cannabis dependence than abuse. Second, we examined the temporal relations between CUD and SAD. Third, we examined whether SAD was related to faster transition from age of first cannabis use to CUD onset relative to other anxiety disorders. Fourth, we tested whether having both disorders was associated with greater impairment and psychiatric comorbidity.

Method

The sample consisted of adults from Wave 1 of the National Epidemiological Survey on Alcohol and Related Conditions, 2957 of whom had CUD and no SAD, 1643 had SAD and no CUD, and 340 had CUD–SAD.

Results

SAD was more likely to be related to cannabis dependence than abuse. This relation remained after controlling for race, sex, and some other psychiatric disorders (including some anxiety disorders). Age-of-onset data suggest SAD onset prior to CUD onset for most CUD–SAD respondents. CUD–SAD was related to greater impairment and psychiatric comorbidity than either disorder alone.

Conclusions

Although SAD is related to CUD, it has a stronger association with cannabis dependence than abuse. This link is not better accounted for by other psychopathology measured in this study. SAD onset prior to CUD for the majority of CUD–SAD respondents. Importantly, the co-occurrence of these two disorders appears to result in greater impairment and distress than either disorder alone.

Introduction

Individuals with cannabis use disorders (CUD) often struggle with anxiety. People with cannabis dependence are over five times more likely to have an anxiety disorder (Stinson et al., 2006), and 73.1% of cannabis dependent adults meet criteria for a primary anxiety disorder (Agosti et al., 2002). Social anxiety disorder (SAD) appears particularly related to CUD. In the National Comorbidity Survey, 29% of individuals with lifetime cannabis dependence had lifetime SAD, whereas rates of other lifetime anxiety disorders ranged from 6.9% to 18.5% (Agosti et al., 2002). Also, adolescents with SAD are seven times more likely to develop cannabis dependence as young adults (Buckner et al., 2008a).

Despite the high comorbidity of CUD–SAD, the literature is limited in several ways. First, it is unclear whether people with SAD are vulnerable to cannabis abuse or dependence. Although elevated social anxiety has been consistently linked to cannabis-related problems (e.g., Buckner et al., 2006a, Buckner et al., 2006b, Buckner et al., 2007, Buckner et al., 2011, Buckner et al., in press, Buckner and Schmidt, 2008, Buckner and Schmidt, 2009), only two studies have examined whether those with SAD are especially vulnerable to cannabis dependence. SAD in adolescence was related to greater risk of cannabis dependence, but not cannabis abuse, by age 30 (Buckner et al., 2008a). In the National Epidemiological Study of Alcohol and Related Conditions (NESARC), rates of lifetime SAD were 15.5% among those with cannabis dependence and 5.0% among those with cannabis abuse (Stinson et al., 2006). Whether SAD contributes to cannabis-related problems over and above other types of psychopathology common to cannabis use (e.g., internalizing and externalizing disorders) has not been sufficiently studied. It may be that the high rates of cannabis dependence among those with SAD are due to co-occurring Axis I disorders. For instance, SAD often co-occurs with other anxiety disorders and depression (Grant et al., 2005a), and these disorders are common among those with cannabis dependence (Agosti et al., 2002). Only two studies have examined the relations between SAD and cannabis-related problems after controlling for relevant demographic and clinical variables. Adolescent SAD predicted cannabis dependence at age 30 after controlling for gender and conduct disorder, alcohol use disorders (AUD), mood disorders, and other anxiety disorders (Buckner et al., 2008a). SAD remained significantly related to cannabis-related problems after controlling for gender, cannabis use frequency, major depressive disorder (MDD), and other anxiety disorders (Buckner and Schmidt, 2009). However, these studies were conducted with young samples with low prevalence of some disorders. Replication with more representative samples is warranted.

The temporal relations between CUD and SAD have also not been fully elucidated. Socially anxious individuals report using cannabis to cope in social situations (Buckner et al., in press) and for conformity and coping motives (Buckner et al., 2007). Coping mediates the relation between social anxiety and cannabis-related problems (Buckner et al., 2007, Buckner et al., in press), suggesting that SAD onset should occur prior to CUD. Anxiety disorders do tend to occur prior to CUD onset (Agosti et al., 2002). Yet, it is possible that CUD occurs prior to SAD for some individuals who may develop a fear of scrutiny by others (a hallmark feature of SAD) as a result of experiencing humiliating consequences of CUD (e.g., behaving foolishly while intoxicated, legal troubles, problems with family or friends). Also, the practice of examining anxiety disorders as a group makes it impossible to determine whether some anxiety disorders occur prior to CUD whereas others occur after. In fact, some types of anxiety appear to be a consequence of cannabis use (e.g., panic; Zvolensky et al., 2008).

Another understudied area is whether those with CUD–SAD demonstrate faster transition from first cannabis use to CUD compared to people with CUD without SAD. Given that socially anxious individuals report using cannabis to manage negative affect (Buckner et al., 2007), it may be that these individuals quickly become reliant upon cannabis to help them cope and thus continue to use despite negative consequences. In partial support of this hypothesis, Marmorstein et al. (2010) found that SAD was related to faster transition from use to cannabis problems after controlling for history of delinquent behaviors. However, this study is limited in that these relations were only examined in boys, and it examined transition from use to problems, not use to CUD.

It is also unclear whether people with CUD–SAD experience greater impairment and more psychiatric disorders than people with CUD or SAD alone. It follows that the comorbid group would exhibit greater impairment (e.g., less occupational attainment) and other types of psychopathology (e.g., higher rates of co-occurring mood disorders, or other anxiety disorders). Yet, it is also conceivable that SAD could protect people with CUD from greater impairment (e.g., if SAD prevents a person from venturing into social situations, thereby decreasing the likelihood of driving while intoxicated). Similarly, CUD could protect people with SAD from experiencing more SAD-related problems if self-medication decreases anxiety symptoms to a less interfering level. Examination of whether CUD–SAD is related to greater impairment and other types of psychiatric disorders could have important implications for prevention and treatment and inform theoretical models of this comorbidity pattern.

The present study sought to fill these gaps in the literature using data from the first wave of the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) NESARC, allowing us to examine the relations between CUD and SAD in a large, representative U.S. sample. Prior work with the NESARC determined that SAD is related to greater odds of lifetime and 12-month CUD (Stinson et al., 2006) and that anxiety disorders (as a group) are related to greater odds of transitioning from cannabis use to dependence (Lopez-Quintero et al., 2011). We extend these findings in several ways. First, given that prior work found SAD to be related to cannabis dependence but not abuse (Buckner et al., 2008a), we directly examined whether those with SAD were more likely to have cannabis dependence than cannabis abuse and whether observed relations between SAD and cannabis dependence remained after controlling for a wide range of relevant variables (e.g., gender, other substance use disorders [SUD]). Second, we examined the temporal relations between CUD and SAD. Given that SAD prospectively predicted onset of cannabis dependence (Buckner et al., 2008a), it was hypothesized that SAD would occur prior to CUD for the majority of CUD–SAD respondents. Third, we strove to extend prior work finding greater social anxiety to be related to faster transition from age of first cannabis use to cannabis-related problems (Marmorstein et al., 2010) by testing whether SAD was related to a faster transition from age of first cannabis use to CUD onset relative to the other anxiety disorders assessed in the NESARC (generalized anxiety disorder [GAD], panic disorder, and specific phobia). Fourth, we examined whether CUD–SAD respondents differed from those with either disorder alone on demographic variables, substance use behaviors, and psychiatric comorbidity.

Section snippets

Sample

The 2001–2002 NESARC surveyed a representative sample of the U.S. adult population (Grant et al., 2003b, Grant et al., 2004a, Grant et al., 2005a). It targeted civilians (18 years and older) residing in households or group living quarters. Face-to-face interviews were conducted with 43,093 respondents, with a response rate of 81%. Blacks, Hispanics, and young adults (18–24 years old) were over-sampled, with data adjusted for over-sampling, household- and person-level non-response.

The weighted

Hypothesis 1: SAD would be more strongly related to cannabis dependence than abuse

Table 1 presents the relationships between cannabis abuse and dependence and anxiety disorders, as well as other psychiatric disorders. Consistent with prediction, SAD was significantly more likely to be related to cannabis dependence than abuse. In fact, all disorders except conduct disorder and pathological gambling were significantly related to cannabis dependence.

Also as predicted, SAD was related to cannabis dependence above and beyond shared variance explained by sex, race, and other

Discussion

This study is the first systematic, epidemiological investigation of the relationships between CUD and SAD. Findings contribute to our understanding of these relationships in several ways. First, although SAD was related to both cannabis abuse and dependence (Lopez-Quintero et al., 2011), the association was greater for dependence than abuse. This finding is consistent with prior work finding SAD to be prospectively related to onset of cannabis dependence but not abuse (Buckner et al., 2008a)

Role of funding source

Funding for this study was provided by NIH Grants DA019606, DA020783, DA023200 and MH076051 (Dr. Blanco), and by the New York State Psychiatric Institute (Drs. Blanco and Schneier). NIMH had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Contributors

Authors Buckner and Heimberg designed the current study, managed the literature searches and summaries of previous related work, and wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.

Conflict of interest

Dr. Schneier has received funds from GlaxoSmithKline for speaking. The remaining authors declare that they have no conflicts of interest.

References (38)

  • B.F. Grant et al.

    The Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS): reliability of alcohol and drug modules in a general population sample

    Drug Alcohol Depend.

    (1995)
  • B.F. Grant et al.

    Co-occurrence of 12-month mood and anxiety disorders and personality disorders in the US: results from the national epidemiologic survey on alcohol and related conditions

    J. Psychiatr. Res.

    (2005)
  • B. Han et al.

    Associations between duration of illicit drug use and health conditions: results from the 2005-2007 national surveys on drug use and health

    Ann. Epidemiol.

    (2010)
  • C. Lopez-Quintero et al.

    Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

    Drug Alcohol Depend.

    (2011)
  • M.J. Zvolensky et al.

    Prospective associations between cannabis use, abuse, and dependence and panic attacks and disorder

    J. Psychiatr. Res.

    (2008)
  • V. Agosti et al.

    Rates of psychiatric comorbidity among U.S. residents with lifetime cannabis dependence

    Am. J. Drug Alcohol Abuse

    (2002)
  • J. Alonso et al.

    Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

    Acta Psychiatr. Scand.

    (2004)
  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders

    (1994)
  • R.A. Battisti et al.

    Chronic use of cannabis and poor neural efficiency in verbal memory ability

    Psychopharmacology (Berl)

    (2010)
  • Cited by (75)

    • Cannabis use and social anxiety in young adulthood: A meta-analysis

      2022, Addictive Behaviors
      Citation Excerpt :

      It appears that the literature in young adulthood is more complex in that we observed mixed evidence for the role of social anxiety in cannabis outcomes relative to the more consistent findings from epidemiologic adult samples. Epidemiologic research in this sector has used adult samples, with findings that SAD is uniquely related to CUD (Buckner, Heimberg, Schneier, et al., 2012). Our results found that study samples with less clinical levels of social anxiety experienced greater cannabis problems, suggesting that clinical risk may only partially explain heightened risk for cannabis-related problems.

    View all citing articles on Scopus
    View full text