Specificity of social anxiety disorder as a risk factor for alcohol and cannabis dependence
Introduction
Social anxiety disorder (SAD) is frequently comorbid with both alcohol abuse and dependence (Davidson et al., 1993, Grant et al., 2005, Kessler et al., 1997) as well as cannabis dependence (Agosti et al., 2002, Lynskey et al., 2002). For instance, 48% of individuals with a lifetime diagnosis of SAD also meet criteria for a lifetime diagnosis of an AUD (Grant et al., 2005). The 12-month prevalence of AUDs among individuals with SAD is 13.1% (Grant et al., 2005) compared to only 8.5% among the general population (Grant et al., 2004, Grant et al., 2004). Similarly, findings from the National Comorbidity Study (NCS) indicate that there is a 4.2% lifetime prevalence rate for cannabis dependence in the general population, whereas among individuals with SAD, the prevalence rate of cannabis dependence is elevated to 29.0% (Agosti et al., 2002). Yet, little is known about the specificity or temporal sequencing of the relationships between SAD and these substance use disorders. Elucidation of these relationships could have important implications for the prevention and treatment of these conditions among socially anxious individuals (Heimberg and Becker, 2002).
The high rates of comorbidity between SAD and AUD and cannabis dependence are cause for concern because misuse of alcohol or cannabis tends to compound the already significant problems of patients with SAD. For example, SAD patients with AUD report more severe impairment than patients with SAD without AUD (Schneier et al., 1989) and alcoholics with SAD demonstrate more severe symptoms of alcohol dependence and display more depressive symptomatology than alcoholics without SAD (Thomas et al., 1999b). Cannabis dependence among individuals with SAD is problematic because smoking cannabis has a larger effect on respiratory function than smoking tobacco (Bloom et al., 1987, Sherrill et al., 1991), including cellular changes that may serve as a risk factor for cancer (Fligiel et al., 1997, Sarafian et al., 1999). Long-term cannabis use is associated with legal problems and increased alcohol and tobacco use (Patton et al., 2002, Reilly et al., 1998) and driving under the influence of cannabis leads to increased automobile crash risk (Ramaekers et al., 2004).
Among the anxiety disorders, SAD appears to show a particularly problematic risk profile for comorbid AUD and CUD. For example, SAD is associated with higher rates of AUD relative to most other anxiety disorders (Kessler et al., 1997). SAD is also correlated with cannabis dependence at rates more than twice that of any other anxiety disorder (Agosti et al., 2002). On the matter of sequencing, evaluation of typical age of onset of SAD and AUD suggests that SAD serves as a risk factor for subsequent AUD (Kessler et al., 1997, Randall et al., 2001a, Randall et al., 2001b, Schneier et al., 1989). Additionally, in a 13-year longitudinal investigation (Crum and Pratt, 2001), individuals with subclinical symptoms of SAD showed a greater risk for AUD relative to individuals without subclinical SAD symptomatology. Unexpectedly, individuals diagnosed with SAD using DSM-III standards did not show an increased risk of subsequent AUD, but changes in diagnostic criteria for SAD from DSM-III to DSM-IV-TR complicate interpretation of these findings in relation to contemporary diagnostic definitions. In particular, DSM-III criteria included avoidance as a necessary symptom for social phobia and avoidance is no longer a necessary criterion for SAD. This change is not trivial because it may very well be those individuals with SAD who do not avoid social situations who are most vulnerable to problematic alcohol use, especially if they use alcohol in social situations in an attempt to attenuate anxiety reactions. Similarly, among German adolescents, SAD is associated with subsequent regular and hazardous alcohol use but not DSM-IV alcohol abuse or dependence at 4-year follow-up (Zimmermann et al., 2003). That study, however, did not follow participants very far into the typical period of onset of alcohol dependence, thereby limiting its interpretability. Although there are no known longitudinal investigations of the relationship between SAD and cannabis abuse and/or dependence, given that marijuana users report they use to marijuana to cope with stress and anxiety (Hathaway, 2003, Ogborne et al., 2000), it follows that a similar temporal relationship would occur between SAD and cannabis dependence.
The limited literature in this area makes it difficult to draw firm conclusions regarding the risk for alcohol and cannabis use disorders among those with SAD. Importantly, it is unknown whether the development of AUD or CUD is unique to SAD versus other forms of anxiety. The question of specificity is critical because SAD is highly comorbid with other anxiety disorders (Davidson et al., 1993, Merikangas and Angst, 1995) and other anxiety conditions are associated with increased rates of AUD (Kushner et al., 1990) and cannabis dependence (Zvolensky et al., 2006). When all anxiety disorder diagnoses were combined, anxiety disorders preceded AUD in the Oregon Adolescent Project (Rohde et al., 1996). However this study did not investigate the temporal relations among specific anxiety disorders. The few studies that have examined specific anxiety conditions and their temporal associations with AUD and CUD suggest that other anxiety disorders were more likely to be sequelae of alcohol and cannabis use, whereas SAD may serve as a risk factor for subsequent AUD and CUD. For instance, among individuals with co-occurring panic and AUD, panic onset tends to follow AUD (Kushner et al., 1990). Age of onset of panic is also later than that of CUD among individuals with both conditions (Zvolensky et al., 2006). Similarly, age of onset of substance use disorder is earlier than that of generalized anxiety disorder (GAD) among individuals with both disorders (Kessler et al., 2002).
It is also unclear whether SAD and/or other anxiety conditions demonstrate specific relationships to AUD or cannabis dependence after accounting for other types of psychopathology related to these substance use disorders. Considering that SAD is highly comorbid with mood disorders (Stein and Kean, 2000) and that depression is related to both alcohol and cannabis use problems (Buckner et al., in press), often preceding the onset of alcohol use (King et al., 2004) and cannabis use (Paton et al., 1977), it may be that the high rates of alcohol and cannabis dependence among individuals with SAD are due to co-occurring mood pathology. Likewise, externalizing disorders, particularly conduct disorder, are highly comorbid with anxiety disorders (Russo and Beidel, 1994, Zoccolillo, 1992) and predict later AUDs and CUDs (Myers et al., 1995), so they must be controlled in analyses of connections between anxiety and substance use disorders. And, of course, alcohol and cannabis use are themselves highly comorbid (Agosti et al., 2002), making it is necessary to examine the effects of one substance after controlling for effects of the other.
Further, the majority of studies in this area tend to combine alcohol abuse and alcohol dependence diagnoses (Crum and Pratt, 2001, Schneier et al., 1989), making it difficult to demarcate whether individuals with SAD are at increased risk for alcohol abuse, dependence or both. This distinction is important because alcohol dependence is a more debilitating disorder (American Psychiatric Association, 1980) and it appears that individuals with SAD are particularly vulnerable to this more severe condition. For example, epidemiological studies using DSM-IV criteria suggest SAD is more likely to be associated with increased risk of alcohol dependence than alcohol abuse (Grant et al., 2005, Kessler et al., 1997). Further, among individuals seeking treatment for alcohol-related problems, 23–39% meet diagnostic criteria for SAD (Kushner et al., 1990, Schneier et al., 1989, Smail et al., 1984, Thomas et al., 1999a). Individuals with higher levels of alcohol-related problems also experience significantly higher levels of social anxiety (Buckner et al., 2006c, Lewis and O’Neill, 2000). In regards to cannabis, greater SAD symptoms are associated with greater number of CUD symptoms (Buckner et al., 2006a, Buckner et al., 2006b) and the NCS data indicate that SAD is associated with increased rates of cannabis dependence but not abuse (Agosti et al., 2002).
Given the ambiguities described above, the present investigation contributes to the elucidation of the relations of anxiety disorders with AUDs and CUDs in several ways. First, the comorbidity of specific anxiety disorders and AUDs and CUDs was evaluated. Second, longitudinal analyses examined whether particular anxiety disorders serve as risk factors for subsequent AUDs or CUDs. Third, relevant variables (e.g., depression, conduct disorder) served as covariates to ensure that observed effects were not better accounted for by these conditions. Fourth, the relationships between SAD and specific AUDs and CUDs were examined after also controlling for other anxiety disorders to ensure observed relationships were not due to comorbidity of anxiety pathology. Last, analyses clarified whether observed relations applied to substance abuse, dependence, or both. Given the data suggesting that SAD is particularly associated with alcohol and cannabis dependence, we hypothesized that, after controlling for theoretically relevant variables, SAD would be significantly associated with alcohol and cannabis dependence, but not abuse. Additionally, given other theoretical and empirical work suggesting that other anxiety disorders appear to be a sequelae of substance use (Kessler et al., 2002, Zvolensky et al., 2006), it was hypothesized that SAD, but not other anxiety disorders, would be associated with the onset of subsequent alcohol and cannabis dependence, thereby demonstrating explanatory specificity.
Section snippets
Participants and procedures
The sample was drawn from the Oregon Adolescent Depression Project (Goodwin et al., 2005, Goodwin et al., 2004, Lewinsohn et al., 1993). Participants were randomly selected from nine senior high schools representative of urban and rural districts in western Oregon. A total of 1709 adolescents completed the initial (T1) assessments between 1987 and 1989, with an overall participation rate of 61%. Approximately one half of the T1 sample was female (53.7%), with a mean age of 16.6 years (SD = 1.2).
Descriptive information
Table 1 summarizes demographic characteristics of the sample. Diagnostic frequencies, odds ratios, and confidence intervals were computed to examine the relations between T1 predictor variables and T4 criterion variables (alcohol abuse, alcohol dependence, cannabis abuse, cannabis dependence) (Table 2). Additionally, 84 (4.9%) reported a T1 lifetime history of AUD and 92 (5.4%) participants reported a T1 lifetime history of CUD.
First, relations between T1 anxiety disorders and criterion
Discussion
The present study serves as the first known prospective investigation of the temporal relationship between current definitions of SAD and specific alcohol use and cannabis use disorders after controlling for baseline AUDs and CUDs, as well as other relevant variables. Results indicated that SAD may serve as a unique and significant risk factor for subsequent alcohol and cannabis dependence, but not abuse. These effects were above and beyond the variance accounted for by a variety of
Conflicts of interests
There are no conflicts of interest to report.
Acknowledgements
This research was supported in part by NIMH awards MH40501, MH50522, and MH52588, by the John Simon Guggenheim Foundation and NIDA Grant DA12951 awarded to Dr. Peter M. Lewinsohn. This research was also supported in part by a National Research Service Award from the National Institute of Drug Abuse (F31 DA12457-01) awarded to Julia D. Buckner.
References (68)
Historical development and present status of the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS)
Journal of the American Academy of Child and Adolescent Psychiatry
(2000)- et al.
Peer influence and gender differences in problematic cannabis use among individuals with social anxiety
Journal of Anxiety Disorders
(2006) - et al.
Social anxiety and problematic cannabis use: evaluating the moderating role of stress reactivity and perceived coping
Behaviour Research and Therapy
(2006) - et al.
Social anxiety and problematic alcohol consumption: the mediating role of drinking motives and situations
Behavior Therapy
(2006) - 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.
Cigarette smoking and panic attacks among young adults in the community: the role of parental smoking and anxiety disorders
Biological Psychiatry
(2005) - et al.
The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence: United States, 1991–1992 and 2001–2002
Drug and Alcohol Dependence
(2004) - et al.
Lifetime comorbidity among anxiety disorders and between anxiety disorders and other mental disorders in adolescents
Journal of Anxiety Disorders
(1997) - et al.
Alcohol expectancies and social deficits relating to problem drinking among college students
Addictive Behaviors
(2000)
DSM-III disorders in a large sample of adolescents
Journal of the American Academy of Child and Adolescent Psychiatry
Retrospective assessment of prepubertal major depression with the Kiddie-SADS-E
Journal of the American Academy of Child Psychiatry
Dose related risk of motor vehicle crashes after cannabis use
Drug and Alcohol Dependence
Comorbidity of childhood anxiety and externalizing disorders: prevalence, associated characteristics, and validation issues
Clinical Psychology Review
Alcohol abuse in social phobia
Journal of Anxiety Disorders
Preliminary tests of a cognitive model of generalized anxiety disorder
Behaviour Research and Therapy
Co-occurrence of conduct disorder and its adult outcomes with depressive and anxiety disorders: a review
Journal of the American Academy of Child and Adolescent Psychiatry
Rates of psychiatric comorbidity among U.S. residents with lifetime cannabis dependence
American Journal of Drug and Alcohol Abuse
Respiratory effects of non-tobacco cigarettes
British Medical Journal
Tutorial in biostatistics survival analysis in observational studies
Statistics in Medicine
A coefficient of agreement for nominal scales
Educational and Psychological Measurement
Applied multiple regression/correlation analysis for the behavioral sciences
Motivations for alcohol use among adolescents: development and validation of a four-factor model
Psychological Assessment
Drinking to regulate positive and negative emotions: a motivational model of alcohol use
Journal of Personality and Social Psychology
Development and validation of a three-dimensional measure of drinking motives
Psychological Assessment
Risk of heavy drinking and alcohol use disorders in social phobia: a prospective analysis
American Journal of Psychiatry
The epidemiology of social phobia: findings from the Duke Epidemiological Catchment Area Study
Psychological Medicine
Structured Clinical Interview for Axis I DSM-IV Disorders – Patient Edition (SCID-I/P, Version 2.0)
Respiratory symptoms and mental disorders among youth: results from a prospective, longitudinal study
Psychosomatic Medicine
The epidemiology of social anxiety disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions
Journal of Clinical Psychiatry
Co-occurrence of 12-month alcohol and drug use disorders and personality disorders in the United States: results From the National Epidemiologic Survey on Alcohol and Related Conditions
Archives of General Psychiatry
Cited by (388)
Although I know it: Social anxiety is associated with a deficit in positive updating even when the cost of avoidance is Obvious
2024, Journal of Psychiatric ResearchSocial anxiety and alcohol consumption: The role of social context
2023, Addictive BehaviorsPrevalence and correlates of cannabis use among individuals with DSM-5 social anxiety disorder: Findings from a nationally representative sample
2023, Journal of Psychiatric ResearchDevelopmental Epidemiology of Pediatric Anxiety Disorders
2023, Child and Adolescent Psychiatric Clinics of North AmericaCannabis-related problems and social anxiety: The roles of sex and cannabis use motives updated
2023, Addictive Behaviors