Social anxiety disorder and alcohol use

Alcohol Research & Health, Spring, 2002 by Sarah W. Book, Carrie L. Randall

Social anxiety disorder--an excessive fear of social situations, such as eating or speaking in public--affects 2 to 13 percent of the U.S. population. About one-fifth of patients with social anxiety disorder also suffer from an alcohol use disorder (AUD) (i.e., alcohol abuse or dependence). One theory to explain the comorbidity between social anxiety disorder and AUDs is the tension reduction theory, which posits that people with social anxiety use alcohol to alleviate their fears. This expectation that alcohol reduces anxiety may motivate alcohol consumption even if pharmacological studies do not support that assumption. Social anxiety disorder is treatable with both pharmacotherapy and psychotherapy, and some of those treatments also would be expected to be effective for patients with comorbid AUDs. Evaluation of patients seeking alcoholism treatment for coexisting social anxiety disorder is important for improving treatment outcome. KEY WORDS: comorbidity; anxiety; social phobia; AODU (alcohol and other dr ug use); alcoholic beverage; tension reduction theory of AODU; diagnostic criteria; prevalence; positive AOD (alcohol and other drug) expectancies; drug therapy; psychotherapy; monoamine oxidase; benzodiazepines; serotonin uptake inhibitors; literature review

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Many people experience social anxiety--that is, they feel uncomfortable or even anxious in social situations, such as talking with strangers (or even friends) or speaking in front of a group of people. In the general population, levels of social anxiety exist on a continuum from mild to severe. A clinical diagnosis of social anxiety disorder, also referred to as social phobia, (1) is assigned only when the social anxiety results in significant fear when faced with the situation, impairment of performance, or avoidance of anxiety-provoking situations. People with high levels of social anxiety typically report that alcohol helps them feel more comfortable in social situations. Thus, it is not surprising that individuals with clinically diagnosed social anxiety disorder have a higher incidence of alcohol-related problems than does the general population. This article explores the diagnosis and prevalence of social anxiety disorder and reviews studies evaluating the relationship between alcohol consumption and so cial anxiety. In addition, the article summarizes treatment approaches for social anxiety disorder alone as well as in combination with alcohol-related problems.

SOCIAL ANXIETY DISORDER

According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (1994), social anxiety disorder is defined as excessive fear in social situations in which the person believes he or she will do something embarrassing or have anxiety symptoms (e.g., blushing or sweating) that will be humiliating. The feared situations can vary from interpersonal social interactions in small groups to talking to strangers. Performance fears, such as speaking in public, also are common. People with social anxiety disorder either avoid feared situations or experience them with extreme anxiety. Most individuals with the disorder have the more severe, "generalized" type, in which the person has other social fears in addition to the common fear of public speaking. The complete criteria set for an official diagnosis of social anxiety disorder is detailed in the textbox.

Typically, social anxiety disorder begins in the teenage years and does not improve without treatment. The mechanisms or causes underlying the disease are unknown but may involve multiple predisposing Factors. These potential Factors include genetic background, traumatic early emotional learning experiences, observation and modeling of parental behaviors, and biological irregularities in brain chemical systems. People with the disorder often report having been shy or behaviorally inhibited as small children and, in severe cases, a child with social anxiety may not want to go to school (Beidel 1998).

As young adults, people with social anxiety disorder tend to make life choices based on their fears, such as avoiding classes requiring oral presentations or accepting jobs beneath their ability because they can work alone. Because these life choices circumvent their underlying social fears, many people with social anxiety disorder may be able to function adequately for extended periods of rime. Once the contrived situation changes (e.g., when a promotion is offered), however, the social anxiety fears may resurface. Many people with social anxiety disorder will turn down a promotion rather than encounter the social demands required for the new job. Thus, for many of these people, life is orchestrated around social fears, even if this results in social isolation or less financial independence and academic achievement.

The Prevalence of Social Anxiety Disorder

Prevalence estimates of social anxiety disorder vary considerably, both for social anxiety alone and concurrently with alcohol use disorders (AUDs) (2) (e.g., Kessler et al. 1997; Schneier et al. 1992; Van Ameringen et al. 1991). This variability results in large part from methodological differences among studies. For example, an analysis of data from the Epidemiologic Catchment Area study, a door-to-door survey conducted in four communities across the United Stares in the 1970s, found the prevalence of social anxiety disorder to be only 2 percent (Schneier et al. 1992). In this analysis, a diagnosis of social phobia was given to respondents who admitted to extreme anxiety while eating in front of others, speaking to a small group of people they knew, or speaking to a large group of strangers. In contrast, a later community study, the National Comorbidity Survey, found the prevalence of social anxiety disorder to be as high as 13 percent (Kessler et al. 1998). In this study, respondents acknowledging anxiety in a wider range of social situations were considered to have social anxiety disorder. This higher prevalence rate of social anxiety disorder would make it the third most prevalent psychiatric disorder after alcohol dependence and depression.