1. Social Anxiety Disorder and Alcoholism Sarah W. Book MD Medical University of South Carolina

2. ©2004 Alcohol Medical Scholars Program 2 Why is it important?  Effective Alcoholism pharmacologic treatments have been elusive Mixed reviews for naltrexone (Revia) Small number of studies support ondansetron (Zofran) and topiramate (Topamax) Disulfuram (Antabuse) used despite minimal support in the literature

3. ©2004 Alcohol Medical Scholars Program 3 Why is it Important?  Heterogeneity of “Alcohol Dependence”  Type I Alcoholic Depression or anxiety Later onset  Type II Alcoholic Earlier onset Family history of alcoholism Antisocial personality disorder

4. ©2004 Alcohol Medical Scholars Program 4 Why is it Important?  Alcoholics with Social Anxiety Unique example of Type I alcoholic Homogeneous group of alcoholics May respond differentially to specific treatments

5. ©2004 Alcohol Medical Scholars Program 5 What we will be talking about  What is Social Anxiety?  What is Alcohol Dependence?  Social Anxiety and Alcohol Dependence in the same individual Are they related? Can Social Anxiety induce Alcohol use? Can Alcohol Dependence induce Social Anxiety?

6. ©2004 Alcohol Medical Scholars Program 6 What we will be talking about  Treatment of Co-Occuring Social Anxiety and Alcohol Dependence  Conclusions

7. ©2004 Alcohol Medical Scholars Program 7 Diagnosis of Social Anxiety  Hallmark: Fear of scrutiny Specific Generalized More severe than Specific What this talk is mainly about Avoids situations or endures them

8. ©2004 Alcohol Medical Scholars Program 8 Social Anxiety Disorder  Interferes in normal life 85% report impaired academic performance 92% endorse occupational impairment 70% said it impaired their social life Turner et al 1992

9. ©2004 Alcohol Medical Scholars Program 9 Epidemiology of Social Anxiety Disorder  Lifetime prevalence ~10% Women:Men=3:2 More likely to be financially dependent 22% with Social Anxiety on welfare or disability 11% with no disorder

10. ©2004 Alcohol Medical Scholars Program 10 Natural History of Social Anxiety Disorder  Age of onset in mid-teens  90% of those with Social Anxiety had onset prior to age 25 ECA Data

11. ©2004 Alcohol Medical Scholars Program 11 Alcohol Dependence Tolerance Withdrawal Substance taken in larger amounts then intended Persistent unsuccessful attempts to cut down or control substance use A great deal of time spent getting, using, or recovering from substance Important activities given up or reduced to continue use Continued use despite psychological or physical problem

12. ©2004 Alcohol Medical Scholars Program 12 Epidemiology of Alcohol Dependence  Lifetime prevalence 20% in men, 8% in women  Education: > High School  Married  Frequently Abstain from Alcohol Schuckit et al 1997

13. ©2004 Alcohol Medical Scholars Program 13 What Does an Alcoholic Look Like?  Average Alcoholic: Educated Married Doesn’t drink every day

14. ©2004 Alcohol Medical Scholars Program 14 Natural History of Alcohol Dependence  Age of onset mid 20’s to early 30’s  By age 31, 50% of those who will develop alcohol dependence already have (Schuckit, 2000)

15. ©2004 Alcohol Medical Scholars Program 15 Social Anxiety & Alcohol Dep. in the Same Individual  Are these two related? Anecdotal Studies Drinking co-occurs with nervousness Anxiety symptoms or anxiety disorder? Alcohol withdrawal causes anxiety symptoms Assortative mating Psychiatric impairment increases risk of choosing psychiatrically impaired spouse This alcoholics may marry persons with social anxiety and children at higher risk for both

16. ©2004 Alcohol Medical Scholars Program 16 Social Anxiety and Alcohol  Age of Onset Social anxiety: mid teens Alcohol dependence: mid 20’s Social Anxiety likely to precede alcohol dependence

17. ©2004 Alcohol Medical Scholars Program 17 Social Anxiety & Alcohol Use  Tension Reduction How does alcohol reduce anxiety? Pharmacological effect Belief that alcohol has been ingested Alcohol Expectancy Define: that component of ETOH effect which is due to belief.

18. ©2004 Alcohol Medical Scholars Program 18 Social Anxiety & Alcohol Use  Expectancies may be gender related Men: ETOH makes me one of the guys Women: ETOH makes me look like a ‘troubled woman’ Women with social anxiety may be less likely to use ETOH as a coping mechanism in social situations Corcoran and Michels 1998

19. ©2004 Alcohol Medical Scholars Program 19 Social Anxiety & Alcohol Use  Alcoholics may be more likely to have positive expectancies  Alcohol does reduce social anxiety (maybe more than general tension)  People with social anxiety may be more likely to have positive expectancies AND may be more likely to drink in social situations

20. ©2004 Alcohol Medical Scholars Program 20 Social Anxiety & Alcohol Use  Early on: Anxiety drives ETOH use  Later on: ETOH use exacerbates or causes anxiety Kushner et al, 1990

21. ©2004 Alcohol Medical Scholars Program 21 Alcohol Induced Anxiety  Alcohol withdrawal causes anxiety  Anxiety improves several weeks after cessation of drinking  After we control for withdrawal and prolonged withdrawal, anxiety disorders are no more prevalent than in the general population (Schuckit and Hesselbrock 1994)

22. ©2004 Alcohol Medical Scholars Program 22 Alcohol Induced Anxiety  Social Anxiety Disorder affects 2-13% of general population  In one group of alcoholics, after controlling for alcohol withdrawal, 9% met criteria for Social Anxiety Disorder  This is not different than the general population

23. ©2004 Alcohol Medical Scholars Program 23 Treatment of Social Anxiety  Psychotherapy Cognitive Behavioral Therapy (CBT) shown to be effective (Heimberg, 2001) Thoughts, feelings, and behaviors are a cycle Goal of CBT: restructure problematic thought patterns and encourage more adaptive behaviors If thoughts and behaviors change, feelings (e.g. anxiety) will also change

24. ©2004 Alcohol Medical Scholars Program 24 Treatment of Social Anxiety  Medication SSRI’s: fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), es-citalopram (Lexapro) MAOI’s Benzodiazepines: alprazolam (Xanax), and clonazepam (Klonopin) GABAergic anticonvulsants: gabapentin (Neurontin)

25. ©2004 Alcohol Medical Scholars Program 25 Treatment of Alcohol Dependence  Psychotherapy CBT, Motivational Enhancement Therapy (MET) and Twelve Step Facilitation (TSF) Focus of CBT: change drinking behavior MET: conceptualizes the therapist as a coach, helping the client along the “stages of change”

26. ©2004 Alcohol Medical Scholars Program 26 Treatment of Alcohol Dependence  Psychotherapy (cont) Twelve Step Facilitation (TSF) Modeled after 12 Steps of Alcoholics Anonymous (AA) Therapist helps client work through steps 1-4 Encourages AA attendance outside of therapy time

27. ©2004 Alcohol Medical Scholars Program 27 Treatment of Alcohol Dependence  Medications disulfuram (Antabuse) naltrexone (Revia) ondansetron (Zofran) topiramate (Topamax)

28. ©2004 Alcohol Medical Scholars Program 28 Treatment of Comorbid Social Anxiety and Alcoholism  What We Know - not very much  Psychotherapy Women may do better with CBT than TSF Enhancing CBT treatment for Alcoholism to address Social Anxiety did not improve outcomes Randall et al 2001

29. ©2004 Alcohol Medical Scholars Program 29 Treatment of Comorbid Social Anxiety and Alcoholism  Some medications useful for Social Anxiety may not be safe for Alcohol Dependence Benzodiazepines MAOIs

30. ©2004 Alcohol Medical Scholars Program 30 Treatment of Comorbid Social Anxiety and Alcoholism  Paroxetine more effective than placebo in one pilot study  Subjects had Social Anxiety and Alcohol Abuse or Alcohol Dependence N=15 Treatment 8 weeks Randall et al 2001

31. ©2004 Alcohol Medical Scholars Program 31 Treatment of Social Anxiety and Alcoholism  Does order matter? Treat anxiety first? Treat alcoholism first? Treat both simultaneously Maybe treat social anxiety with SSRI and alcoholism with topiramate (gaba-ergic anticonvulsant, shown effective for alcohol dependence, may be effective for anxiety)

32. ©2004 Alcohol Medical Scholars Program 32 Conclusions  Relationship between Social Anxiety and Alcoholism is complex  May be a unique population of Alcoholics which responds preferentially to specific pharmacologic intervention