Social Anxiety Disorder and Alcoholism

Social Anxiety Disorder and Alcoholism Sarah W. Book MD Medical University of South Carolina 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 2 ©2004 Alcohol Medical Scholars Program Why is it Important? Heterogeneity of “Alcohol Dependence” Type I Alcoholic     Depression or anxiety Later onset Earlier onset Family history of alcoholism Antisocial personality disorder  Type II Alcoholic    ©2004 Alcohol Medical Scholars Program 3 Why is it Important?  Alcoholics with Social Anxiety    Unique example of Type I alcoholic Homogeneous group of alcoholics May respond differentially to specific treatments ©2004 Alcohol Medical Scholars Program 4 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? 5 ©2004 Alcohol Medical Scholars Program What we will be talking about  Treatment of Co-Occuring Social Anxiety and Alcohol Dependence Conclusions  ©2004 Alcohol Medical Scholars Program 6 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 ©2004 Alcohol Medical Scholars Program 7 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 ©2004 Alcohol Medical Scholars Program 8 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 ©2004 Alcohol Medical Scholars Program 9 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 ©2004 Alcohol Medical Scholars Program 10 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 ©2004 Alcohol Medical Scholars Program 11 Epidemiology of Alcohol Dependence Lifetime prevalence 20% in men, 8% in women  Education: > High School  Married  Frequently Abstain from Alcohol  Schuckit et al 1997 ©2004 Alcohol Medical Scholars Program 12 What Does an Alcoholic Look Like?  Average Alcoholic:    Educated Married Doesn‟t drink every day ©2004 Alcohol Medical Scholars Program 13 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) ©2004 Alcohol Medical Scholars Program 14 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 15 ©2004 Alcohol Medical Scholars Program Social Anxiety and Alcohol  Age of Onset    Social anxiety: mid teens Alcohol dependence: mid 20‟s Social Anxiety likely to precede alcohol dependence ©2004 Alcohol Medical Scholars Program 16 Social Anxiety & Alcohol Use  Tension Reduction  How does alcohol reduce anxiety?   Pharmacological effect Belief that alcohol has been ingested Define: that component of ETOH effect which is due to belief.  Alcohol Expectancy  ©2004 Alcohol Medical Scholars Program 17 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  ©2004 Alcohol Medical Scholars Program 18 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  ©2004 Alcohol Medical Scholars Program 19 Social Anxiety & Alcohol Use Early on: Anxiety drives ETOH use  Later on: ETOH use exacerbates or causes anxiety  Kushner et al, 1990 ©2004 Alcohol Medical Scholars Program 20 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)  ©2004 Alcohol Medical Scholars Program 21 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  ©2004 Alcohol Medical Scholars Program 22 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 23 ©2004 Alcohol Medical Scholars Program 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) 24 ©2004 Alcohol Medical Scholars Program 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” ©2004 Alcohol Medical Scholars Program 25 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 ©2004 Alcohol Medical Scholars Program 26 Treatment of Alcohol Dependence  Medications     disulfuram (Antabuse) naltrexone (Revia) ondansetron (Zofran) topiramate (Topamax) ©2004 Alcohol Medical Scholars Program 27 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 ©2004 Alcohol Medical Scholars Program 28 Treatment of Comorbid Social Anxiety and Alcoholism  Some medications useful for Social Anxiety may not be safe for Alcohol Dependence   Benzodiazepines MAOIs ©2004 Alcohol Medical Scholars Program 29 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 ©2004 Alcohol Medical Scholars Program 30 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) 31 ©2004 Alcohol Medical Scholars Program Conclusions  Relationship between Social Anxiety and Alcoholism is complex  May be a unique population of Alcoholics which responds preferentially to specific pharmacologic intervention ©2004 Alcohol Medical Scholars Program 32