Social Anxiety Disorder and Alcoholism Sarah W. Book MD Medical University of South Carolina.
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Transcript of Social Anxiety Disorder and Alcoholism Sarah W. Book MD Medical University of South Carolina.
Social Anxiety Disorder and Alcoholism
Sarah W. Book MD
Medical University of South Carolina
©2004 Alcohol Medical Scholars Program
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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
©2004 Alcohol Medical Scholars Program
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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
©2004 Alcohol Medical Scholars Program
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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
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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?
©2004 Alcohol Medical Scholars Program
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What we will be talking about
Treatment of Co-Occuring Social Anxiety and Alcohol Dependence
Conclusions
©2004 Alcohol Medical Scholars Program
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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
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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
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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
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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
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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
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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
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What Does an Alcoholic Look Like?
Average Alcoholic:
Educated Married Doesn’t drink every day
©2004 Alcohol Medical Scholars Program
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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
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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
©2004 Alcohol Medical Scholars Program
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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
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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.
©2004 Alcohol Medical Scholars Program
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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
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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
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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
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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
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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
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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
©2004 Alcohol Medical Scholars Program
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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)
©2004 Alcohol Medical Scholars Program
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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
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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
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Treatment of Alcohol Dependence
Medications
disulfuram (Antabuse) naltrexone (Revia) ondansetron (Zofran) topiramate (Topamax)
©2004 Alcohol Medical Scholars Program
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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
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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
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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
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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)
©2004 Alcohol Medical Scholars Program
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Conclusions
Relationship between Social Anxiety and Alcoholism is complex
May be a unique population of Alcoholics which responds preferentially to specific pharmacologic intervention