It is well documented that many individuals endorse the belief that alcohol reduces social anxiety. Individuals with social phobia, therefore, might be expected to use alcohol as a coping strategy in an attempt at self-medication. The purpose of the present paper was to review the published literature on the relationship between alcohol use and social phobia to test the self-medication hypothesis (SMH). Support for one aspect of the SMH was found; individuals with social phobia use alcohol to reduce anxiety. Support for the second premise, that alcohol actually reduces social anxiety, was less conclusive.
Social phobia was first described in 1970 (Marks, 1970), but it was only differentiated as a distinct anxiety disorder in 1980 in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) (American Psychiatric Association, 1980). Prior to this time, social phobia was incorporated into a poorly differentiated category of anxiety neuroses (Levin, Schneier, & Liebowitz, 1989) and was considered by many to be a personality disorder (Turner & Beidel, 1989). Thus, the field of social phobia is only two decades old, but interest has increased at a rapid rate in recent years (Ballenger et al., 1998). Social phobia is no longer the neglected anxiety disorder it was in the mid-1980s (Liebowitz, Gorman, Fyer, & Klein, 1985). There has been growing interest from the research community, the treatment community, and, most recently, the pharmaceutical community Pande et al., 1999 and Stein et al., 1998.
Social anxiety disorder has an age of onset in the early teen years and is frequently accompanied by other Axis I diagnoses, especially generalized anxiety disorder, depression, and alcoholism Himle & Hill, 1991, Lepine & Pelissolo, 1998, Merikangas & Angst, 1995 and Regier et al., 1990. It is one of the few disorders that predates the onset of alcoholism and, therefore, is most often a primary (as opposed to a secondary) disorder (Merikangas & Angst, 1995). Persons with social phobia fear and avoid a wide variety of social and performance situations (e.g., hosting parties, giving unprepared speeches, being the center of attention, writing or eating in public, performing a task, etc.) where they will encounter new people or possible evaluation by others. They fear that they will do something foolish and will be humiliated or embarrassed. Individuals are classified as nongeneralized type if they display persistent fear of one situation or generalized type if they fear multiple social or performance situations. The most prominent physical symptoms include heart palpitations, trembling, sweating, and blushing (Gorman & Gorman, 1987). Anticipatory anxiety eventually leads to avoidance of the feared situation, such that the avoidant behavior actually interferes with occupational functioning, social activities, or interpersonal relationships with others. The intensity of social evaluative anxiety and the magnitude of the avoidant behavior distinguish it from shyness (Chavira & Stein, 1999).
In this paper, we have attempted to review the pertinent literature concerning the SMH of alcohol in social phobia. The answer to the question “Does alcohol reduce social phobic anxiety?” would seem to be unclear as yet, due to methodological shortcomings in the few studies that have specifically addressed this issue. Future studies must include individuals with alcohol problems before definitive conclusions may be drawn. However, there does seem to be adequate evidence that individuals do drink alcohol to reduce social phobic anxiety. Thus, finding the answer to the former question should be an important topic of research that will have important clinical implications.
If alcohol is truly anxiolytic, the acquisition of alternative coping skills to reduce anxiety should be even further stressed in treatment. Even if individuals experience short-term anxiety reduction, their performances on social tasks may be impaired (Keane & Lisman, 1980) and long-term use of alcohol may actually increase stress and anxiety (Kushner, Thuras et al., 2000). Individuals with social phobia would be considered at high-risk for the development of alcohol use disorders and education about these issues may play an important role in prevention (Kushner et al., 1994). If, on the other hand, alcohol is not found to be stress reducing (or if placebo is as tension reducing as alcohol), this information could be used to challenge clients' expectancies. In general, research on self-medication should help further illuminate the etiological relationship between alcohol and social phobia. The establishment of a functional relationship, not just a common comorbidity, is an important step in understanding these clients better and could lead to more effective treatment approaches.
