The aim of this study was to investigate the relationship between social anxiety and dissociation among male patients with alcohol dependency. Participants were 176 male patients consecutively admitted to an alcohol dependency treatment unit. The Liebowitz Social Anxiety Scale, the Dissociative Experiences Scale, the Beck Depression Inventory, the Spielberger State and Trait Anxiety Inventory, the Michigan Alcoholism Screening Test, and the Symptom Checklist-90-Revised were administered to all participants. The dissociative (N = 58, 33.0%) group had significantly higher social anxiety scores than the non-dissociative participants. Patients with a history of suicide attempt or childhood abuse had elevated social anxiety scores compared to those without. In multivariate analysis, dissociative taxon membership predicted both of the two social anxiety subscale scores consisting of fear/anxiety and avoidance in a highly significant level while trait anxiety was a significant covariant for these subscales. Among dissociative symptoms, only depersonalization and amnesia/fugue were predictors of social anxiety. Dissociation and social anxiety are interrelated among alcohol-dependent men. This relationship may have implications for prevention and treatment of alcohol dependency among men with a childhood trauma history in particular.
Subjects with high levels of social anxiety typically report that alcohol makes them feel more comfortable in social situations (Book and Randall, 2002). Apparently, alcohol serves as self-medication for them. In line with these reports, both clinical studies (Thomas et al., 1999 and Pe et al., 2002) and those conducted in the general population (Kushner et al., 1990, Himle and Hill, 1991, Schneier et al., 1992 and Magee et al., 1996) demonstrated that social anxiety and alcohol use disorder co-occur more frequently than expected by chance. Approximately 25% of individuals with alcohol dependence in the community meet criteria for social anxiety disorder; being women under greater risk for both conditions than men, 30.3% and 19.3%, respectively (Kessler et al., 1997). Similar rates of lifetime social anxiety disorder have been obtained from those who seek treatment for alcohol dependency (Thomas et al., 1999). In support of the self-medication hypothesis, social anxiety disorder preceded the onset of alcohol problems in approximately 80% of cases in a community sample (Sareen et al., 2001).
There is recent interest in a possible relationship between social anxiety and dissociation (Hinrichsen et al., 2003 and Michal et al., 2005). This approach is not at odds with common sense, because dissociative disorders do not only lead to subjective disturbances but they also affect interpersonal relationships (Liotti, 2006). Dissociation is considered as a post-traumatic developmental psychopathology closely related to child abuse and neglect (Putnam, 1997). Dissociation, which results from a disintegration of consciousness, memory, identity, and perception, is considered to serve as a coping mechanism against intolerable or trauma-associated memories and feelings. Alongside alexithymia, it is also linked to functional somatic symptoms and somatization behavior (Tutkun et al., 2004). As such, dissociation leads gradually to emotional detachment from social environment and to an avoidance of trauma-related and anxiety-provoking stimuli in interpersonal relationships. For instance, childhood sexual abuse is shown to be associated with adult distress indirectly through an impact on mediating variables such as shame or self-blame, interpersonal difficulties, and avoidant coping strategies (Whiffen and Macintosh 2005). Nevertheless, concurrent social anxiety disorder is common among patients with chronic dissociative disorders such as dissociative identity disorder (Ellason et al., 1996 and Kiziltan et al., 1998), 45.8% and 23.3% respectively, and depersonalization disorder (Michal et al., 2005 and Michal et al., 2006a).
We hypothesize that there is a complex relationship between social anxiety, substance use, dissociation, and childhood trauma. Several studies suggest that this hypothesis is worth to investigate. Like social anxiety disorder, childhood trauma has also been reported as frequent both among dissociative patients (Putnam, 1997) and substance-dependent subjects (Evren et al., 2006). A considerable proportion of treatment-seeking substance users also exhibit elevated levels of dissociative symptoms and disorders (Dunn et al., 1993, Wenzel et al., 1996 and Karadag et al., 2005). Childhood emotional abuse also predicted dissociation among subjects with alcohol dependency (Schäfer et al., 2007). In treatment-seeking male alcohol-dependents, the severity of childhood abuse was reported to be associated with social anxiety disorder (Langeland et al., 2004). In a study evaluating the relationships between childhood sexual abuse, social anxiety, and symptoms of post-traumatic stress disorder in women, pressure, age of onset of abuse, abuse by a family friend, and abuse by other perpetrators predicted adult social anxiety significantly (Feerick and Snow, 2005).
As a part of the hypothesized link, the present study is concerned with the relationship between social anxiety and dissociative experiences among male patients with alcohol dependence as assessed after a detoxification period. In order to eliminate potential influences on the analysis, we also screened depression, anxiety, severity of alcoholism, and overall severity of the psychiatric condition. We see clinical relevance in this relationship, because both concurrent dissociative disorder (Karadag et al., 2005) and/or social anxiety (Book and Randall, 2002) have been demonstrated as significant factors in premature cessation of treatment among patients with substance and/or alcohol dependency.
