ارتباط بین اختلال اضطراب اجتماعی و اختلالات مصرف الکل: بررسی انتقادی

Abstract Epidemiological studies have demonstrated a significant co-morbidity between social anxiety disorder (SAD) and alcohol use disorders (AUDs). Despite the fact that many studies have demonstrated strong relationships between SAD and AUD diagnoses, there has been much inconsistency in demonstrating causality or even directionality of the relationship between social anxiety and alcohol-related variables. For example, some studies have showed a positive relationship between social anxiety and alcohol-related variables, while others have shown a negative relationship or no relationship whatsoever. In an attempt to better understand the relationship between social anxiety and alcohol, some researchers have explored potential moderating variables such as gender or alcohol expectancies. The present review reports on what has been found with regard to explaining the high co-morbidity between social anxiety and alcohol problems, in both clinical and non-clinical socially anxious individuals. With a better understanding of this complex relationship, treatment programs will be able to better target specific individuals for treatment and potentially improve the efficacy of the treatments currently available for individuals with co-morbid SAD and AUD.

Conclusions and future directions It has only been in the last decade or so that researchers have begun to seriously explore not only which variables contribute to the high co-morbidity between SAD and AUD, but also to examine which treatments are most effective in treating these complicated patients. The current models for explaining the relationship, including the TRT, SRD, and SMH, although quite promising explanations when considered together, also have several serious shortcomings, including failing to explicitly take individual differences such as gender and factors like social context into consideration. Perhaps other models are necessary to further our understanding, as they would provide an alternative and unique angle by which to understand this complex relationship. We recommend taking an approach that considers social contextual variables (i.e., type of situation [social interaction vs. performance], accessibility and appropriateness of alcohol use, and avoidance, fear, and distress regarding the situation) along with alcohol outcome expectancies and gender to explain the SAD–AUD relationship. To our knowledge, a social contextual framework has not yet systematically been applied to the SAD–AUD relationship and we believe that much could be gleaned from increased use of this perspective in this area of co-morbidity research. With regard to the current models (TRT, SRD, SMH), they have received some support in the empirical literature, though the findings have not always been consistent. Part of the problem with studies testing these models to date relates to numerous inconsistencies across studies, including the fact that myriad methods for measuring social anxiety and alcohol-related variables have been used across studies. Further, many studies employ very different participants, from those who are shy, to university students scoring high on one or more of a variety of social anxiety measures, to those who are seeking treatment for SAD or an AUD. There will have to be some agreement on which measures are most accurate in diagnosing and classifying individuals, and in providing continuous indices of important features of these two disorders, with the goal of conducting studies that can be reasonably compared. Our review of the literature suggests the tentative conclusion that of the continuous social anxiety measures used to date, those measuring fear of negative evaluation appear most consistently linked to alcohol-related variables. And of the alcohol-related measures used across studies, those measuring alcohol problems (as opposed to alcohol use levels) appear most consistently linked in a positive direction to social anxiety variables. Recently, research has turned towards exploring which potential variables moderate the relationship between social anxiety disorder and alcohol problems. Several of those variables, including gender, situational context, alcohol expectancies, drinking motives (and their inter-relationships), have produced interesting results, but further research is necessary. Our review suggests the tentative conclusion that specific alcohol outcome expectancies regarding expectancies for social anxiety reduction are important in explaining the drinking behavior of co-morbid individuals, and that these may be particularly important for men. Similarly, coping drinking motives appear particularly important in contributing to the co-occurrence of social anxiety and drinking problems. Further research is necessary to explore how motivation and expectancy interact in explaining the co-morbidity between SAD and AUD. With regard to treatments for those suffering from SAD and AUD, little is known about the most effective treatment, though large, multi-site research projects such as Project MATCH are an excellent first step. Additional research is needed to further explore the unexpected finding that a CBT approach designed to simultaneous treat social anxiety and alcohol problems in co-morbid individuals led to worse drinking outcomes than a CBT alcohol-only treatment (Randall, Thomas, & Thevos, 2001). The currently accepted treatment approach for treating those with co-morbid SAD–AUD, is to first treat the alcohol problem, often in a 12-step program, and then to treat the SAD, typically using some form of CBT. This is problematic because the AUD treatment facilitators are generally not trained in SAD treatment, and similarly, the SAD treatment facilitators are often not trained in AUD treatment, and thus the sequential treatment fails to adequately address the inter-relations between the two disorders. In order to better treat those co-morbid with SAD–AUD, more needs to be done to educate and integrate these two treatment protocols, since it makes little sense to treat these disorders as if they were completely separate entities, when we know from research and clinical experience that they are intertwined. As previously mentioned, beginning with alcohol, treatment can be very problematic for an individual with SAD, as the group settings (e.g., 12-step program) likely cause significant social anxiety that could lead to avoidance of the setting or difficulty actively participating and attending to the group content. Without facilitators trained in dealing with SAD, the prognosis would seem to be poor for socially anxious individuals. More research is also necessary in determining whether bimodal approaches are more effective than single-mode treatments. Further understanding is also needed in determining whether individual or group CBT is best for co-morbid individuals, as some may find the group atmosphere highly intimidating (possibly contributing to drop out) while others may find that group treatment really gives them the support they need to conquer their alcohol addiction as well as an ideal setting for practicing social exposure. In summary, it is imperative that more research is done to identify which variables contribute to the relationship between SAD–AUD. By identifying the key variables in this relationship, more effective treatments can be developed, and thereby lower the concerning co-occurrence rates of these two disorders. We hope that this review has provided some insight into which variables play a role in the relationship between social anxiety and problem alcohol usage that might prove beneficial in improving treatments in future for those with this common form of psychiatric co-morbidity.