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The Diagnosis and Treatment of Substance Abuse/ Dependence and Co-Occurring Social Anxiety Disorder

The Diagnosis and Treatment of Substance Abuse/ Dependence and Co-Occurring Social Anxiety Disorder

Social anxiety is a very common disorder and is especially common among
individuals with substance abuse or dependence (substance use disorders [SUDs]). Several epidemiologic surveys have estimated the
prevalence of social anxiety disorder (also called social phobia) in the
general population to be between 3% and 13% (Kessler et al., 1994; Schneier et al., 1992). However, in SUD clinics, the rate
is significantly greater. Zimmermann and colleagues (2004) surveyed 150
individuals seeking treatment for an SUD in Switzerland, using the
clinician-administered Leibowitz Social Anxiety Scale
(LSAS), and found that 20% of the participants screened positive for
generalized social phobia and 42.6% screened positive for nongeneralized
social phobia. Myrick and Brady (1997) evaluated 158 individuals entering an
outpatient clinical treatment trial for cocaine dependence and found that 13%
met criteria for social anxiety disorder. Finally, of 159 individuals seeking
treatment for heroin dependence, 18% to 25% screened positive for social
anxiety disorder (Grenyer et al., 1992).

In addition to social anxiety being prevalent in the drug treatment setting,
addiction is also commonly found in anxiety treatment clinics and may be
responsible for resistance to traditional anxiety disorder treatments (Coplan et al., 1993). In Australia, 146 individuals seeking
treatment for either social phobia or panic disorder at an anxiety treatment
program were evaluated (Page and Andrews, 1996). The researchers hypothesized
that they would see higher rates of sedative-hypnotic abuse and dependence
among the participants with panic disorder and higher rates of alcohol misuse
among the individuals with social phobia. They found, however, that both the
participants with social phobia and those with panic disorder had a rate of
sedative-hypnotic misuse that was eight times that of the general population.
Also, only the participants with social phobia had elevated rates of an alcohol
use disorder (Page and Andrews, 1996).

When two disorders co-occur, like social anxiety disorder
and addiction, causality (if it exists) is often difficult to unravel.
For example, chronic alcohol or illicit drug use can be anxiogenic.
Some treatment providers would argue that if an individual with an anxiety
disorder and co-occurring substance dependence has successful treatment for the substance dependence, recovering into a
sober lifestyle, their anxiety disorder will also be ameliorated. This line of
reasoning would be based on the assumption that the substance dependence
preceded the anxiety disorder and the direction of causality would be from
addiction to anxiety. As a disorder co-occurring with substance dependence,
social anxiety disorder most likely does not fit into these assumptions. The
average age of onset of social anxiety disorder is in the mid-teens (Schneier et al., 1992), at a time when social interpersonal
attitudes and relationships are being formed--also a time when experimentation
with illicit drugs and alcohol generally would begin. The average age of
alcohol dependence, for example, is roughly a decade later, in the mid-20s (Schuckit et al., 1998), making the direction of causality,
if it exists, more likely to be from social anxiety to substance dependence.

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