The Diagnosis and Treatment of Substance Abuse/ Dependence and Co-Occurring Social Anxiety Disorder
By Sarah W. Book, M.D., M.S.C.R., and Hugh Myrick, M.D.
January 1, 2006
Dr. Book is assistant professor of
psychiatry and behavioral sciences at the Medical
University of South Carolina. She also conducts research
funded by the National Institute of Alcohol Abuse and Alcoholism at the Charleston Alcohol Research
Center.Dr. Myrick is associate professor of
psychiatry and behavioral sciences at the Medical
University of South
Carolina and is also involved in research with the Charleston Alcohol Research
Center. He is the
associate director of the Mental Health Service Line at the Ralph H. Johnson
Veterans Administration Medical Center in Charleston, S.C., and the medical
director of the Center for Drug and Alcohol Programs at the Medical University
of South Carolina.
One possible neurobiological link between social anxiety disorder and
substance dependence may be the neurotransmitter dopamine(Drug information on dopamine). Individuals with
social anxiety disorder have been shown to have a decreased binding of dopamine
in the basal ganglia (Tiihonen et al., 1997) and
social anxiety disorder has been shown to have a high incidence in individuals
with parkinsonism (Stein et al., 1990), a disease
known to be associated with decreased dopamine binding. Some have theorized
that dopamine, especially striatal dopamine, is a key
component in the manifestation of social anxiety disorder and that it acts as a
gatekeeper for the involvement of other neurochemicals,
such as serotonin or γ-aminobutyric acid (GABA)
(Li et al., 2001).
Interestingly, all drugs of abuse ultimately increase dopamine in the basal
ganglia (Kalivas, 2001). Although it does not explain
the ultimate development of substance dependence, if the hypoactive dopaminergic tone associated with social anxiety can be
temporarily ameliorated with drugs of abuse, this may explain why a person with
social anxiety disorder may find using drugs to be effective self-medication.
Another possible neurochemical link between social
anxiety disorder and substance dependence may involve the neurotransmitter
GABA. Although an animal model of social anxiety disorder has been somewhat
elusive, there is considerable preclinical evidence to support a role for GABA
in anxiety disorders in general. Several studies have shown that, in a mouse
model, an inhibited ability to synthesize GABA results in increased anxiety (Kash et al., 1999; Stork et al., 2003, 2002). In addition
to preclinical data that support the role of GABA in anxiety in general,
pharmaceutical agents that enhance GABA-for example, benzodiazepines and
non-benzodiazepine anticonvulsants-have been shown to be effective in the
treatment of social anxiety disorder (Davidson et al., 1991; Pande et al., 2004, 1999; Van Ameringen
et al., 2004). Although not quite as central as dopamine, GABA also plays an
important role in addiction (Malcolm, 2003).
If a patient presents with both disorders to either an addiction or an
anxiety treatment setting, what is the optimal treatment approach?
Unfortunately, there has been little work done in this area. As most treatment
facilities rely heavily on traditional group therapy and 12-step treatment
approaches (such as Narcotics Anonymous or Alcohol(Drug information on alcohol)ics Anonymous) for the
treatment of SUDs, individuals with social anxiety
may have considerable difficulty engaging and participating in such
group-oriented activities. As such, a tailored approach to treatment including
more individualized treatment and strategy development for participation in
groups is needed.
Some of the medications used for social anxiety, for example the
benzodiazepines, may not be safe to use if the patient has a co-occurring
addiction (Book and Randall, 2002). The selective serotonin reuptake inhibitors
are the first line treatment of social anxiety disorder (Ballenger et al.,
1998) and, although there is some evidence that they can worsen addiction in
some populations (Kranzler et al., 1996; Pettinati et al., 2000), in the right patient with social
anxiety disorder and co-occurring addiction, they may be the best choice. The
efficacy of paroxetine(Drug information on paroxetine) (Paxil)
for individuals with social anxiety disorder and a co-occurring alcohol use
disorder has been evaluated (Randall et al., 2001). They found that the paroxetine-treated participants had significantly more
improvement of social anxiety than did the placebo-treated participants over
the eight-week study. However, although the alcohol use variables also were
more improved in the paroxetine group than they were
in the placebo group, the difference was not significant. This pilot study is
currently being followed up on a larger scale. Although the work of Zimmermann
et al. (2004) and of Myrick and Brady (1997) would indicate that treatment
solutions are needed for individuals with social anxiety disorder and drug
addiction, no such studies have been done. Clearly, research trials involving
therapeutic approaches to treat comorbid social
anxiety and substance use disorders are needed.
Supported by National Institute of
Alcohol Abuse and Alcoholism grants 2 P50 AA10761-03, K23 AA014430 (SWB) and
K23 AA00314-01 (HM), and a U.S. Department of Veterans Affairs Merit Grant
1 . Ballenger JC, Davidson JT, Lecrubier Y et al.
(1998), Consensus statement on social anxiety disorder from the International
Consensus Group on Depression and Anxiety. J Clin
Psychiatry 59(suppl 17):54-60.
2. Book SW, Randall CL (2002), Social anxiety disorder and alcohol use. Alcohol
Res Health 26(2):130-135.
3 . Coplan JD, Tiffon L,
Gorman JM (1993), Therapeutic strategies for the patient with
treatment-resistant anxiety. J Clin Psychiatry 54(suppl):69-74.
4. Davidson JR, Ford SM, Smith RD, Potts NL (1991), Long-term treatment of
social phobia with clonazepam. J Clin
5. Grenyer BF, Williams G, Swift W, Neill O (1992),
The prevalence of social-evaluative anxiety in opioid
users seeking treatment. Int J Addict 27(6):665-673.
6. Kalivas PW (2001), Drug addiction: to the cortex
and beyond! Am J Psychiatry 158(3):349-350 [editorial].
7. Kash SF, Tecott LH,
Hodge C, Baekkeskov S (1999), Increased anxiety and
altered responses to anxiolytics in mice deficient in
the 65-kDa isoform of glutamic
acid decarboxylase. Proc Natl
Acad Sci U S A 96(4):1698-1703.
8. Kessler RC, McGonagle KA, Zhao S et al. (1994),
Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the
United States. Results from the National Comorbidity
Survey. Arch Gen Psychiatry 51(1):8-19.
9. Kranzler HR, Burleson JA, Brown J, Babor TF (1996), Fluoxetine
treatment seems to reduce the beneficial effects of cognitive-behavioral
therapy in type B alcoholics. Alcohol Clin Exp Res 20(9):1534-1541.
10. Li D, Chokka P, Tibbo P
(2001), Toward an integrative understanding of social
phobia. J Psychiatry Neurosci 26(3):190-202.
11. Malcolm RJ (2003), GABA systems, benzodiazepines, and
substance dependence. J Clin Psychiatry 64(suppl 3):36-40.
12. Myrick H, Brady KT (1997), Social phobia in cocaine-dependent individuals. Am J Addict 6(2):99-104.
13. Page AC, Andrews G (1996), Do specific anxiety disorders show specific drug
problems? Aust N Z J Psychiatry 30(3):410-414.
14. Pande AC, Davidson JR, Jefferson JW et al. (1999),
Treatment of social phobia with gabapentin: a
placebo-controlled study. J Clin Psychopharmacol
15. Pande AC, Feltner DE,
Jefferson JW et al. (2004), Efficacy of the novel anxiolytic
pregabalin in social anxiety disorder: a
placebo-controlled, multicenter study. J Clin Psychopharmacol
16. Pettinati HM, Volpicelli
JR, Kranzler HR et al. (2000), Sertraline
treatment for alcohol dependence: interactive effects of medication and
alcoholic subtype. Alcohol Clin Exp Res 24(7):1041-1049 [see comment].
17 . Randall CL, Johnson MR, Thevos AK et
al. (2001), Paroxetine for social anxiety
and alcohol use in dual-diagnosed patients. Depress Anxiety 14(4):255-262.
18. Schneier FR, Johnson J, Hornig CD et al. (1992),
Social phobia. Comorbidity and morbidity in an epidemiologic sample. Arch Gen
19. Schuckit MA, Daeppen JB,
Tipp JE et al. (1998), The clinical course of
alcohol-related problems in alcohol dependent and nonalcohol
dependent drinking women and men. J Stud Alcohol 59(5):581-590.
20. Stein MB, Heuser IJ, Juncos JL, Uhde TW (1990), Anxiety disorders in patients with
Parkinson's disease. Am J Psychiatry 147(2):217-220
21. Stork O, Ji FY, Obata K (2002),
Reduction of extracellular GABA in the mouse amygdala during and following confrontation with a
conditioned fear stimulus. Neurosci Lett 327(2):138-142.
22. Stork O, Yamanaka H, Stork S et al. (2003), Altered conditioned fear
behavior in glutamate decarboxylase 65 null mutant
mice. Genes Brain Behav 2(2):65-70.
23. Tiihonen J, Kuikka J,
Bergstrom K et al. (1997), Dopamine reuptake site densities in patients with
social phobia. Am J Psychiatry 154(2):239-242.
24. Van Ameringen M, Mancini C, Pipe B et al. (2004), An open trial of topiramate in the
treatment of generalized social phobia. J Clin
25. Zimmermann G, Pin MA, Krenz S et al. (2004),
Prevalence of social phobia in a clinical sample of drug dependent patients. J
Affect Disord 83(1):83-87.
FROM PHYSICIANS PRACTICE
Five Steps to Improving Patient Access Judy Capko,
May 21, 2013
Patient access is getting increased attention through reform initiatives. Here are five steps you can take to make sure patients get appropriate access to care in your office.
SearchMedica SEARCH RESULT
Find peer-reviewed literature and websites for practicing medical professionals