Social anxiety disorder uniquely predicts alcohol use disorder, research indicates

People with social anxiety are at increased risk of alcohol use disorder, according to new research published in Drug and Alcohol Dependence. The findings provide evidence that this connection remains distinctive to social anxiety and does not hold true for other manifestations of anxiety disorders.

Alcohol use disorder is a chronic medical condition characterized by an inability to control alcohol consumption despite its negative consequences on health, relationships, and daily functioning. It involves a range of symptoms, from tolerance (needing more alcohol to achieve the same effects) to withdrawal symptoms when alcohol use is reduced or stopped.

Social anxiety disorder, also known as social phobia, is a mental health disorder characterized by intense fear and anxiety in social situations. People with social anxiety disorder often worry about being judged, embarrassed, or humiliated by others, leading them to avoid social interactions whenever possible.

While social anxiety disorder has been linked to the development of alcohol use disorder, a large study and a subsequent review article raised doubts about the relationship between these two conditions. These conflicting findings prompted the researchers of the present study to re-examine the available data.

“During my postdoc period, I participated in a Norwegian study where we provided various kinds of statistical evidence on social phobia being a risk factor for alcohol use disorder,” said study author Tom Rosenström, a research fellow affiliated with the PsyTEAM Research Group at the University of Helsinki. “However, one large study published at the same year found no association and the later reviews cited the studies to support the view that the evidence on the topic was mixed and that more data was warranted.”

“I wanted to act on this because causal evidence is important for treatment research and hard to come by in psychiatric epidemiology and because I happened to have access to parts of the data used by the group who reported the null finding and did not see it there. Furthermore, these kind of population samples are very expensive to collect and perhaps too expensive to merely settle this one issue with ‘more data.”

For the current study, the researchers analyzed two waves of data from the National Comorbidity Survey (NCS), a large-scale epidemiological study conducted in the United States to assess the prevalence and correlates of mental disorders among the general population.

The first wave (NCS-1) was conducted from 1990 to 1992. It involved a large sample of individuals aged 15 to 54 years from various regions in the contiguous 48 states of the United States. The second wave (NCS-2) was a follow-up survey conducted from 2001 to 2002. Out of the initial 8,098 respondents who participated in NCS-1, the researchers focused their analysis on a subset of 5,001 individuals who participated in NCS-2.

The data included information about 12-month DSM diagnoses for social phobia, alcohol use dependence/abuse, agoraphobia, generalized anxiety disorder, panic disorder, simple phobia, and post-traumatic distress.

The researchers used a combination of theoretical analysis and statistical techniques to investigate the relationship between social anxiety disorder and alcohol use disorder. They were particularly interested in the concept of “temporality,” which refers to the ordering of events over time. In other words, they wanted to understand whether having social anxiety disorder at the baseline (initial assessment) was associated with an increased likelihood of developing alcohol use disorder at a later time point (follow-up assessment).

The researchers were also interested in the concept of “specificity,” meaning whether the relationship between social anxiety disorder and alcohol use disorder was unique or whether other anxiety disorder also predicted the development of alcohol use disorder.

Rosenström and his colleagues found evidence for both temporality and specificity. Social anxiety disorder at baseline was significantly associated with higher odds of alcohol use disorder at the follow-up assessment. This association remained significant even after adjusting for age, sex, baseline alcohol use disorder status, and other anxiety disorders. Notably, social anxiety disorder was the only anxiety disorder that consistently predicted alcohol use disorder across all adjustments.

The results indicate “that social phobia on average elevates risk for later alcohol use disorder and the data on the question may not by mixed, despite such claims in the literature,” Rosenström told PsyPost.

But what explains the differences in the findings? The researchers said it stemmed from different methodological choices.

For example, the previous study jointly analyzed data from two large survey samples: the NCS and the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). These two surveys had different time intervals between baseline and follow-up interviews. The data was pooled together, but the researchers did not account for the different time intervals, potentially affecting the interpretation of causal effects. Rosenström and his colleagues, in contrast, specifically concentrated on the NCS data.

The new study has some of its own limitations, such as not having access to NESARC data for a complete re-analysis. However, the researchers emphasized that when properly considering temporality and accounting for various factors, the data supported the theory that social anxiety has a direct effect on the risk of developing alcohol use disorder.

The findings are also in line with a previous study published by Rosenström and his colleagues. That study, which analyzed data from 2,801 Norwegian adult twins, found social anxiety disorder had a distinct and robust connection with alcohol use disorder, suggesting that individuals with social anxiety are at a higher risk of experiencing alcohol-related issues.

“Successfully treating social anxiety could have the cumulative benefit of reducing substance use disorders in the population, although more work is needed to be certain,” Rosenström said. “There are always major caveats in psychiatric epidemiology but, until further arguments emerge, I feel the total evidence on social phobia being a risk factor for alcohol use disorder is no longer mixed.”

The study, “Social anxiety disorder is a risk factor for alcohol use problems in the National Comorbidity Surveys“, was authored by Tom H. Rosenström and Fartein Ask Torvik.