Brief Treatment and Crisis Intervention Advance Access originally published online on July 6, 2006
Brief Treatment and Crisis Intervention 2006 6(3):268-282; doi:10.1093/brief-treatment/mhl007
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Original Article |
Anxiety Sensitivity and Situation-Specific Drinking in Women With Alcohol Problems
From the Department of Psychology, Dalhousie University (Reyno, Stewart), Department of Psychiatry, Dalhousie University (Stewart), Maritime School of Social Work, Dalhousie University (Brown, Wiens), and Department of Psychology, Acadia University (Horvath)
Contact author: Sherry H. Stewart, Department of Psychiatry, Dalhousie University, 8th Floor, AJL Memorial Building, 5909 Veterans Memorial Lane, Halifax, NS B3H 2E2, Canada. E-mail: sherry.stewart{at}dal.ca.
We examined the unique contributions of depression, anxiety, and anxiety sensitivity (AS) in predicting frequency of drinking in different high-risk situations among 60 women receiving treatment for alcohol problems. Participants completed the Beck Depression Inventory-II, Beck Anxiety Inventory, Anxiety Sensitivity Index, and Short Form Inventory of Drinking Situations (IDS-42). Together, the negative emotionality variables reliably predicted scores on the IDS-42 negative and temptation drinking situations subscales but did not reliably predict scores on the IDS-42 positive drinking situations subscales. With one exception, only AS contributed unique variance in predicting negative and temptation context drinking. Both AS and depression contributed unique variance in predicting drinking in conflict with others situations. Implications for treating comorbid emotional and alcohol-use disorders in women are discussed.
KEY WORDS: comorbidity, anxiety sensitivity, depression, situation-specific drinking, alcohol-use disorders, women
Self-reported anxiety and depression frequently co-occur with heavy or "at-risk" and problem levels of alcohol consumption in females. Anxiety, depression, and somatoform disorders are more commonly observed in female at-risk drinkers (more than 20 g of alcohol per day) compared with female moderate drinkers/abstainers (Bott, Meyer, Rumpf, Hapke, & John, 2005). King, Bernardy, and Hauner (2002) found female "problem drinkers" (those who consume 11 or more drinks per week or 5 or more drinks on one occasion at least once per week) recruited from treatment centers and the community report greater depressive symptoms and perceived stressful life events compared with female light drinkers.
There has been some controversy as to whether anxiety and depressive disorders and symptoms are causes and/or consequences of heavy and problem drinking in women. Wang and Patten (2002) used longitudinal data from the Canadian National Health Survey to examine the effects of alcohol consumption on major depression. Consistent with the position that heavy drinking causes elevated depression, the researchers found an increased risk of major depression at follow-up for females who reported persistent heavy drinking (more than five drinks on at least one occasion per month) compared with women who reported light/moderate levels of alcohol consumption. In contrast, research with adolescents indicates that the onset of psychiatric disorders tends to precede alcohol abuse/dependence in this population (Rohde, Lewinsohn, & Seeley, 1996). Similarly, emotional disorders tend to precede problem drinking in women, suggesting that for females, anxiety and depression may contribute to the development of alcohol-use problems (Gilman & Abraham, 2001; Hartka et al., 1991; Helzer & Pryzbeck, 1988; Kessler et al., 1997).
In individuals with depression and/or anxiety, comorbid drinking problems have been attributed to the tension-reducing and numbing properties of alcohol. In essence, individuals with elevated arousal or negative affect drink to reduce or cope with psychological distress or to "self-medicate" (Conger, 1956). C. J. Holahan, C. K. Holahan, Moos, Cronkite, and Randall (2003) conducted a longitudinal study examining associations between depression, levels of alcohol consumption, and drinking to cope with life stress in a community sample of adults receiving treatment for depression. Baseline drinking to cope with negative life situations was associated with increased alcohol consumption at each stage of follow-up. In a related longitudinal study, C. J. Holahan, Moos, C. K. Holahan, Cronkite, and Randall (2001) found baseline drinking to cope was associated with a stronger relationship between symptoms of anxiety and depression and drinking problems at follow-ups of 1, 4, and 10 years.
Drinking to cope with anxiety may be more common in some anxiety disorders, such as social phobia (Thomas, Randall, & Carrigan, 2003), or in subgroups with specific psychological characteristics (Kushner, Abrams, Thuras, & Hanson, 2000). For example, anxiety sensitivity (AS; the fear of anxiety-related physical and mental sensations) may be an underlying factor contributing to the commonly observed comorbidity between some anxiety disorders and substance abuse/dependence. Higher levels of AS are observed in individuals with comorbid anxiety and alcohol-use disorders compared to those with either disorder alone. Also, the risk of alcoholism is particularly increased in individuals with anxiety disorders characterized by high levels of AS, such as panic disorder, social phobia, and posttraumatic stress disorder (Cox, Norton, Swinson, & Endler, 1990; Morris, Stewart, & Ham, 2005; Stewart, 1996). AS may also be involved in the link between depression and alcohol-use problems as high levels of AS are observed in individuals with depression (Otto, Pollack, Fava, Uccello, & Rosenbaum, 1995).
AS has been posited to mediate the relationship between anxiety disorders and alcohol use/abuse (Kushner, Thuras, Abrams, Brekke, & Stritar, 2001). This mediator model proposes that the association between certain anxiety disorders and alcohol abuse is at least partially explained or accounted for by the relationship of the anxiety disorder to AS and AS to alcohol abuse. In this model, high AS leads to increased anxiety symptoms, which in turn promote coping-motivated drinking. Anxiety disorder individuals with high AS will consume greater quantities of tension-reducing substances such as alcohol due to the anxiety-dampening properties of these substances. Over time, these individuals will learn to self-medicate or control their anxiety/tension through alcohol use. Sensitivity to alcohol's tension reduction effects may be enhanced in individuals with higher levels of AS. Consistent with this possibility, individuals with higher AS report increased drinking to cope with negative affective states (Stewart & Zeitlin, 1995; Stewart, Zvolensky, & Eifert, 2002) and display greater reduction of anticipatory anxiety following alcohol consumption (MacDonald, Baker, Stewart, & Skinner, 2000; Stewart & Pihl, 1994).
The relative contribution of depression, anxiety, and AS to problem drinking has been examined in university students (Koven, Heller, & Miller, 2005). AS and anxiety measures predicted problem drinking, whereas depressive symptoms did not contribute significant variance to drinking behaviors and attitudes when assessed anxiety variables were statistically controlled. One dimension of AS, fear of cognitive dyscontrol (FCD), accounted for the relationship between AS and problem drinking. This finding is consistent with that of Lawyer, Karg, Murphy, and McGlynn (2002). These researchers also found the FCD factor of the Anxiety Sensitivity Index (ASI) more strongly correlated with drinking in certain high-risk situations among university students. Koven et al. (2005) suggest that individuals with high FCD may drink to seek relief from anxiety and to increase their perceptions of control, although the contributions of FCD may be outweighed by mental and physical dependence following habitual alcohol misuse.
The observed relationship between AS and alcohol consumption has encouraged researchers to examine associations between AS and patterns of situation-specific drinking. Examination of the contexts in which people drink can tell us something about their underlying motives for alcohol use. For example, if they frequently drink heavily in situations involving conflict with others, presumably, their drinking is motivated by a desire to deal with the negative affect triggered by interpersonal conflict. Researchers have found a significant association between ASI scores and negative situation substance use in males being treated for substance abuse in a Veteran Affairs inpatient center (DeHass, Calamari, Blair, & Martin, 2001). In nonclinical samples of university students, ASI scores predicted negative context drinking (in situations involving conflict with others, unpleasant emotions, and physical discomfort) and not positive context drinking (Lawyer et al., 2002; Samoluk & Stewart, 1998). ASI scores have also predicted drinking in testing personal control situations, indicating that in some temptation situations, high AS individuals may drink to prove to themselves that they have control over their alcohol use (Samoluk & Stewart, 1998).
The present study builds on previous research examining the association of negative emotionality factors with situation-specific drinking behaviors. The goal of the study was to examine the unique contribution of depression, anxiety, and AS in predicting frequency of drinking in different situations among women receiving treatment for alcohol problems. Based on previous research (DeHass et al., 2001; Koven et al., 2005; Lawyer et al., 2002; Samoluk & Stewart, 1998), it was predicted that the measures of negative emotionality would together predict negative and temptation context drinking and not positive context drinking. It was predicted that AS would predict negative and temptation context drinking even after the contributions of anxiety and depression were controlled (cf. Koven et al., 2005). It was also predicted that the Mental Incapacitation Concerns (MIC) factor of the ASI (similar to the FCD factor) would be more strongly associated with negative context drinking than the Physical Concerns (PC) factor of the ASI (similar to the Fear of Somatic Sensations factor). A third, commonly studied AS factor, Social Concerns (SC), was also examined in relation to negative and temptation context drinking for exploratory purposes.i
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Participants
As part of a larger project exploring women's use of alcohol as self-medication for depression (Stewart et al., 2006), participants were recruited from a public treatment service for women with alcohol, gambling, or drug problems in the Nova Scotia Capital District Health Authority. A sample of 60 women currently receiving treatment for alcohol problems agreed to participate in this study. The average age of the participants was 41.3 years (range 18–61 years). Approximately two thirds of the sample (68.9%) was unemployed.ii Income levels were reported by 54 participants, with the following breakdown: 48.1% reported income of less than $10,000 Canadian per annum, 18.5% reported income between $10,000 and $20,000 per annum, 13.0% reported income between $20,000 and $30,000 per annum, 3.7% reported income between $30,000 and $40,000 per annum, 5.6% reported income between $40,000 and $50,000 per annum, and 11.1% reported income above $60,000 per annum. Ethnicity of the participants was as follows: 77.2% Caucasian, 8.3% Native, 6.2% African Canadian, and 8.3% mixed.iii Approximately one third (36.2%) of the participants had completed some postsecondary education (university, diploma, or college). Only 28.1% of the sample reported living with a partner or spouse. Just under half of the participants reported that they were suffering from at least one other substance use problem in addition to their alcohol-use problem (48.3%).
Measures
Demographic Measure.
A self-report questionnaire designed by the authors was used to assess various demographic variables (i.e., age, education, living arrangement) and history and treatment of alcohol and other drug-use problems. In addition, the questionnaire included questions on typical quantity of alcohol consumption per drinking occasion (number of standard alcoholic beverages) and typical frequency of alcohol use (days per month) in the year prior to the initiation of the participant's current treatment program. Quantity and frequency were assessed in a manner similar to that used in previous research (e.g., Stewart, Peterson, & Pihl, 1995).
Anxiety Sensitivity Index.
The ASI was used to assess AS levels in the sample (Peterson & Reiss, 1992). The ASI is a self-report measure assessing fear of anxiety sensations and beliefs that the sensations are potentially harmful. The ASI has very good psychometric properties in a variety of clinical and nonclinical populations (Olatunji et al., 2005; Peterson & Heilbronner, 1987; Rodriguez, Bruce, Pagano, Spencer, & Keller, 2004; Schmidt & Joiner, 2002). Along with the overall total ASI score, three primary factors of the ASI (PC, MIC, and SC) were also scored based on the three-factor solution recommended by Zinbarg, Barlow, and Brown (1997).
Beck Depression Inventory-II.
The Beck Depression Inventory-II (BDI-II) (Beck, Steer, & Brown, 1996) is a 21-item self-report measure that assesses cognitive, affective, and somatic symptoms of depression. For each item, respondents choose from a group of sentences the one that best describes how they have been feeling in the previous 2 weeks. Research supports the reliability and validity of this depression measure (Dozios, Dobson, & Ahnberg, 1998; Hiroe et al., 2005; Steer, Ball, Ranieri, & Beck, 1997).
Beck Anxiety Inventory.
The Beck Anxiety Inventory (BAI) (Beck & Steer, 1990) is a 21-item self-report measure that assesses symptoms of anxiety. This measure requires the respondent to rate the degree they were bothered by each symptom in the past week on a 4-point scale that ranges from 0 (not bothered at all) to 3 (severely bothered). Research supports the reliability and validity of this measure (Contreas, Fernandez, Malcarne, Ingram, & Vaccarino, 2004; Osman, Kopper, Barrios, Osman, & Wade, 1997).
Inventory of Drinking Situations.
The brief (42 items) version of the Inventory of Drinking Situations (IDS-42) was used to assess heavy drinking frequency across different situations (Annis, Graham, & Davis 1987). The IDS-42 consists of subscales assessing positive context drinking (pleasant times with others, social cues to drink, pleasant emotions), negative context drinking (conflict with others, unpleasant emotions, physical discomfort), and temptation context drinking (testing personal control, urges and temptations). The IDS-42 shows excellent psychometric properties among both clinical samples of individuals who abuse alcohol and nonclinical samples alike. These properties include good convergent and discriminant validity and good structural validity (Carrigan, Samoluk, & Stewart, 1998; Stewart, Conrod, Samoluk, Pihl, & Dongier, 2000; Stewart, Samoluk, Conrod, Pihl, & Dongier, 1999). Participants rated frequency of heavy drinking in different situations in their past year of drinking prior to their current treatment.
Procedure
Participants were recruited from a public treatment service for women with alcohol, gambling, or drug problems. Women reporting alcohol-use problems and currently receiving treatment for alcohol problems were invited to participate in this study. After providing informed consent, study participants completed the questionnaires and sociodemographic measures described above. Each participant received $20.00 Canadian as compensation for their time and effort.
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The study data were analyzed using SPSS for Windows (version 11). No serious violations of assumptions for regression were identified, and no univariate or multivariate outliers were detected.
Sample Means
For this sample, the mean and standard deviations for the emotionality measures were as follows: BDI, 31.02 (SD = 11.15)iv; ASI, 34.48 (SD = 14.04); and BAI, 27.18 (SD = 13.50). Mean scores on the IDS-42 lower order subscales ranked from highest to lowest were as follows: Unpleasant Emotions, 3.11 (SD = 0.64); Social Cues to Drink, 2.97 (SD = 0.87); Conflict with Others, 2.89 (SD = 0.73); Pleasant Times with Others, 2.88 (SD = 0.76); Pleasant Emotions, 2.81 (SD = 0.75); Testing Personal Control, 2.78 (SD = 0.92); Urges and Temptations, 2.78 (SD = 0.87); and Physical Discomfort = 2.38 (SD = 0.77). The IDS-42 subscale means and standard deviations are very similar to values previously reported for IDS-42 subscale scores in women alcoholics (Birch, Stewart, & Brown, in press). Scores on BDI, ASI, and BAI are elevated relative to norms from women in the general population as might be expected in a sample of women with alcohol problems.
Adequate to excellent internal consistency was observed for the IDS-42 subscales, with Cronbach's alphas ranging from .73 to .91. Mean score for the three ASI subscales ranked from highest to lowest were as follows: "SC," 2.68 (SD = 0.88); "PC," 2.09 (SD = 0.92); and "MIC," 1.95 (SD = 1.29). Cronbach's alphas for the ASI factors were good for the PC and MIC subscales (.82 and .84, respectively), but internal consistency was lower for the SC subscale (.59).v
Correlations Between Emotionality Measures and IDS-42 Subscale Scores
The total score on each emotionality measure was correlated with the lower order factors or subscales on the IDS-42 (see Table 1). A Bonferroni-adjusted alpha of .002 (.05/24 comparisons) was used for determining statistical significance. One-tailed tests were used since directional predictions had been made a priori. With this correction, only the ASI significantly correlated with drinking in contexts involving conflict with others, unpleasant emotions, physical discomfort, testing personal control, and urges and temptations (i.e., negative context and temptation drinking). The negative emotionality measures were not associated with drinking in contexts involving social cues to drink, pleasant emotions, or pleasant times with others (positive context drinking).
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Regression Analyses for Negative Emotionality Variables Predicting IDS-42 Subscales
Standard multiple regressions were used to assess how well the negative emotionality measures together predicted situation-specific drinking on the various IDS-42 subscales and to see which of these gave unique predictive information (see Table 2).
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For the IDS-42 dependent variable conflict with others, the proportion of variance that could be predicted from the independent variables was 33.3%. The independent variables reliably predicted the dependent variable (p < .001). Both the ASI and BDI contributed significantly to the regression (p < .001 and p < .05, respectively). For the IDS-42 dependent variable unpleasant emotions, the proportion of variance in the dependent variable that could be predicted by the independent variables was 19.1%. The independent variables reliably predicted the dependent variable (p < .01). A trend was found for the ASI to contribute unique variance to the regression (p < .06). Similar findings were evident for IDS physical discomfort. Proportion of variance that could be predicted by the independent variables was 25.2% (p < .001). Only the ASI contributed significantly to the regression (p < .01).
For the IDS-42 dependent variable Testing Personal Control, the proportion of variance that could be predicted from the dependent variables was 29.1%. The independent variables reliably predicted the dependent variable (p < .001). Only the ASI contributed significantly to the regression (p < .005). For the IDS-42 dependent variable Urges and Temptations, the proportion of variance that could be predicted from the dependent variables was 20.5%. The independent variables reliably predicted the dependent variable (p < .01). Once again only the ASI contributed significantly to the regression (p < .05).
For the IDS-42 dependent variable Pleasant Times with Others, the proportion of variance that could be predicted from the dependent variables was only 3.3%. The independent variables did not reliably predict the dependent variable (p = .78). For the IDS-42 dependent variable Social Cues to Drink, the proportion of variance that could be predicted from the dependent variables was only 2.0%. The independent variables did not reliably predict the dependent variable (p = .63). For the IDS-42 dependent variable Pleasant Emotions, the proportion of variance that could be predicted from the dependent variables was only 8.8%. The independent variables did not reliably predict the dependent variable (p = .19).
Correlations Between ASI Subscale and IDS-42 Subscale Scores
Next, the scores on the PC, MIC, and SC subscales from the ASI were correlated with the lower order factors or subscales on the IDS-42 (see Table 3). A Bonferroni-adjusted alpha of .002 (.05/24 comparisons) was used for determining statistical significance of the correlations between the ASI subscale scores and the IDS-42 subscale scores. Again, one-tailed tests were used as directional predictions had been made a priori. With this correction, the PC subscale scores correlated significantly with all the negative and temptation situations subscales of the IDS-42, the MIC subscale scores correlated significantly with the Testing Personal Control subscale, and the SC subscale scores correlated significantly with the Conflict with Others, Physical Discomfort, and Testing Personal Control subscales.
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Regression Analyses for ASI Subscale Scores Predicting IDS-42 Subscale Scores
Standard multiple regression was used to assess how well the ASI subscale scores as a group predicted negative, temptation, and positive context drinking on the IDS-42 subscales (see Table 4). These measures in combination reliably predicted negative and temptation context drinking and not positive context drinking. The PC factor of the ASI contributed unique variance to the regression predicting scores on the Physical Discomfort subscale of the IDS-42. Also trends were observed for the PC subscale to contribute unique variance to the prediction of two other IDS-42 subscales: Unpleasant Emotions and Urges and Temptations (both p < .06). The SC factor of the ASI contributed unique variance to the Conflict with Others and Testing Personal Control subscales of the IDS-42 (see Table 4).
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Discussion |
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Consistent with the study hypotheses, participants' scores on the ASI were significantly correlated with scores on the IDS-42 subscales assessing negative context drinking (i.e., Conflict with Others, Unpleasant Emotions, Physical Discomfort) and temptation drinking (i.e., Testing Personal Control, Urges and Temptations). ASI scores were not significantly associated with positive context drinking (i.e., Pleasant Emotions, Pleasant Times with Others, and Social Cues to Drink). As with nonclinical samples (Samoluk & Stewart, 1998), it appears that women in treatment for alcohol-use problems reporting high levels of AS are more likely than others to drink in negative and temptation contexts but no more likely than others to drink in positive context situations.
The PC and SC factors of the ASI showed a stronger relationship with negative context drinking than did the MIC factor. This is in contrast to previous findings with nonclinical samples (Koven et al., 2005; Lawyer et al., 2002). Among women in treatment for substance use problems, it appears that concerns with loss of mental control (e.g., phrenophobia) do not influence drinking in negative and temptation contexts. Alternatively, fears of somatic sensations reflecting physiological tension (i.e., increased heart rate, feeling shaky) influence drinking in situations involving physical discomfort, unpleasant emotions, and urges and temptations, whereas concerns about the social consequences of one's anxiety influence drinking in situations involving conflict with others and testing personal control. The unique relationship between scores on the SC factor and the IDS-42 Testing Personal Control subscale suggest that testing personal control drinking may be socially driven among women with alcohol-use problems. It may be that socially concerned individuals are trying to prove to others that they can control their drinking.
The study findings are consistent with the self-medication theory that would predict increased consumption of alcohol by individuals with high AS due to the anxiety-dampening properties of this substance. In negative contexts, the tension-reducing properties of alcohol may act to negatively reinforce alcohol consumption. In temptation situations, cognitive preoccupation with past drinking behaviors (e.g., failed attempts to restrain drinking) may lead to psychological distress that promotes alcohol use (Collins, 1993). In both negative and temptations contexts, drinking to cope with unpleasant emotions and/or physical discomfort may regulate alcohol consumption.
Alternatively, rather than acting as a motivating factor for the consumption of alcohol in distressing situations, high AS may develop in chronic heavy drinkers from increasing concerns about withdrawal symptoms (sensations of bodily arousal). In the latter case, high AS would be a consequence of alcohol misuse rather than a contributing factor in the development of alcohol-use problems. Most likely, a vicious cycle is at play where frequent drinking to cope with negative situations may increase withdrawal symptoms, further contributing to the use of alcohol to reduce physiological arousal/tension and control withdrawal symptoms.
In studies with nonclinical samples, individuals who report higher levels of drinking-to-cope motives (as opposed to drinking for social motives) consume more alcohol in general and more on days with negative experiences (Cooper, Frone, Russell, & Mudar, 1995; Mohr et al., 2005). Drinking in negative contexts is associated with longer durations of high alcohol consumption levels and solitary (nonsocial) drinking behaviors (Annis et al., 1987), and drinking to cope is associated with increased alcohol-related problems and alcohol-use disorders (Carpenter & Hasin, 1999; Cooper, 1994; Cooper et al., 1995). These findings suggest that coping-motivated drinking may be a risk factor for the development and maintenance of alcohol abuse/dependence.
AS may play a unique role in negative affect-driven, coping-related drinking. In the current study, higher levels of AS predicted drinking in negative and temptation contexts, even after controlling for anxiety and depression. This suggests that AS better relates to negative context drinking than other negative emotionality factors. Stewart et al. (2000) also found a significant relationship between AS and negative context drinking in a sample of substance-abusing women but not between AS and temptation context drinking. This discrepant finding may be attributed to the different cohorts in the two studies. More specifically, the women in the current study were clients specifically in treatment for alcohol problems, whereas the women in the Stewart study were community-recruited substance abusers in general, only some of whom had alcohol-use problems.
The research findings indicate that the relationship between AS and alcohol use cannot be accounted for by the relationship of AS with anxiety as AS contributes unique variance to negative context drinking after statistically controlling for anxiety symptoms (cf. DeHass et al., 2001). Preliminary evidence also suggests that AS mediates or partially accounts for the association between posttraumatic stress disorder symptoms and negative situation drinking (Stewart et al., 2000). However, further research is needed to see if AS also acts as a mediator of alcohol misuse in other types of anxiety disorders that commonly co-occur with alcohol abuse/dependence such as social phobia and panic disorder/agoraphobia.
Consistent with the unique relationship between AS and alcohol use, Swendsen et al. (2000) conducted a prospective study examining associations between daily reported mood states (i.e., nervousness, sadness) and alcohol consumption. Of negative mood states, only anxiety predicted subsequent alcohol consumption. Specifically, the authors found that earlier reports of nervousness predicted later increased consumption of alcohol beverages. Alcohol ingestion was in turn associated with a short-term reduction in nervous mood. Consistent with these findings, Hussong, Galloway, and Feagans (2005) also found a significant association between fear-related daily mood states and increased drinking in university students reporting higher levels of coping-motivated drinking. Participants actually drank less on days when they experienced sad mood.
In this sample, both AS and depression independently predicted drinking in situations involving conflict with others. This finding highlights the unique relationship of depression and drinking in distressing interpersonal situations and suggests that women with substantial depressive symptoms may be most likely to relapse in negative drinking contexts specifically involving conflict with others. This is an important point in treatment planning for women suffering from comorbid depression and alcohol-use disorders.
There are several limitations in this study. First, although the women in this study self-reported alcohol-use problems and were currently receiving treatment for alcohol misuse, diagnostic measures of alcohol abuse and dependence were not administered. Similarly, although we included measures of depression and anxiety, no diagnostic measures of depressive and anxiety disorders were included in the present study. Secondly, the use of a cross-sectional, correlational methodology precludes the establishment of causality and directionality. For example, although the study findings show a relationship between AS and negative and temptation context drinking, further research is needed to determine whether a causal relationship exists and, if so, whether AS causes alcohol misuse in these situations and/or vice versa. Finally, it is unclear if the results of this study would also apply to men. Previous research suggests that anxiety-related variables including AS are more strongly associated with coping-motivated drinking and alcohol abuse in women than men (Cox, 1987; Sher, 1991; Stewart, Karp, Pihl, & Peterson, 1997; Stewart & Zeitlin, 1995). However, a significant association between AS and negative context drinking has also been found in males with alcohol abuse problems (DeHass et al., 2001).
AS appears to strongly relate to alcohol consumption in certain high-risk situations among women in treatment for alcohol-use problems, suggesting that AS should be a target for assessment and treatment in this population. A recent randomized controlled study with female university students with high and low AS found that a brief cognitive behavior therapy program targeting elevated AS symptoms lead to reduced alcohol problems as well as reduced conformity-motivated drinking and emotional relief alcohol expectancies (Watt, Stewart, Birch, & Bernier, 2006). Another randomized controlled trial among women with substance use problems showed that brief interventions targeting the underlying motivations for substance misuse (including one that focused on AS) resulted in significant reductions in substance use problems (Conrod et al., 2000). These studies' results support the contention that brief treatments targeting high AS may actually reduce alcohol and other substance use problems; however, replication among treatment-seeking populations with more severe alcohol problems is warranted (Watt, Conrod, Stewart, & Schmidt, in press).
Further study is needed to determine if AS is actually a longitudinal risk factor for the development of alcohol abuse/dependence as research suggests that AS develops in childhood. Learning experiences in childhood and genetics have been suggested to play equal roles in the development of this personality factor (Stein, Jang, & Livesley, 1999; Watt, Stewart, & Cox, 1998). Targeting AS in youth, therefore, could potentially prevent the development of alcohol misuse in later life. In fact, a recent randomized controlled trial of a set of targeted interventions designed to treat the underlying risk factors for alcohol abuse in high-school students showed that an intervention targeting elevated AS resulted in increased alcohol abstinence and decreased problematic drinking (Conrod, Stewart, Comeau, & MacLean, in press). As this study was conducted with older adolescents who had already begun drinking, future research should investigate the preventative efficacy of such an approach by administering such brief AS-focused interventions even earlier, before youth begin experimenting with drinking.
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Acknowledgments |
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This research was supported by a grant from the Nova Scotia Health Research Foundation awarded to Sherry H. Stewart, Catrina G. Brown, Peter Horvath, and Juliana Wiens. The first author completed this project as a comprehensive requirement toward the completion of her PhD in Clinical Psychology at Dalhousie University. The research assistance of Sarah Larsen is gratefully acknowledged. The authors would also like to thank the women clients who participated in this study and the Directors and service providers at Addiction Prevention and Treatment Services, Capital District Health Authority, Nova Scotia, Canada, for their assistance with participant recruitment. Conflict of interest: None declared.
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Footnotes |
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i Lawyer et al. (2002) examined a two-factor solution of AS (FCD versus fear of somatic sensations), whereas we used the commonly accepted three-factor solution (Zinbarg, Barlow, & Brown, 1997).
ii Approximately one quarter of the sample did not provide information on employment status.
iii Approximately one fifth of the sample did not report ethnicity.
iv For participants with some partial data missing from the BDI-II, missing values replacement was performed based on item means, prior to calculation of the BDI-II total score.
v Although lower, the SC subscale alpha is marginally acceptable (i.e., close to .60) given consideration of its short scale length (Costa & McCrae, 1992; Meehl & Golden, 1982).
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References |
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