1 Department of Psychiatry and Institute for Extramural Medicine, VU University Medical Centre, Amsterdam and 2 Amsterdam Institute for Addiction Research, Amsterdam Medical Centre, University of Amsterdam, Amsterdam and 3 Leiden University Medical Centre, Leiden, The Netherlands
* Author to whom correspondence should be addressed at: VU University Medical Centre, GGZBA, Lassusstraat 2, 1075 GV Amsterdam, Netherlands. Tel.: +00 31 20 573 6600; E-mail: a.schade{at}ggzba.nl
(Received 13 October 2003; first review notified 9 December 2003; in revised form 16 December 2003; accepted 21 December 2003)
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ABSTRACT |
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INTRODUCTION |
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A possible explanation for the high comorbidity rates is the self medication hypothesis. Initially, use of alcohol may decrease anxiety symptoms, but later on it promotes persistent and excessive use of alcohol through negative reinforcement (Kushner et al., 2000). This study focuses on comorbid social phobia and agoraphobia because these anxiety disorders tend to precede alcohol dependence. Panic disorder and generalized anxiety disorder, on the other hand, tend to develop after the onset of alcohol dependence (Kushner et al., 1990
; Brady and Lydiard 1993
; Romach and Doumani 1997
). The presence of a phobic disorder substantially increases the risk of developing and maintaining alcohol use disorders (Kushner et al., 1990
).
Because alcohol-dependent patients with comorbid phobic disorders form a substantial proportion of treatment-seeking alcoholics and phobic patients, we need to know more about the clinical characteristics of this group of patients if we are to provide optimum treatment. To our knowledge, this subject has been studied only once before. The study by Thomas et al. compared treatment-seeking pure alcoholics with treatment-seeking alcoholics with social phobia in terms of demographic and clinical characteristics (Thomas et al., 1999). They showed that the comorbid patients had higher mean scores on an alcohol dependence scale, and more dependence symptoms on the SCID, but they did not drink larger amounts of alcohol or more frequently than the pure alcoholics. Also, the comorbid patients had more symptoms of depression, as measured with Beck's Depression Inventory (Beck and Steer, 1987
) and they suffered more frequently from major depressive disorders, as measured with the Computerized Diagnostic Interview Schedule (C-DIS) (Robins et al., 1988
). A limitation of the study of Thomas et al. is that it excluded patients with other substance use disorders (except nicotine and cannabis) and not all patients were assessed at least 4 weeks after detoxification. As withdrawal symptoms can influence the assessment of anxiety symptoms (Schuckit and Monteiro, 1988
; Schadé et al., 2003
) the results in the alcohol-dependent group with comorbid social phobia in particular should be interpreted with caution.
The purpose of the present study was to answer the following questions. (1) What are the clinical characteristics of treatment-seeking alcohol-dependent patients with a comorbid phobic disorder? (2) Are alcohol dependence and other clinical characteristics of comorbid patients different from those of pure alcohol-dependent patients? (3) Are anxiety symptoms and other clinical characteristics of comorbid patients different from those of pure phobic patients? To this end we compared three groups of treatment-seeking patients: alcohol-dependent patients with a comorbid phobic disorder, alcohol-dependent patients and patients with social phobia or agoraphobia. The demographic and clinical characteristics of the three groups were compared. To determine whether the comorbid patients had a different kind of alcohol dependence or phobic disorder, we compared each single diagnosis group with the comorbid group. In order to diagnose the comorbid anxiety and depressive disorders validly, the assessment took place at least 6 weeks after detoxification (Schuckit and Monteiro, 1988; Driessen et al., 2001
).
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MATERIALS AND METHODS |
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Procedures
ALC/ANX and ALC
From November 1998 to February 2001 all consecutive patients suffering from alcohol dependence detoxified at the outpatient or inpatient clinics of the Jellinek Alcohol Treatment Centre, Amsterdam, who had been abstinent for at least 4 weeks were asked by their therapist to participate in the present study. At intake, trained interviewers administered the European version of the Addiction Severity Index (EuropASI) (Kokkevi and Hartgers, 1995). Since excessive use of alcohol and subsequent withdrawal are likely to influence the presence and severity of anxiety symptoms, sufficient time needs to elapse between detoxification and the diagnosis of comorbid anxiety disorders (Driessen et al., 2001
). Schuckit and Monteiro (1988)
suggest a period of at least 4 weeks' abstinence before a valid diagnosis of comorbid Axis I disorders can be reached. The patients were diagnosed using the Structured Clinical Interview for DSM-IV (SCID) (First et al., 1996
). They were then asked to fill out several self-report questionnaires.
ANX From November 1998 to February 2001 all consecutive patients at the Amsterdam Outpatient Clinic for Anxiety Disorders diagnosed using the SCID who met the criteria for social phobia, panic disorder with agoraphobia or agoraphobia without a history of panic attacks were asked to participate in the present study. They were then asked to fill out several self-report questionnaires. The EuropASI was administered by telephone.
Subjects
ALC/ANX and ALC
Patients were included if they met the DSM-IV criteria for alcohol dependence, diagnosed using the SCID, and a minimum score of 5 on the EuropASI alcohol severity scale (range 09), indicating that alcohol use constitutes a problem of at least moderate severity for which treatment is necessary. Patients were allocated to the two groups under study based on the presence or absence of comorbid anxiety disorders: (1) if they met the criteria for comorbid social phobia, panic disorder with agoraphobia or agoraphobia without a history of panic attacks (ALC/ANX), and (2) if they did not meet the criteria for a comorbid anxiety disorder (ALC). Excluded from the ALC group were patients with the following non-phobic disorders: panic disorder without agoraphobia, generalized anxiety disorder, obsessive compulsive disorder and posttraumatic stress disorder. Although simple phobia is a phobic disorder, the presence of a simple phobia was not taken into account in the allocation to the two groups. Simple phobia does not have a rate of comorbidity with alcohol dependence beyond expected community base rates (Kushner et al., 1990). Co-occurrence of other DSM-IV diagnoses (including other substance use disorders) was not an exclusion criterion for participation in either group.
ANX Patients were included if they fulfilled DSM IV criteria for social phobia, panic disorder with agoraphobia or agoraphobia without a history of panic attacks. Alcohol dependence and alcohol misuse were exclusion criteria, although we excluded only two patients with comorbid alcohol dependence. Patients with all other comorbid diagnoses (including other substance use disorders) were included.
Assessment
Structured Clinical Interview for DSM-IV (SCID)
All diagnoses were assessed using the SCID, including the number of alcohol dependence criteria and the age of onset of alcohol dependence.
EuropASI The EuropASI assessed demographic characteristics such as sex, age, employment and partnership status, and clinical characteristics such as emotional, physical and sexual abuse.
Alcohol use measures
Self-reported alcohol consumption (days with any amount of alcohol drunk and days with five or more alcoholic drinks per day (heavy drinking days) in the 30 days prior to the assessment), the number of previous alcohol treatments and the duration of the alcohol problem were recorded. The ASI severity score (range 09) covers such things as number of drinking days and amounts of alcohol consumed, duration of the alcohol problem and alcohol treatment history.
Self-report measures
Anxiety
Agoraphobic avoidance was measured on the Fear Questionnaire (FQ) agoraphobia scale (Marks and Mathews, 1997), fear of panic attack symptoms using the Bodily Sensations Questionnaire (BSQ) (Chambless et al., 1984
), and common cognitions of agoraphobic patients during panic attacks using the Agoraphobic Cognitions Questionnaire (ACQ) (Chambless et al., 1984
). Avoidance of social phobic situations was assessed on the Fear Questionnaire (FQ) (Marks and Mathews, 1997
) social phobia scale, maladaptive cognitions in social situations were measured with the Social Cognitions Inventory (SCI) (Van Meijgaard et al., 1987
), and social anxiety was measured with the Inventory of Interpersonal Situations (IIS) (Van Dam-Baggen and Kraaimaat, 1999
).
Other clinical characteristics
General psychopathology was assessed using the total score on the Symptom Checklist (SCL-90) (Derogatis, 1997) and depressive symptoms using the Beck Depression Inventory (BDI) (Beck and Steer, 1987
).
Analysis
The ALC/ANX, ALC and ANX groups were compared for continuous variables using GLM-ANOVA and logistic regression for categorical variables. The multi-comparison results from the three groups were corrected with Bonferroni adjustments. The family-wise error rate was thus set at 0.05. As we made three comparisons, the difference is considered significant at 0.016 (0.05 divided by 3). Given the different prevalence of alcohol dependence and phobic disorders between men and women, the effect of sex was taken into account in all the analyses. This was studied in two steps. First we assessed whether sex was a potential effect-modifier using the interaction term. If this was not the case, sex was added to the model to adjust for its confounding effect. Because there were significant differences between the ALC/ANX group and the ANX group in the type of phobic disorders, only patients diagnosed with agoraphobia in each of the two groups were used in the analyses to determine possible differences in agoraphobic characteristics. The same procedure was followed for the patients diagnosed with social phobia.
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RESULTS |
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Demographic and clinical characteristics
In order to answer the questions posed in this study we compared the ALC/ANX group, the ALC group and the ANX group on demographic and clinical characteristics (Table 1). An important finding was that comorbid patients (ALC/ANX) showed a substantial number of other diagnostic and clinical characteristics besides alcohol dependence and phobic disorder. They had high scores on depressive symptoms (BDI) and general psychopathology (SCL-90): 25% of patients had a current and 52% a lifetime depressive disorder. The major-ity had no partner and were unemployed, they had a high incidence of other substance use (benzodiazepines, cocaine, cannabis) and a substantial proportion of comorbid patients had been emotionally, physically and sexually abused.
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Alcohol use characteristics (ALC/ANX group and ALC group)
To determine whether the comorbid patients suffered from a more severe or different kind of alcohol dependence, we compared the ALC/ANX group and the ALC group on several alcohol use/dependence characteristics (Table 2). As Table 2 shows, no significant differences were found. Alcohol-dependent patients with a comorbid phobic disorder and pure alcohol-dependent patients do not significantly differ in age of onset of alcohol dependence, severity of alcohol dependence, number of heavy drinking days or duration of the alcohol problem.
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DISCUSSION |
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The study by Thomas et al. compared alcoholics with and without social phobia. In line with our findings it found no difference between the two groups on amount and frequency of alcohol consumption (Thomas et al., 1999). In that study, however, comorbid patients showed higher scores on an alcohol-dependence scale (Skinner and Horn, 1984
) and more SCID alcohol dependence symptoms were assessed. There are several possible explanations for the differences in alcohol characteristics between the two studies. Thomas et al., used the DSM-III-R version of the SCID with a maximum of nine dependence symptoms, whereas we used the SCID-DSM-IV version with a maximum of eight dependence symptoms. Also, some patients in the study by Thomas et al. were diagnosed within 1 week of abstinence. Some of the SCID dependence symptoms are similar to withdrawal symptoms, so it is likely that at 12 weeks' abstinence it was withdrawal symptoms that were assessed, especially in the case of the comorbid patients (Johnston et al., 1991
), resulting in a higher number of alcohol dependence symptoms.
Significantly more comorbid patients were diagnosed with benzodiazepine dependence or misuse. They probably used more benzodiazepines as a medication for existing anxiety symptoms. Moreover, their withdrawal symptoms were probably more severe than those of pure alcoholics because alcohol-dependent patients with at least one comorbid anxiety disorder report greater severity of withdrawal symptoms compared to pure alcoholics (Johnston et al., 1991). A possible explanation for the difference between the ALC/ANX group and the ANX group on types of phobic disorder is the higher comorbidity rate of social phobia and alcohol dependence in the general population (Kessler et al., 1994
).
Reported emotional, physical and sexual abuse was very common among the three groups of patients, especially in the ALC/ANX and ALC groups. This finding is also reported in the literature, which notes an association with childhood sexual or physical abuse, especially in the case of women (Langeland and Hartgers, 1998). Sexual abuse is associated with the presence of social phobia in alcohol-dependent men and women, and also with agoraphobia in alcohol-dependent men (Langeland, 2003
).
The high levels of dysfunctioning indicated by the socio- demographic characteristics of the comorbid group, the high levels of psychopathology, and the high frequency of childhood emotional, physical and sexual abuse raise the question of whether alcohol dependence combined with a phobic disorder represents a distinct diagnostic entity. The comorbid condition should differ clearly from both alcohol dependence and phobic disorder. In the present study this does not seem to be the case: only two clinical characteristics, high depressive symptoms (measured with the BDI) and benzodiazepine dependence/misuse were found to be more common in the comorbid group compared to the two pure diagnostic groups. A high prevalence of depressive symptoms among anxiety disorders has often been shown (Schneier et al., 1992; Merikangas and Angst 1995
; Goodwin 2002
) but the comorbid group showed more depressive symptoms than the ANX group. A relative difference in only two clinical characteristics, however, is not enough to indicate that comorbidity is more than just the co-occurrence of alcohol dependence and phobic disorders.
The strength of the present study lies in the fact that, for the first time, these three groups of patients have been compared on a wide variety of clinical characteristics. Each group has a large enough sample size and the groups are assessed and analysed using the same method. The study also has some limitations. First, all the participants in the study were treatment-seeking patients. It could be that patients with a double diagnosis of alcohol dependency and severe anxiety disorders do not seek alcohol treatment, or discharge themselves from the clinic owing to their anxiety symptoms. On the other hand, patients suffering from a combination of mood, anxiety and substance disorders are more likely to perceive the need for professional help and seek it (Mojtabai et al., 2002). Second, we only included alcohol-dependent patients with a comorbid phobic disorder from an alcohol treatment clinic, which might have introduced some selection bias. At the Anxiety Clinic, however, only two patients with alcohol dependence and a comorbid phobic disorder were found and subsequently excluded. This seems to indicate that comorbid patients are much more likely to seek help for their alcohol dependence than for their anxiety disorder. Based on this observation, we conclude that the decision to recruit comorbid patients only from the alcohol treatment clinic has not introduced serious selection bias.
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CONCLUSION |
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FOOTNOTES |
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REFERENCES |
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Brady, K. T. and Lydiard, R. B. (1993) The association of alcoholism and anxiety. Psychiatric Quartile 64, 135149.
Chambless, D. L., Caputo, G. C., Bright, P. and Gallagher, R. (1984) Assessment of fear of fear in agoraphobics: the body sensations questionnaire and the agoraphobic cognitions questionnaire. Journal of Consulting and Clinical Psychology 52, 10901097.[CrossRef][ISI][Medline]
Derogatis, I. R. (1997) SCL-90: Administration, scoring and procedures manual-I for the R(evised) version. John Hopkins University School of Medicine, Baltimore.
Driessen, M., Meier, S., Hill, A., Wetterling, T., Lange, W. and Junghanns, K. (2001) The course of anxiety, depression and drinking behaviours after completed detoxification in alcoholics with and without comorbid anxiety and depressive disorders. Alcohol and Alcoholism 36, 249255.
First, M. B., Spitzer, R. L., Gibbon, M. and Williams, J. B. W. (1996) Structured Clinical Interview for DSM-IV axis disorders SCID-1/P (version 2.0). Biometrics Research Department, New York.
Goodwin, R. D. (2002) Anxiety disorders and the onset of depression among adults in the community. Psychological Medicine 32, 11211124.[CrossRef][ISI][Medline]
Johnston, A. L., Thevos, A. K., Randall, C. L. and Anton, R. F. (1991) Increased severity of alcohol withdrawal in in-patient alcoholics with a co-existing anxiety diagnosis. British Journal of Addiction 86, 719725.[ISI][Medline]
Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., Wittchen, H. U. and Kendler, K. S. (1994) Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States Results from the National Comorbidity Survey. Archives of General Psychiatry 51, 819.[Abstract]
Kokkevi, A. and Hartgers, C. (1995) EuropASI: European adaptation of a multidimensional assessment instrument for drug and alcohol dependence. European Addiction Research 1, 208210.
Kushner, M. G., Abrams, K. and Borchardt, C. (2000) The relationship between anxiety disorders and alcohol use disorders: a review of major perspectives and findings. Clinical Psychology Review 20, 149171.[CrossRef][ISI][Medline]
Kushner, M. G., Sher, K. J. and Beitman, B. D. (1990) The relation between alcohol problems and the anxiety disorders. American Journal of Psychiatry 147, 685695.[Abstract]
Langeland, W. (2003) Childhood Trauma in Treated Alcoholics. University of Amsterdam, Amsterdam.
Langeland, W. and Hartgers, C. (1998) Child sexual and physical abuse and alcoholism: a review. Journal of Studies on Alcohol 59, 336348.[ISI][Medline]
Marks, I. M. and Mathews, A. M. (1997) Brief standard self-rating for phobic patients. Behaviour Research and Therapy 17, 263267.
Merikangas, K. R. and Angst, J. (1995) Comorbidity and social phobia: evidence from clinical, epidemiologic, and genetic studies. European archives of psychiatry and clinical neuroscience 244, 297303.[ISI][Medline]
Mojtabai, R., Olfson, M. and Mechanic, D. (2002) Perceived need and help-seeking in adults with mood, anxiety, or substance use disorders. Archives of General Psychiatry 59, 7784.
Noyes, R., Crowe, R. R., Harris, E. L., Hamra, B. J., McChesney, C. M. and Chaudhry, D. R. (1986) Relationship between panic disorder and agoraphobia. A family study. Archives of General Psychiatry 43, 227232.[Abstract]
Robins, L. N., Wing, J., Wittchen, H. U., Helzer, J. E., Babor, T. F., Burke, J., Farmer, A., Jablenski, A., Pickens, R. and Regier, D. A. (1988) The Composite International Diagnostic Interview An epidemiologic Instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Archives of General Psychiatry 45, 10691077.[Abstract]
Ravelli, A., Bijl, R. and Van Zessen, G. (1998) Comorbiditeit van psychiatrische stoornissen in de Nederlandse bevolking; resultaten van de Netherlands Mental Health Survey and Incidence Study (NEMESIS). Tijdschrift voor Psychiatrie 40, 531544.
Romach, K. R. and Doumani, S. (1997) Alcoholism and anxiety disorders. In Dual Diagnosis and Treatment, Kranzler, H. R. and Rounsaville, B. J., eds. pp. 137175. Marcel Dekker, New York.
Ross, H. E., Glaser, F. B. and Germanson, T. (1988) The prevalence of psychiatric disorders in patients with alcohol and other drug problems. Archives of General Psychiatry 45, 10231031.[Abstract]
Schadé, A., Marquenie, L. A., Van Balkom, A. J., De Beurs, E., Van Dyck, R. and Van den Brink, W. (2003) Do comorbid anxiety disorders in alcohol-dependent patients need specific treatment to prevent relapse? Alcohol and Alcoholism 3, 255262.
Schneider, U., Altmann, A., Baumann, M., Bernzen, J., et al. (2001) Comorbid anxiety and affective disorder in alcohol-dependent patients seeking treatment: the first Multicentre Study in Germany. Alcohol and Alcoholism 36, 219223.
Schneier, F. R., Johnson, J., Hornig, C. D., Liebowitz, M. R. and Weissman, M. M. (1992) Social phobia Comorbidity and morbidity in an epidemiologic sample. Archives of General Psychiatry 49, 282288.[Abstract]
Schuckit, M. A. and Monteiro, M. G. (1988) Alcoholism, anxiety and depression. British Journal of Addiction 83, 13731380.[ISI][Medline]
Skinner, H. A. and Horn, J. L. (1984) Alcohol Dependence Scale (ADS): User's Guide. Addiction Research Foundation, Toronto.
Thomas, S. E., Thevos, A. K. and Randall, C. L. (1999) Alcoholics with and without social phobia: a comparison of substance use and psychiatric variables. Journal of Studies on Alcohol 60, 472479.[ISI][Medline]
Van Dam-Baggen, R. and Kraaimaat, F. (1999) Assessing social anxiety: the Inventory of Interpersonal Situations (ISS). European Journal of Psychological Assessment 15, 2538.[CrossRef][ISI]
Van Meijgaard, I., Tros, A., Van der Molen, H. and Wolters, F. (1987) De sociale cognitielijst: een nadere validatie. De Psycholoog 22, 383389.