The relationship between anxiety disorders and alcohol use disorders: a review of major perspectives and findings

Contribution of early environmental stress to alcoholism vulnerability

The most problematic aspects of alcohol abuse disorder are excessive alcohol consumption and the inability to refrain from alcohol consumption during attempted abstinence. The root causes that predispose certain individuals to these problems are poorly understood but are believed to be produced by a combination of genetic and environmental factors. Early environmental trauma alters neurodevelopmental trajectories that can predispose an individual to a number of neuropsychiatric disorders, including substance abuse. Prenatal stress (PNS) is a well-established protocol that produces perturbations in nervous system development, resulting in behavioral alterations that include hyperresponsiveness to stress, novelty, and psychomotor stimulant drugs (e.g., cocaine, amphetamine). Moreover, PNS animals exhibit enduring alterations in basal and cocaine-induced changes in dopamine and glutamate transmission within limbic structures, which exhibit pathology in drug addiction and alcoholism, suggesting that these alterations may contribute to an increased propensity to self-administer large amounts of drugs of abuse or to relapse after periods of drug withdrawal. Given that cocaine and alcohol have actions on common limbic neural substrates (albeit by different mechanisms), we hypothesized that PNS would elevate the motivation for, and consumption of, alcohol. Accordingly, we have found that male C57BL/6J mice subject to PNS exhibit higher operant responding and consume more alcohol during alcohol reinforcement as adults. Alterations in glutamate and dopamine neurotransmission within the forebrain structures appear to contribute to the PNS-induced predisposition to high alcohol intake and are induced by excessive alcohol intake. Accordingly, we are exploring the interactions between neurochemical changes produced by PNS and changes induced by consumption of alcohol in adulthood to model the biological bases of high vulnerability to alcohol abuse.

Emerging adult outcomes of adolescent psychiatric and substance use disorders

This study investigates the age 25 outcomes of late adolescent mental health and substance use disorders. A hierarchical cluster analysis of age 19 DSM-III-R mental health and substance diagnoses placed participants into one of 9 clusters: Anxious, Depressed, Antisocial, Drug Abuser, Problem Drinker, Anxious Drinker, Depressed Drug Abuser and Antisocial Drinker, and No Diagnosis. Diagnoses were generated from the University of Michigan Composite International Diagnostic Interview. Repeated measures multivariate analyses of variance revealed distinct trajectories of improvement and decline among the 9 clusters. Clusters with co-occurring substance and mental health disorders improved over adolescent levels, but continued to have higher levels of depression symptoms, poorer global functioning, and higher levels of substance use than the No Diagnosis cluster. Members of the The Problem Drinkers cluster, who tended to have alcohol use disorders only at age 19, did not differ from their peers with no diagnoses. Drug use disorders in adolescence, with or without a co-occurring mental health disorders, were associated with a poor prognosis in emerging adulthood. Clinical interventions should distinguish among these diverse clinical presentations.

Trait anxiety and ethanol: anxiolysis in high-anxiety mice and no relation to intake behavior in an addiction model

Anxiety has been proposed to play a role in the development of alcohol addiction, but the exact mechanisms by which this occurs remain unclear. The present study aimed to verify the relationship between basal anxiety levels, the anxiolytic-like effect of ethanol, and ethanol intake in mice exposed to an addiction model. In one experiment Swiss mice were characterized as high-anxiety (HA), medium-anxiety (MA), or non-anxiety (NA) in the elevated plus maze and then received saline or ethanol 2 g/kg acutely and chronically and were again exposed to the same test. NA mice decreased while MA mice maintained anxiety indices over the test days, regardless of treatment. HA ethanol-treated mice showed an anxiolytic-like effect, both acutely and chronically, while the saline-treated ones maintained their basal anxiety levels. In another experiment HA and MA mice were exposed to an addiction model based on a 3-bottle free-choice paradigm (ethanol 5% and 10%, and water) consisting of four phases: acquisition (10 weeks), withdrawal (W, 2 weeks), reexposure (2 weeks), and quinine-adulteration (2 weeks). HA and MA control mice had access only to water. Mice were characterized as addicted, heavy-drinker and light-drinker [Fachin-Scheit DJ, Ribeiro AF, Pigatto G, Goeldner FO, Boerngen-Lacerda R. Development of a mouse model of ethanol addiction: naltrexone efficacy in reducing consumption but not craving. J Neural Transm 2006;113:1305-21.]. No difference was observed between HA and MA mice in their preference for and intake of ethanol. No correlation was observed between ethanol intake, during any phase, and anxiety indices measured in the basal tests and during the W phase. The differences in anxiety indices between HA and MA groups persisted in the test performed during ethanol withdrawal, suggesting a "trait" anxiety profile. The data suggest that despite the fact that high anxiety trait levels are important for the anxiolytic-like effects of ethanol, they are not a determining factor for high ethanol intake, at least not under these experimental conditions.

Predictors of alcohol use prior to deployment in National Guard Soldiers

Frequent and heavy alcohol use is associated with negative mental and physical health consequences. Previous research has suggested that alcohol misuse is associated with demographic, personality, and mental health variables. This study examined the relative contribution of these factors in predicting drinking among National Guard soldiers prior to deployment to a combat zone. Members of a National Guard Brigade Combat Team (N=515) completed questionnaires assessing drinking behaviors in the past year (frequency, quantity, binge, and total drinking), as well as demographic, personality, and mental health variables. As a group, demographic and personality variables significantly predicted all drinking outcomes. Negative emotionality and disconstraint were independent predictors of all drinking variables. Younger age predicted higher quantity of drinking, while being unmarried predicted greater total drinking and higher frequency of binge drinking. Once the influence of personality variables were accounted for, mental health was not associated with any drinking variable. The results of this study illustrate the role of factors associated with problematic drinking in a sample of high-risk individuals.

Binge drinking in women at risk for developing eating disorders

OBJECTIVE

To determine binge drinking rates in college-age women at risk for eating disorders and to examine factors related to binge drinking over time.

METHOD

Participants were 480 college-age women who were at high risk for developing an eating disorder (ED) and who had a body mass index (BMI) between 18 and 32. Participants were assessed annually for 4 years.

RESULTS

Participants reported high rates of binge drinking and frequent binge drinking throughout college. Binge drinking was positively correlated with dietary restraint, coping using substances, coping using denial, and life events.

DISCUSSION

The study's findings suggest that binge drinking is highly prevalent in women at high risk for developing eating disorders. Results also indicated that binge drinking was related to dieting and maladaptive coping patterns. Intervention for women with strong weight and shape concerns should also address problematic alcohol use.

Cognitive-behavioral therapy for panic disorder in patients being treated for alcohol dependence: Moderating effects of alcohol outcome expectancies

Anxiety disorders commonly co-occur with alcohol use disorders and reliably mark a poor response to substance abuse treatment. However, treating a co-occurring anxiety disorder does not reliably improve substance abuse treatment outcomes. Failure to account for individual differences in the functional dynamic between anxiety symptoms and drinking behavior might impede the progress and clarity of this research program. For example, while both theory and research point to the moderating role of tension-reduction alcohol outcome expectancies (TR-AOEs) in the association between anxiety symptoms and alcohol use, relevant treatment studies have not typically modeled TR-AOE effects. We examined the impact of a hybrid cognitive-behavioral therapy (H-CBT) treatment for panic disorder (independent variable) on response to a community-based alcohol dependence treatment program (dependent variable) in patients with higher vs. lower TR-AOEs (moderator). The H-CBT treatment was generally effective in relieving participants' panic symptoms relative to controls. However, TR-AOEs interacted with study cohort (H-CBT vs. control) in predicting response to substance abuse treatment. As expected, the H-CBT was most effective in improving alcohol use outcomes among those with the highest TR-AOEs. The study's primary methodological limitations are related to the quasi-experimental design employed.

Should personality traits be considered when refining substance misuse treatment programs?

The interplay between stable personality characteristics and environmental factors is emphasised in most contemporary approaches to individual differences. This interaction appears to be important in understanding the development of substance use and misuse. Impulsivity related personality traits such as sensation-seeking, novelty seeking, reward-sensitivity and behavioural disinhibition, are strongly linked to adolescent and adult substance use and misuse. The role of anxiety-related traits, in the development of substance misuse is less clear. Nonetheless, anxiety disorders are very common amongst adult substance misusers and almost certainly play a critical role in the maintenance of a substance use disorder and influence treatment effectiveness. The data suggest that personality influences treatment outcomes and yet these individual differences are generally not addressed in treatment. We argue in this review that interventions which are matched to these relevant personality traits may improve treatment outcomes for substance misusers.

Anxiety disorders moderate the association between externalizing problems and substance use disorders: data from the National Comorbidity Survey-Revised

Anxiety disorders and externalizing problems are both associated with substance use disorders. However, the nature of this relationship remains unclear. To examine whether presence of an anxiety disorder changes the association between externalizing problems (conduct disorder, oppositional defiant disorder, and attention deficit hyperactivity disorder) and substance use disorders, we analyzed data from the National Comorbidity Survey-Replication, which is based on a nationally representative sample of 9282 English-speaking adults. Presence of externalizing problems was associated with an increased odds for alcohol abuse (OR: 6.7, CI: 5.6-8.1), alcohol dependence (OR: 7.6, CI: 5.9-9.6), substance abuse (OR: 9.9, CI: 8.1-12.2), and substance dependence (OR: 13.1, CI: 9.6-17.8). Similarly, anxiety disorders were associated with increased odds for substance use disorders. The highest association was found between post-traumatic stress disorder and substance use disorder (OR: 9.2, CI: 5.4-15.5). Individuals who met diagnostic criteria for an anxiety disorder and externalizing problems showed consistently and significantly lower odds for substance use problems than subjects with externalizing problems without a comorbid anxiety disorder. The results suggest that presence of any anxiety disorder reduces the association between externalizing problems and substance use disorders, possibly because the fear of bodily symptoms prevents individuals with externalizing problems from engaging in drug-seeking behaviors.

Substance use disorders in an obsessive compulsive disorder clinical sample

The prevalence and clinical correlates of substance use disorders (SUDs) were examined in a clinical sample of Obsessive Compulsive Disorder (OCD). As part of their intake interview into an observational study of the course of OCD, 323 participants completed a battery of standardized measures. Twenty-seven percent of the sample met lifetime criteria for a SUD. 70% of participants with comorbid SUDs reported that OCD preceded SUD onset by at least one year. Younger age at OCD onset and presence of Borderline Personality Disorder (BPD) were each associated with increased risk of alcohol use disorders but only BPD was associated with increased risk of drug use disorders. SUDs affect more than one-quarter of individuals who seek treatment for OCD. Individuals with a juvenile-onset of OCD or comorbid BPD may be especially vulnerable to SUDs. Further research is needed to identify risk factors for SUDs and to better understand their impact on OCD course.

Selbstmedikation und Sozialphobie

Zusammenfassung. Hintergrund: Der Fragebogen „Trinken wegen sozialer Angst” (TWSA; Wagner, Stangier, Heidenreich & Schneider, 2004 ) erfasst das Motiv, Alkohol zur Reduktion sozialer Angst einzusetzen. Das Instrument wurde bisher nur bei Alkoholabhängigen untersucht. Hier sollen Reliabilität und konvergente Validität in einer sozialphobischen sowie einer gesunden Stichprobe geprüft werden. Methode: 120 Patienten mit Sozialphobie und 120 Gesunde bearbeiteten den TWSA. Zur Überprüfung der Konstruktvalidität wurden Maße zur Psychopathologie, die Alkoholwirkungserwartungen und die Höhe des Alkoholkonsums erfasst. Ergebnisse: Der TWSA hat eine gute Reliabilität (Cronbachs α = .96). Es zeigen sich bedeutsame Korrelationen mit Maßen zur sozialen Angst. Ebenfalls ergeben sich Zusammenhänge zu Alkoholwirksamkeitserwartungen sowie zur konsumierten Alkoholmenge. Teilnehmer mit Sozialphobie erzielten höhere Werte als Gesunde. Diskussion: Die Ergebnisse belegen, dass der TWSA auch bei Patienten mit Sozialphobie und gesunden Personen reliabel und valide eingesetzt werden kann. Die für Patienten mit Sozialphobie erhöhten Werte unterstreichen die Notwendigkeit der Diagnostik komorbider substanzbezogener Störungen.

A comparative study of two methods for attaining constant alcohol levels

AIMS

Alcohol effects or drug-alcohol interactions are preferably studied at constant blood levels. To achieve pseudo-steady state levels, various methods are used, which usually produce adequate averages but variable individual concentration profiles. The aim was to compare two modes of alcohol administration: a 'two-step prekinetic procedure' and a 'clamping method'.

METHODS

The two-step prekinetic procedure started with determination of individual pharmacokinetic (PK) parameters, during a prestudy occasion. Individual infusion regimens were calculated afterwards, based on a pseudo-steady state breath alcohol concentration (BrAC) of 0.65 g l(-1) and applied on a separate occasion. For the clamping procedure, a spreadsheet-based paradigm was developed using BrAC-guided adjustments of infusion rates, to maintain stable BrAC levels of 0.6 g l(-1).

RESULTS

The mean BrAC during clamping [0.61 g l(-1), 95% confidence interval (CI) 0.58, 0.63] did not differ from its intended level of 0.6 g l(-1) (1.0% on average). In contrast, the mean BrAC during the prekinetic procedure was significantly lower than the 0.65 g l(-1) set-point (0.59 g l(-1), 95% CI 0.54, 0.63) and deviated from this target by 9.7% on average. The clamping method also showed less variation between subjects [coefficient of variation (CV) 6.2%] compared with the prekinetic procedure (CV 14.6%).

CONCLUSIONS

Although the two methods differ considerably in their approach, clamping of BrAC resulted in more accurate alcohol levels than infusion based on PK modelling and does not require an extra prestudy occasion. The novel alcohol clamping paradigm can be of value in future studies of alcohol interactions or the pharmacodynamics of acute alcohol administration.

Acute and chronic alcohol dose: population differences in behavior and neurochemistry of zebrafish

The zebrafish has been in the forefront of developmental genetics for decades and has also been gaining attention in neurobehavioral genetics. It has been proposed to model alcohol-induced changes in human brain function and behavior. Here, adult zebrafish populations, AB and SF (short-fin wild type), were exposed to chronic treatment (several days in 0.00% or 0.50% alcohol v/v) and a subsequent acute treatment (1 h in 0.00%, 0.25%, 0.50% or 1.00% alcohol). Behavioral responses of zebrafish to computer-animated images, including a zebrafish shoal and a predator, were quantified using videotracking. Neurochemical changes in the dopaminergic and serotoninergic systems in the brain of the fish were measured using high-precision liquid chromatography with electrochemical detection. The results showed genetic differences in numerous aspects of alcohol-induced changes, including, for the first time, the behavioral effects of withdrawal from alcohol and neurochemical responses to alcohol. For example, withdrawal from alcohol abolished shoaling and increased dopamine and 3,4-dihydroxyphenylacetic acid in AB but not in SF fish. The findings show that, first, acute and chronic alcohol induced changes are quantifiable with automated behavioral paradigms; second, robust neurochemical changes are also detectable; and third, genetic factors influence both alcohol-induced behavioral and neurotransmitter level changes. Although the causal relationship underlying the alcohol-induced changes in behavior and neurochemistry is speculative at this point, the results suggest that zebrafish will be a useful tool for the analysis of the biological mechanisms of alcohol-induced functional changes in the adult brain.

Substance use behaviors, mental health problems, and use of mental health services in a probability sample of college students

This research examined 1) the prevalence of substance use behaviors in college students, 2) gender and academic level as moderators of the associations between mental health problems and substance use, and 3) mental health service use among those with co-occurring frequent binge drinking and mental health problems. As part of the Healthy Minds Study, a probability sample of 2843 college students completed an Internet survey on mental health problems, substance use behaviors, and utilization of mental health care. Response propensity weights were used to adjust for differences between respondents and non-respondents. Major depression, panic disorder, and generalized anxiety disorder were positively associated with cigarette smoking. Frequent binge drinking was negatively associated with major depression and positively associated with generalized anxiety disorder, and these associations were significantly stronger for males than females. Among students with co-occurring frequent binge drinking and mental health problems, 67% perceived a need for mental health services but only 38% received services in the previous year. There may be substantial unmet needs for treatment of mental health problems and substance use among college students.

Differential effects of GABAB autoreceptor activation on ethanol potentiation of local and lateral paracapsular GABAergic synapses in the rat basolateral amygdala

Many studies have demonstrated that GABAergic inhibition within the basolateral amygdala (BLA) plays an integral role in the regulation of anxiety, an important behavioral component in the etiology of alcoholism. Although ethanol has recently been shown to enhance BLA GABAergic inhibition via two distinct populations of inhibitory cells, local and lateral paracapsular (lpcs) interneurons, little is known about the mechanisms underlying ethanol potentiation of these two inhibitory pathways. Ethanol is known to enhance GABAergic inhibition in many brain regions via a complex array of pre- and postsynaptic mechanisms. In addition, ethanol's presynaptic effects are often subject to GABA(B) autoreceptor (GABA(B)-R) modulation. Therefore, in this study, we characterized GABA(B)-R function and modulation of ethanol actions at local and lpcs GABAergic synapses. At local synapses, we found significant paired-pulse depression (PPD, 250 ms inter-pulse interval) which was abated by SCH-50911 (GABA(B)-R antagonist). No significant PPD was detected at lpcs synapses, but SCH-50911 significantly potentiated lpcs-evoked IPSCs. Baclofen (GABA(B)-R agonist) had similar depressant effects on local- and lpcs-evoked IPSCs, however baclofen pretreatment only reduced ethanol potentiation at local synapses. Ethanol also significantly enhanced the frequency of spontaneous and miniature IPSCs, and these effects were also sensitive to GABA(B)-R modulators. Collectively, these data suggest that stimulus-independent inhibitory responses recorded from BLA principal neurons primarily reflect the activity of local GABAergic interneurons and provide additional evidence that ethanol potentiates local BLA inhibitory synapses primarily via a presynaptic enhancement of GABA release that is tightly regulated by GABA(B)-Rs. In contrast, ethanol potentiation of lpcs GABAergic synapses is not sensitive to GABA(B)-R activation and does not appear to involve increased presynaptic GABA release.

Self-medication of anxiety disorders with alcohol and drugs: Results from a nationally representative sample

Self-medication--the use of alcohol or drugs in an attempt to reduce anxiety--has often been invoked as an explanatory mechanism for the high co-occurrence of anxiety and substance use disorders (for reviews, see Allan, C. A. (1995). Alcohol problems and anxiety disorders-A critical review. Alcohol & Alcoholism, 30(2), 145-151; Kushner, M. G., Abrams, K., & Borchardt. (2000). The relationship between anxiety disorders and alcohol use disorders: A review of major perspectives and findings. Clinical Psychology Review, 20(2), 149-171). The current study expands upon previous self-medication research by: (1) examining prevalence and comorbidity of self-medication for anxiety disorders (panic disorder, social phobia, specific phobia, and generalized anxiety disorder); (2) using a nationally representative sample (National Epidemiologic Survey on Alcohol and Related Conditions; N=43,093) to do so; and (3) by differentiating self-medication with alcohol from self-medication with drugs. Prevalence rates ranged from 18.3% (self-medication with alcohol for generalized anxiety disorder) to 3.3% (self-medication with both alcohol and drugs for specific phobia and panic disorder without agoraphobia). Multiple logistic regression analyses determined that self-medication with alcohol was associated with increased likelihood of any mood or personality disorder diagnosis, while self-medication with both alcohol and drugs further increased these associations over and above self-medication with alcohol alone. Findings remained significant after adjusting for sociodemographic and substance use disorder variables, which suggests that independently of substance use disorders, self-medication can be viewed as a marker of severity.

Levetiracetam for the treatment of co-occurring alcohol dependence and anxiety: case series and review

OBJECTIVES

Alcohol dependence is frequently associated with anxiety disorders. The exact nature of the relationship between alcohol dependence and anxiety disorders is unknown, but emerging evidence suggests that in a majority of cases, the anxiety disorder is independent of the alcohol use disorder. There is pre-clinical and clinical evidence that levetiracetam, a newer generation anticonvulsant medication, may be efficacious in the treatment of co-occurring alcohol use and anxiety disorders.

METHODS

In an open label clinical trial, three patients with alcohol dependence and a co-morbid anxiety disorder were treated with levetiracetam in doses up to 1500 mg twice daily for up to 8 weeks.

RESULTS

All three participants reported reductions in alcohol consumption and anxiety symptoms during the study period. Levetiracetam was generally well tolerated.

CONCLUSION

This study suggests that levetiracetam deserves further study in the treatment of alcohol dependence and co-occurring anxiety disorders.

Drinking for negative reinforcement: the semantic priming of alcohol concepts

Cognitive models of alcohol abuse posit that the context typically associated with alcohol use, such as negative affect, implicitly activates alcohol use cognitions, which in turn leads to alcohol consumption. We selected 40 undergraduate women based upon their alcohol use and reported anxiety sensitivity, and proposed that drinking for the purpose of negative reinforcement would predict increased semantic priming between anxiety and alcohol concepts. A lexical decision task compared the response latencies of alcohol targets preceded by anxiety words to those same targets preceded by neutral words (anxiety-alcohol priming). Level of anxiety sensitivity did not relate to anxiety-alcohol priming, but drinking following social conflict was associated with increased anxiety-alcohol priming. This study specifically suggests that the contextual antecedents to drinking behavior relate to the organization of semantic information about alcohol, and more generally supports cognitive models of substance abuse.

Early social isolation in male Long-Evans rats alters both appetitive and consummatory behaviors expressed during operant ethanol self-administration

BACKGROUND

Postweaning social isolation in rats produces profound and long-lasting cognitive and behavioral deficits in adult animals. Importantly, this housing manipulation alters sensitivity to a number of drugs of abuse including ethanol. However, most studies with ethanol have utilized continuous or limited home-cage access to examine interactions between juvenile social experience and drinking. More recently, social isolation was shown to increased ethanol responding in a "dipper" model of self-administration (Deehan et al., 2007). In the current study, we utilize a "sipper" operant self-administration model to distinguish the effects of isolation rearing on ethanol seeking- and drinking-related behaviors.

METHODS

Postweaning juvenile male Long-Evans rats were placed into 2 housing groups for 6 weeks: one group consisted of individually housed animals; the second group was housed 4 animals per cage. Following the isolation period, anxiety-like behavior was assessed to confirm the efficacy of the isolation procedure. In some animals, ethanol drinking in the home cage was assessed using a continuous access, 2-bottle choice paradigm. All animals were then individually housed and trained to lever-press for a sipper tube containing either an ethanol solution or a sucrose solution.

RESULTS

Postweaning social isolation increased the expression of anxiety-like behavior in the elevated plus maze but not the light-dark box. Ethanol consumption was also increased during continuous home-cage access with the 2-bottle choice paradigm. During operant self-administration, isolation housing increased the response rate and increased ethanol consumption but did not alter responding for or consumption of sucrose. The housing manipulation did not change the total number of lever responses during extinction sessions. Paired-pulse inhibition deficits that are characteristic of juvenile isolation remained intact after prolonged experience with sucrose self-administration.

DISCUSSION

The effects of postweaning social isolation on ethanol drinking in the home cage are also manifest during operant self-administration. Importantly, these alterations in adult operant self-administration are ethanol-specific.

Repeated stimulation of CRF receptors in the BNST of rats selectively induces social but not panic-like anxiety

Increased extra-hypothalamic corticotrophin-releasing factor (CRF) neurotransmission has been suggested as one putative factor in the pathophysiology of anxiety disorders. We have previously reported that administering repeated subanxiogenic doses (termed 'priming') of the CRF receptor agonist urocortin 1 (Ucn1) into the basolateral amygdala (BLA) of rats elicited long-lasting behavioral changes in social interaction (SI) and elevated plus maze (EPM) tests of anxiety. Although substantial similarity exists, the bed nucleus of the stria terminals (BNST) and the amygdala are thought to play distinct roles in anxiety responses. Rats primed with Ucn1 in the BLA not only demonstrated increased anxiety-like behaviors, but also physiological sensitivity to intravenous sodium lactate infusions, which is seen in subjects with panic or posttraumatic stress disorders, but not social or generalized anxiety disorders. In the present study, we tested if similar priming with subanxiogenic doses of Ucn1 in the BNST of rats will induce either chronic anxiety or sensitivity to sodium lactate. After determining the dose of Ucn1 that is subanxiogenic when injected into the BNST, repeated intra-BNST injections of this subanxiogenic dose of Ucn1 (6 fmol/100 nl) elicited persistent (present even after 4 weeks) anxiety-like responses in the SI but not EPM test. Prior local injection of a CRF receptor antagonist, astressin, into the BNST blocked this effect. Unlike Ucn1 priming in the BLA, rats primed in the BNST showed no cardiovascular changes following lactate infusion. Thus, BNST priming appears to selectively model the pathophysiology of subjects with anxiety syndromes like social anxiety, which are not lactate sensitive.

Anxiety disorders and risk for suicide attempts: findings from the Baltimore Epidemiologic Catchment area follow-up study

Our objective was to determine whether the presence of an anxiety disorder was a risk factor for future suicide attempts. Data were drawn from the 13-year follow-up Baltimore Epidemiological Catchment Area survey (n=1,920). Multiple logistic regression analysis was used to determine the association between baseline anxiety disorders (social phobia, simple phobia, obsessive-compulsive disorder, panic attacks, or agoraphobia) and subsequent onset suicide attempts. The presence of one or more anxiety disorders at baseline was significantly associated with subsequent onset suicide attempts (adjusted odds ratio 2.20, 95% confidence interval 1.04-4.64) after controlling for sociodemographic variables and all baseline mental disorders assessed in the survey. These findings suggest that anxiety disorders are independent risk factors for suicide attempts, and underscore the importance of anxiety disorders as a serious public health problem.

The effect of comorbid substance use disorders on treatment outcome for anxiety disorders

This study examined the impact of concurrent substance use disorders (SUDs) on outcomes for psychotherapy targeting anxiety disorders. Study 1 (N=484) sought to determine the prevalence of SUDs in a sample referred to a community anxiety disorders clinic, as well as the impact of comorbid SUDs on outcomes for a subsample (n=200) completing cognitive behavior therapy (CBT). Around one-quarter (22-29%) of patients with one or two anxiety disorders met criteria for at least one SUD, but this rate was substantially higher (46%) for patients with three anxiety disorders. Concurrent SUDs were associated with higher levels of anxiety but not depression or stress, compared to those without a SUD. However, concurrent SUDs did not moderate treatment outcomes. Study 2 (N=103) focused on the impact of alcohol use on diagnosis-specific symptom measures and generic measures of distress and disability, following a course of CBT for panic disorder or social phobia. Pre-treatment alcohol use did not predict changes in panic symptoms, performance anxiety, distress, or disability, but it did predict changes in social interaction anxiety. Problem drinking per se did not have any predictive utility in terms of treatment outcome. These findings suggest that clinicians treating patients for a primary anxiety disorder and concurrent SUD can be relatively optimistic about treatment outcomes.

Specificity of familial transmission of anxiety and comorbid disorders

This study examines the specificity and impact of comorbid disorders in probands on the familial transmission of panic and social anxiety disorders. It employs a contemporary family study design with 225 probands (with and without panic and social anxiety disorders) sampled from outpatient clinics and the local community. Their 1053 adult first-degree relatives were assessed for lifetime disorders, based on best estimate diagnoses derived from semi-structured psychiatric diagnostic interviews (Schedule for Affective Disorders and Schizophrenia), multi-informant family history information, and medical records. Generalized estimating equations were used to examine the familial aggregation of panic and social anxiety disorders, and the contributions of comorbid disorders. Results show specificity of familial aggregation of both panic disorder and social anxiety in probands and relatives (i.e., panic odds ratio=3.7, 95%CI 1.5-9.3; social anxiety odds ratio=1.8, 95%CI 1.1-2.9) after controlling for comorbid disorders. There was no contribution of common comorbid disorders (depression, alcoholism, generalized anxiety disorder and agoraphobia) in probands on the familial aggregation of either disorder. These findings confirm prior studies of specificity of familial transmission of panic and social anxiety disorders, and demonstrate that the association between these disorders in probands is not attributable to comorbid mood, anxiety or substance use disorders. Therefore, despite the high magnitude of co-occurrence of panic disorder and social anxiety, there may be distinct etiologic factors underlying each disorder. These findings have implications for studies of the etiology, genetics, and treatment of these disorders.

Ein Überblick über experimentelle Befunde zur Wirkung von Alkohol auf klinisch relevante Angst

Zusammenfassung. Hintergrund: Ein überzufälliger Zusammenhang zwischen Angststörungen und Alkoholproblemen ist belegt. Trotz zahlreicher Studien mit subklinischen Populationen ist die Befundlage zur anxiolytischen Wirkung von Alkohol jedoch uneindeutig. Fragestellung: Wirkt Alkohol bei klinisch relevanten Ängsten anxiolytisch? Welche Einflussfaktoren existieren und welche Mechanismen sind beteiligt? Methode: Ein Review empirischer Studien zur anxiolytischen Wirkung von Alkohol bei pathologischer Angst. Ergebnisse: Die Ergebnisse der 11 publizierten Studien werden dargestellt. Der Fokus liegt auf der Wirkung von Alkohol bei Sozialphobie (N = 7), Panikstörung (N = 3) und spezifischer Phobie (N = 1). Zusammenfassend ist eine anxiolytische Wirkung an eine Mindestmenge Alkohol (BAK: > 0.05%), positive Wirkungserwartungen sowie andere psychologische Faktoren gebunden. Diskussion: Die Selbstmedikationshypothese hat nur unter Berücksichtigung verschiedener biologischer und psychologischer Faktoren Bestand. Mögliche Implikationen für die Behandlung werden diskutiert.

Psychiatric comorbidity related to alcohol use among adolescents

INTRODUCTION

Alcohol use is apparently related to high prevalences of psychiatric comorbidity, although scientific studies focusing the problem among adolescents are still lacking.

OBJECTIVE

To evaluate the performance of adolescents with different patterns of alcohol use on screening instruments for psychiatric disorders.

METHOD

Forty-one adolescents seeking assistance for alcohol-related problems were compared to a nonclinical sample of 43 adolescents. These 84 users were divided in three sub-groups according to pattern of recent alcohol intake. All subjects responded to validated versions of screening scales for mental disorders. Comparison of groups was held through Analysis of variance (ANOVA).

RESULTS

Self Report Questionnaire (SRQ) aims to evaluate the presence of mental disorders. Heavy users presented significant higher scores than the other groups (p < .05) and half of them presented a psychiatry diagnosis. The same was observed for the CES-D. Using the cut-off, 76.9% of daily-users adolescents were considered depressive. In the Beck Anxiety Inventory the same was observed and 50.0% of those adolescents who drank daily could be considered at risk of presenting anxiety disorders.

CONCLUSION

We detected higher prevalences of mental disorders among heavy alcohol users. This reinforces the importance of detailed diagnostic investigation of patients.

Early ethanol consumption predicts relapse-like behavior in adolescent male rats

BACKGROUND

Alcohol abuse disorders emerge over time with repeated consumption of ethanol, but not all ethanol drinkers develop these disorders. There are pre-existing characteristics that indicate which drinkers are most likely to abuse alcohol. Adolescence, novelty seeking, and high stress reactivity are among the characteristics of the most vulnerable individuals. In addition, an individual's response to his or her first exposure to the drug influences future consumption. We assessed an array of behavioral and hormonal characteristics in adolescent (28-day-old) male rats before exposure to ethanol, and then determined which rats were most prone to high levels of alcohol drinking.

METHODS

The assessments consisted of measures of anxiety (elevated plus maze), response to novelty (open field locomotion, novel object exploration), and circulating corticosterone levels after mild restraint and after the elevated plus maze task. After this test battery, the rats were placed in lickometer cages nightly (5 pm to 9 am) for evaluation of fluid consumption. Rats were first habituated to the cages with water in the lickometer bottles, and then given 10% (v/v) ethanol for 3 nights as the only available fluid. After this forced ethanol exposure, the rats were allowed to choose between 8% ethanol and water for 10 consecutive nights. After 2 nights of abstinence, the rats were again placed in the lickometer cages and given a choice between 8% ethanol and water to assess ethanol consumption in response to alcohol deprivation, a measure of relapse-like behavior.

RESULTS

Ethanol consumption on the third day of forced consumption was significantly correlated with ethanol consumption on days 8 to 10 of the choice phase, which in turn was significantly correlated to relapse-like consumption. Preference for ethanol was also significantly correlated with early consumption. Novel object exploration, open field activity, open arm time in the elevated plus maze, initial water consumption, and circulating corticosterone levels did not significantly predict deprivation-stimulated consumption.

CONCLUSIONS

These results suggest that consumption during early exposure to ethanol establishes a pattern leading to development of increased alcohol consumption and preference in adolescent male rats. In addition, they represent an animal model of the well-described observation that humans who consume large quantities of ethanol during early exposure are the most likely to repeat heave drinking behavior. Furthermore, early consumption is distinct from novelty seeking, anxiety, and stress hormone levels which are also thought to contribute to vulnerability to alcoholism.

The role of drinking motives in social anxiety and alcohol use

Although social anxiety and problem drinking commonly co-occur, the relationship between social anxiety and drinking among college students is not well understood. The current study examined the relationship between drinking motives, or reasons for drinking, and social anxiety in 239 volunteers. Contrary to hypotheses, high (n=83), moderate (n=90), and low (n=66) social anxiety groups did not differ in endorsement of coping and conformity drinking motives. Further, social anxiety was negatively related to weekly alcohol use and unrelated to alcohol-related problems. Post hoc hierarchical multiple regression analyses conducted for each social anxiety group indicated that coping motives were related to greater alcohol use and problems for those in the high and moderate social anxiety groups, but not for the low social anxiety group. It appears that drinking motives, particularly coping motives, have promise in providing a greater understanding of the social anxiety-drinking relationship. Drinking motives could aid in identification of socially anxious students at risk for alcohol problems and inform intervention strategies.

Panic disorder, trait anxiety, and alcohol use in pregnant and nonpregnant women

OBJECTIVE

The present study examined differences in rates of panic disorder and trait anxiety in pregnant and nonpregnant women receiving care at an urban obstetrics and gynecology clinic. The study further examined correlates and differences in alcohol use among these women. In addition, the study assessed whether panic disorder and trait anxiety influence alcohol use and whether pregnancy status moderates these associations.

METHODS

The sample consisted of 412 pregnant and 139 nonpregnant women receiving care at Virginia Commonwealth University (VCU) Health Systems' obstetrics and gynecology clinics for the first time. Participants completed a questionnaire packet, including instruments about emotional and psychologic functioning (eg, panic disorder, anxiety), health-related behaviors (eg, alcohol use), and demographic information.

RESULTS

Pregnant women were less likely than nonpregnant women to have panic disorder. There were no differences in trait anxiety levels between pregnant and nonpregnant women. After controlling for demographics, panic disorder and trait anxiety were significant predictors of greater alcohol use in pregnant and nonpregnant women. An interaction revealed that pregnant and nonpregnant women with low trait anxiety had similar levels of alcohol use; however, nonpregnant women with high trait anxiety consumed significantly more alcohol than pregnant women with high trait anxiety.

CONCLUSIONS

Current study findings support the need to examine panic disorder and trait anxiety as potential risk factors for alcohol use among pregnant and nonpregnant women in the community. Findings have important implications for assessment and treatment of panic, anxiety, and alcohol use.

Psychometric evaluation of the five-factor Modified Drinking Motives Questionnaire--Revised in undergraduates

The psychometric properties of the Modified Drinking Motives Questionnaire--Revised (Modified DMQ-R) [Blackwell, E., & Conrod, P. J. (2003). A five-dimensional measure of drinking motives. Unpublished manuscript, Department of Psychology, University of British Columbia], based on a five-factor model of drinking motives with separate coping-anxiety and coping-depression factors, were evaluated in undergraduates. In Study 1, confirmatory factor analyses supported the correlated five-factor model in two samples of undergraduate drinkers (N=726 and N=603). Furthermore, the five-factor model fit the data better than a four-factor model conceptually equivalent to that of Cooper [Cooper, M. L. (1994). Motivations for alcohol use among adolescents: Development and validation of a four-factor model. Psychological Assessment, 6, 117-128] (i.e., with coping-anxiety and coping-depression items constrained to a single factor). In Study 1, drinking motives were predictive of concurrent drinking frequency and typical number of alcoholic beverages per occasion, over and above demographics. In Study 2, the Modified DMQ-R scores showed good to excellent test-retest reliability in a sample of undergraduates who were relatively frequent drinkers (N=169). Also, drinking motives prospectively predicted number of drinks consumed per week and alcohol-related problems, over and above demographics and initial alcohol use. Notably, coping-anxiety and coping-depression motives were distinctly related to alcohol consumption and alcohol problems.

Alcohol use and prior substance abuse treatment in relation to gambling problem severity and gambling treatment outcome

Recent research has made it clear that problematic gambling is often accompanied by problematic alcohol use. Unfortunately, little is known about the nature of this association, especially as it relates to gambling treatment outcome. The purpose of this study is to explore the effect of current alcohol use level and previous substance abuse treatment on the symptoms of a large cohort of pathological gamblers as well as on their response to treatment for pathological gambling. The sample included 464 men and 301 women recruited at six gambling treatment programs in Minnesota. Gambling treatment patients were assessed on a number of gambling problem severity and related clinical variables using the Gambling Treatment Outcome Monitoring System (GAMTOMS). Patients with frequent alcohol use had greater gambling involvement at baseline than infrequent alcohol users. Patients with a previous history of substance abuse treatment had more severe psychosocial problems, ostensibly resulting from their gambling behavior, than patients without past substance abuse treatment. A MANOVA with repeated measures showed that neither pretreatment alcohol use, nor past substance abuse treatment exerted significant effects on gambling treatment outcome. While the level of pretreatment alcohol use and a history of substance abuse treatment are markers for greater gambling problem severity, treatment outcome for pathological gambling was not adversely impacted by these variables.

Long-term ethanol self-administration by the nonhuman primate, Macaca fascicularis, decreases the benzodiazepine sensitivity of amygdala GABA(A) receptors

BACKGROUND

Rodent models of chronic alcohol exposure are typically constrained to relatively short periods of forced ethanol due to the lifespan of these animals. Nonhuman primate models, particularly those employing long-term self-administration, are conceptually more similar to human alcoholic individuals.

METHODS

We performed whole-cell patch clamp recordings on acutely dissociated amygdala neurons isolated from cynomolgus macaque coronal temporal lobe slices. Slices were prepared from control monkeys or monkeys allowed to self-administer oral ethanol for 18 months. Flunitrazepam and acute ethanol modulation of currents gated by exogenous gamma-aminobutyric acid (GABA) application was assessed in these isolated neurons. Complementary experiments were performed on amygdala total RNA using quantitative real-time reverse transcription/polymerase chain reaction to understand potential ethanol-dependent adaptations to subunit composition.

RESULTS

Gamma-aminobutyric acid-gated currents from ethanol-exposed macaque amygdala neurons exhibited reduced modulation by flunitrazepam compared with control neurons. However, this was specific for benzodiazepines as the modest inhibition of GABA-gated currents by acute ethanol was not affected by the chronic ethanol consumption. We also measured mRNA expression levels for the beta, gamma, and delta subunits in total amygdala RNA isolated from control and ethanol-drinking animals. beta1 and gamma2 expression was significantly reduced in samples from ethanol-exposed amygdala.

CONCLUSIONS

Our findings demonstrate that chronic ethanol self-administration reduces the benzodiazepine sensitivity of amygdala GABA(A) receptors. This reduced sensitivity may be the result of decreased expression of an amygdala gamma subunit. These findings suggest that, while rodent and nonhuman primate models of chronic ethanol exposure share many characteristics, the specific molecular adaptations associated with the amygdala GABAergic system may not be identical.

Perceived health moderates the association between smoking rate and panic vulnerability variables among daily smokers

Our aim in this investigation was to evaluate the moderating role of perceived health in the relation between smoking rate and panic variables in a community-based sample of 220 daily smokers (98 females; M(age)=23.76 years, SD=8.76). As hypothesized, the interaction between smoking and perceived health incrementally predicted anxiety sensitivity (fear of anxiety) and anxious arousal symptoms, but not depressive symptoms. Individuals who had higher smoking rates and lower perceived health reported higher levels of anxiety sensitivity and anxious arousal, but not depressive symptoms. The primary implication of these findings is that there may be segments of the cigarette smoking population who are at relatively greater risk for anxiety symptoms and fear of bodily sensations by virtue of individual differences in perceived health. The identification of such moderating effects is clinically important, because it helps to refine our understanding of complex associations between drug behavior and panic vulnerability.

Anxiety disorders and their clinical correlates in multiple sclerosis patients

OBJECTIVE

To assess prevalence rates and clinical correlates of anxiety disorders in patients with multiple sclerosis (MS).

METHODS

Demographic and neurological data were collected on 140 consecutive clinic attendees, and their lifetime and point prevalences of anxiety disorders were determined with the Structured Clinical Interview for DSM-IV disorders (SCID-IV). All subjects completed the self-report Hospital Anxiety and Depression Scale (HADS). Suicidal intent was rated with the Beck Suicide Scale (BSS), psychosocial stressors and supports were quantified with Social Stress and Support Interview (SSSI), and cognition assessed with Neuropsychological Screening Battery for MS.

RESULTS

The lifetime prevalence of any anxiety disorder was 35.7%, with panic disorder (10%), obsessive compulsive disorder (8.6%), and generalized anxiety disorder (18.6%), the most common diagnoses obtained. Subjects with an anxiety disorder were more likely to be female, have a history of depression, drink to excess, report higher social stress and have contemplated suicide. The diagnosis of an anxiety disorder had been missed in the majority of subjects, therefore, they had not received treatment. A discriminant function analysis identified a series of variables that correctly classified 75% of patients with an anxiety disorder.

CONCLUSION

Anxiety disorders are common in patients with MS, but are frequently overlooked and under-treated. Risk factors include being female, a co-morbid diagnosis of depression, and limited social support. Clinicians should evaluate all MS subjects for anxiety disorders, as they represent a treatable cause of disability in MS.

The type 1 equilibrative nucleoside transporter regulates anxiety-like behavior in mice

Activation of adenosine receptors in the brain reduces anxiety-like behavior in animals and humans. Because nucleoside transporters regulate adenosine levels, we used mice lacking the type 1 equilibrative nucleoside transporter (ENT1) to investigate whether ENT1 contributes to anxiety-like behavior. The ENT1 null mice spent more time in the center of an open field compared with wild-type littermates. In the elevated plus maze, ENT1 null mice entered more frequently into and spent more time exploring the open arms. The ENT1 null mice also spent more time exploring the light side of a light-dark box compared with wild-type mice. Microinjection of an ENT1-specific antagonist, nitrobenzylthioinosine (nitrobenzylmercaptopurine riboside), into the amygdala of C57BL/6J mice reduced anxiety-like behavior in the open field and elevated plus maze. These findings show that amygdala ENT1 modulates anxiety-like behavior. The ENT1 may be a drug target for the treatment of anxiety disorders.

Paroxetine reduces social anxiety in individuals with a co-occurring alcohol use disorder

Patients with social anxiety disorder who are seen in clinical practice commonly have additional psychiatric comorbidity, including alcohol use disorders. The first line treatment for social anxiety disorder is selective-serotonin-reuptake-inhibitors (SSRIs), such as paroxetine. However, the efficacy of SSRIs has been determined with studies that excluded alcoholics. Forty two subjects with social anxiety and a co-occurring alcohol use disorder participated in a 16-week, double-blind, placebo-controlled clinical trial to determine the efficacy of paroxetine for social anxiety in patients with co-occurring alcohol problems. Paroxetine was superior to placebo in reducing social anxiety, as measured by the Liebowitz Social Anxiety Scale total and subscale scores and additional measures of social anxiety. This study provides the first evidence-based recommendation for the use of an SSRI to treat social anxiety in this patient population.

Anxiety disorders: treatable regardless of the severity of comorbid alcohol dependence

AIMS

Clinical and epidemiological research has shown that comorbidity is the rule rather than exception in the case of psychiatric disorders. Cognitive behavioral therapy (CBT) has been clearly demonstrated to be effective in treating anxiety and avoidance symptoms in patient samples of social phobia and agoraphobia without comorbid alcohol use disorders. It has recently been shown that treatment of comorbid anxiety disorders in alcohol-dependent patients can also be very successful. The purpose of the present study was to find predictors of treatment success for comorbid anxiety disorders in alcohol-dependent patients.

METHODS

The study was conducted in a sample of 34 completers with a double diagnosis of alcohol dependence and agoraphobia or social phobia who received CBT for their comorbid anxiety disorder in a 32-week randomized controlled trial comparing alcohol and CBT anxiety disorder treatment with alcohol treatment alone. In the current report, treatment success was defined as a clinically significant change (recovery) on the anxiety discomfort scale.

RESULTS

The severity of comorbid alcohol dependence did not influence the beneficial effect of CBT on the anxiety disorder. Psychological distress (SCL-90), neuroticism (NEO N), conscientiousness (NEO C), gender, employment and age of onset of alcohol dependence showed some predictive value.

CONCLUSIONS

Alcohol-dependent males with a comorbid anxiety disorder seem to benefit most from CBT if their alcohol dependence started after age 25, if they are employed and if their general psychopathology is less severe. The most important conclusion, however, is that even severely alcohol-dependent patients with an anxiety disorder can benefit from psychotherapy for their anxiety disorder.

Origin of the comorbidity of anxiety disorders and alcohol dependence: findings of a general population study

A representative general population sample (n = 7,076) was used to study retrospectively and prospectively the nature of the relationship between co-morbid alcohol dependence and anxiety disorders. Four different models were tested: (1) anxiety disorders increase the risk of alcohol dependence; (2) alcohol dependence increases the risk of anxiety disorders; (3) family history or childhood traumatisation increase the risk of both alcohol dependence and anxiety disorders, and (4) comorbid conditions are a separate psychopathological entity. The data show that alcohol dependence does not precede the onset of anxiety disorders, that anxiety disorders do precede the onset of alcohol dependence, that family history is not very likely to be the third factor explaining the elevated comorbidity, and that in women childhood trauma might be partially responsible for the association between both disorders. The data are inconsistent with regard to comorbidity as a distinct psychopathological entity. These findings are of great importance for treatment planning in patients with alcohol dependence and comorbid anxiety disorders.

Gender differences in the relationship between alcohol use and anxiety symptoms among Nigerian college students

Few studies have addressed the effect of gender on the relationship between alcohol and anxiety. Students in a Nigerian university, grouped into five separate categories of alcohol use completed the Zung's Self Rating Anxiety Scale. Although a non-linear "J shaped" relationship was found between alcohol use and anxiety symptoms among males, a linear relationship was found among females. Women tend not to share the positive effect moderate alcohol use confers on anxiety status. This gender difference may be an important consideration when planning preventive strategies for alcohol related problems in Nigerian youths.

Chronic hydrocephalus and alcohol abuse in a young male suicide

The paper describes a case of suicide in a young man affected by compensated chronic hydrocephalus who was subject to alcohol abuse. The case was studied by means of a complex set of analyses, including circumstantial and clinical data, anatomohistopathological findings, and chemicotoxicologic tests. What clearly emerges in the case is the importance of a continuing neuropsychological follow-up in patients with shunted hydrocephalus. The forensic interest in the case is due to the peculiar autopsy findings discussed in relation to the possible causes of sudden death in subjects with hydrocephalus.

Use of alcohol and drugs to self-medicate anxiety disorders in a nationally representative sample

This study examined the prevalence and correlates of self-medication of anxiety disorders with alcohol and drugs in a nationally representative sample (N = 5877). A modified version of the Composite International Diagnostic Interview was used to make DSM-III-R mental disorder diagnoses. Frequencies of self-medication ranged from 7.9% (social phobia, speaking subtype) to 35.6% (generalized anxiety disorder). Among respondents with an anxiety disorder, self-medication was significantly associated with an increased likelihood of comorbid mood disorders, substance use disorders, distress, suicidal ideation, and suicide attempts. Self-medication behavior remained significantly associated with an increased likelihood of suicidal ideation (adjusted odds ratio = 1.66; 1.17-2.36) as well as suicide attempts (adjusted odds ratio = 2.23; 1.50-3.31), even after adjusting for a number of sociodemographic and psychiatric variables. These results suggest that individuals with anxiety disorders who self-medicate their symptoms with alcohol or drugs may be at increased risk for mood and substance use disorders and suicidal behavior.

Symptoms of traumatic stress and substance use in a non-clinical sample of young adults

The link between symptoms of traumatic stress and substance abuse is well established in the literature, but the specific features of trauma that contribute to substance abuse remain elusive and have not been studied in non-clinical samples. The current study assessed the relationship between traumatic symptoms and alcohol use in a sample of Midwestern college students. Using multiple regression analysis, traumatic stress symptoms, overall, accounted for 55% of the variance in use of alcohol. Most importantly, dissociative behavior, intrusive thoughts, as well as low levels of tension reduction behaviors uniquely contributed to the self-reported use of alcohol. We discuss the importance of educating college-aged students about this relationship as a preventative measure to alcohol and other drug use/abuse.