Research paper

! 4 Anxiety and Substance Abuse

college students (e.g., Buckner et al., 2006; Gilles et al., 2006; Lewis & O’Neill, 2000 as cited in

Terlecki, et al., 2011).

In order to appropriately understand the data presented in the articles in accordance with

human development, Erik Erikson’s psychosocial theory will be utilized as a central framework.

Being that there are eight stages in his theory, the primary stage correlating with the research

question is the adolescent stage of identity versus role confusion. The assumed age range for an

individual experiencing this conflict is eleven through eighteen. The central objective for

succeeding in this stage is exploration, allowing adolescents to decide who they are, what they

value, and how they fit into society. Role confusion can easily lead to social anxiety, possibly

resulting in a harmful form of exploration such as substance use.

Erikson’s Psychosocial Theory

Erik Erikson, a stage theorist who studied Sigmund Freud’s principles, presented a

psychosocial theory involving eight stages of development. Specific ages for the entering and

exiting of each stage were not provided, although ages can be assumed, emphasizing Erikson’s

belief that each individual is unique and will encounter the approaching stage when

developmentally ready (Newman & Newman, 2009). Each stage concerns a conflict involving

biological, psychological, and societal development such as trust versus mistrust or identity

versus role diffusion. While attempting to emotionally and socially adjust to the new stage

approached, psychosocial crises are sparked by novel cultural pressures and expectations

(Newman & Newman, 2009). Crises do “interfere with growth and reduce one’s opportunities to

experience personal fulfillment”; however, an individual may be able to advance to the next

stage without normally developing in the previous stage, later reflecting on the difficulties of the

! 5 Anxiety and Substance Abuse

prior stage (Newman & Newman, 2009, p. 216). This concept is crucial because an individual

who struggles with forces such as mistrust, shame, and guilt, is able to recollect experiences as a

child or adolescent that may have assisted in negative developmental progressions.

Erikson’s Psychosocial Theory: Mechanism

One of Erickson’s primary principles or mechanisms of his psychosocial theory is the

radius of significant relationships (Newman & Newman, 2009). Through social relationships,

regardless of the developmental stage, cultural ideas and expectations are enforced. In early

childhood, significant relationships generally only include parents and siblings, whereas during

adolescence, teenagers begin expanding their social circles and incorporating close friends as

meaningful persons in their lives. As stronger relationships form with those other than

immediately family members, intimacy begins to develop and the adolescent now views him/

herself as a member of a group of peers; “this network of relationships determines the demands

that will be made on the person” (Newman & Newman, 2009, p. 220). Group affiliation

influences each person’s identity and the ways in which they combat the psychosocial crises

encountered at each stage. For instance, if three of an adolescent's closest friends begin

experimenting with alcohol use upon high school entrance, this adolescent may also begin

experimentation due to fear of relationship loss during the complicated stage of identity versus

role confusion. Social relationships are crucial to each stage of development; however, peer

influence and acceptance is especially pivotal during adolescent crises.

Defining Social Anxiety and Substance Use

Social anxiety, the independent variable, is characterized by intense and/or persistent fear

or avoidance of social scrutiny (American Psychiatric Association, 1994 as cited in Terlecki, et

! 6 Anxiety and Substance Abuse

al., 2011). To determine level of social anxiety among participants, Terlecki, et al., (2011),

utilizes the Social Phobia Scale, assessing the adolescent’s fears of social scrutiny when

completing daily activities such as eating and drinking. Heavy alcohol consumption is

characterized by more than five drinks per sitting for men and four for women (Terlecki, et al.,

2011). Wu, et al., (2010) furthers the definition of substance use and considers cigarettes, heavy

drinking, and illicit drug use when defining the dependent variable of substance use. Examples

of illicit drug use include marijuana, cocaine, and heroin. Wu, et al., (2010) defines a frequent

smoker as an adolescent who has smoked at least one cigarette every day for the past six months,

a frequent/heavy drinker has had at least one drink or becomes drunk once per week, and an

illicit drug user has experimented with an illicit drug in the past year. Social anxiety is

determined based on the information gained though the Diagnostic Interview Schedule for

Children (DISC), meeting the DSM-III-R criteria, and indicating diagnosis-specific impairment

(Wu, et al., 2010). Although the means of measuring social anxiety differs between articles, the

definition of social anxiety remains consistent in both. Despite the fact that Wu, et al. (2010)

utilizes a broader definition of substance use, any sense altering substance is likely to be used in

greater quantity by those struggling with social anxiety disorder; however, alcohol use may be

most common due to convenient access.

Past Study 1

The purpose of the study conducted by Wu et al. (2010) is to determine the relationships

between specific anxiety disorders and substance use behaviors, while incorporating gender

differences among adolescents in a community setting. Prior studies have conducted research on

community dwelling adults, discovering that anxiety and substance use disorders are positively

! 7 Anxiety and Substance Abuse

related; however, few studies have been conducted on adolescents within the community, and

even fewer demonstrated consistent results when comparing by gender (Christie et al., 1988;

Brook et al., 2004 as cited in Wu et al., 2010). There was one particular past study of

adolescents in the Great Smokey Mountains region examining childhood anxiety disorders in

relation to alcohol. This study found that adolescents with anxiety disorder were more likely to

abuse alcohol, while those with separation anxiety demonstrated a decreased risk of alcohol use

(Kaplow et al., 2001 as cited in Wu et al., 2010). The Kaplow study does present some valuable

information; however, gender differences were not examined and only adolescents from one

small area participated, prevented the possibility of generalizability. The Wu et al. (2010) study

is unique because it examines three different forms of substance use, smoking, drinking, and

illicit drug use, in correlation with six different anxiety disorders, although this research paper is

primarily concerned with social anxiety.

The independent variables are both gender and anxiety disorders, while the dependent

variable is substance use, specifically smoking, drinking, and illicit drug use. The participants

include 481 adolescents ages 9-17 from Connecticut, Georgia, New York, and Puerto Rico. The

mean age is 15. 369 participants are girls, 49% white, 17% African American, and 27%

Hispanic. 412 are boys, 49% white 17% African American, and 29.4% Hispanic. 4.4% of boys’

and 6% of girls’ parents have struggled with drug and alcohol problems. Parental drug use may

not appear to be an essential fact; however, it has been proven that there is a genetic link to

addiction, making this piece of information crucial. If a large percentage of adolescents reported

having parents with substance abuse problems, the validity of the population studied would

! 8 Anxiety and Substance Abuse

decrease because these adolescents would be more inclined to also struggle with substance

abuse, but this does not appear to be a concern in this study.

As explained briefly in the “defining social anxiety and substance use” section of the

paper, the assessment to measure the variable of social anxiety was gained through the

Diagnostic Interview Schedule for Children (DISC), which consisted of three hour interviews

with one child and one parent or guardian in each household. To further diagnose an individual

with anxiety, he/she would have to meet the DSM-III-R criteria, and indicate diagnosis-specific

impairment. Substance abuse information gained through interviews asks questions regarding

the number of times per week the adolescent had become intoxicated or consumed 5 drinks (5 for

men and 4 for women) on one occasion, the regularity of cigarette smoking, and the regularity of

non-medical illicit drug use.

The hypothesis presents the idea that if adolescent girls demonstrate more anxiety

disorders, then they will show greater patterns of substance use. In terms of the results, girls

show highly significant data at .001 for any anxiety disorder. No significant associations were

found for boys between frequent/heavy drinking and anxiety disorders when controlling for

demographic and familial factors. For girls, frequent or heavy drinking was significantly

associated with any anxiety disorder. For boys, OCD was the only anxiety disorder significantly

associated with drug use with a significance of .05. Boys with social anxiety were significantly

more likely to be smokers, while girls with social anxiety appeared to be less likely to smoke.

From these results, it is clear that the type of substances used do vary based on gender; however,

girls appear more likely to turn to alcohol to cope with social anxiety.

! 9 Anxiety and Substance Abuse

Wu et al. (2010) poses a few possible explanations for the significant data that resulted: it

may be that boys are more susceptible than girls to engaging in tobacco use in response to the

self-presentation concerns, and high rates of habit-based, repetitive, and ritualized behaviors that

typically accompany OCD may place girls who are afflicted with OCD at greater risk of

converting casual substance use into habit-based substance misuse (Wu et al., 2010). Although

OCD is not the disorder that was intended to be examined in this research paper, it is very

possible that OCD is highly correlated to social anxiety. Reliability statistics are not provided in

this article, however several correlations were proven highly statistically significant. Overall, the

implications of the study involve the importance of recognizing and treating childhood anxiety

disorders, especially among girls, in order to help them to avoid developing secondary substance

use disorders.

Past Study 2

The purpose of the second study, conducted by Terlecki, et al. (2011), is to evaluate the

impact of social anxiety on a college alcohol intervention program, BASICS, which is the

experimental group, in comparison to a control group who did not receive any treatment.

BASICS stands for The Brief Alcohol Screening and Intervention for College Students. Students

were randomly assigned to either a control or experimental group. The independent variable is

once again social anxiety and the dependent variable is substance use, specifically alcohol use

reported when participating in BASICS training. Past studies have discovered that social anxiety

disorder is related to alcohol dependence and abuse; however, this particular study examines the

impact of a brief alcohol treatment using social norms feedback among socially anxious heavy

! 10 Anxiety and Substance Abuse

drinking students, which no existing study has conducted (Kessler et al., 1997 as cited in Terlecki

et al., 2011).

Social anxiety is judged based on the Social Phobia Scale (SPS) as well as the

Spielberger Trait Anxiety Inventory (STAI). SPS is highly reliable at .93 and measures student’s

feelings of social scrutiny when completing routine activities such as eating or drinking. STAI is

also reliable at .87, and demonstrates excellent convergent validity. There are four measures

used to determine alcohol consumption: Alcohol Use Disorders Identification Test (AUDIT), the

Daily Drinking Questionnaire, Quantity/Frequency/Peak Index, and Rutgers Alcohol Problem

Index (RAPI). AUDIT is a ten item self-report measure ranging from 0-40, 6 or higher

indicating higher risk drinking. This measure is reliable at .84. The Daily Drinking

Questionnaire is another self-reported measure that utilizes the Likert-scale to ask questions

regarding the influence of drinking on daily life, numbers differing based on gender. Quantity/

Frequency/Peak Index is another self-report measure that asks the number of drinks consumed

during one occasion in the past month, then provides several options such as 0, 1-2, 3-4, 5-6, and

6 or more. Lastly, RAPI is a 23 item self-report measure of the negative consequences of alcohol

consumption. The range for each question is 0-4 with a maximum score of 92. Reliability for

this measure is .92.

Participants include 70 undergraduate college students ranging from 18 to 24 years of age

who attend a large, public, southern university. 75% have been diagnosed with social anxiety

disorder according to SPS. 26% demonstrate high social anxiety and 44% low social anxiety. 38

individuals are placed in the experimental category and receive BASICS training. BASICS

training asks participants to record their daily drinking habits, later motivating the student to

! 11 Anxiety and Substance Abuse

decrease use, therefore developing a discrepancy between use patterns and feeling toward

alcohol consumption. The remaining 32 participants occupy the control group, which does not

receive treatment. 85.7% are white, with a mean age of 20.5 years old. 68.6% are males, 64.3%

upper classmen, 74.3% live off campus, and 37.1% are members of the Greek system.

The hypothesis presented argues that if students score on the higher end of the social

anxiety scale, then BASICS treatment will be less effective in reducing typical alcohol use.

According to the results, those with higher social anxiety, report significantly (.007) heavier

typical drink habits during the post test than students with low social anxiety when controlling

for baseline typical drinks, trait anxiety, and whether or not they receive referral or volunteered

to enter the program. The BASICS group demonstrates significant results at .04, showing lower

weekly alcohol consumption and alcohol-related problems during the follow-up session than the

control group. Possible reasons for the results include the authors belief that those with high

social anxiety may have responded to the intervention in a socially favorably way to avoid

scrutiny for reporting numerous alcohol problems, regular heavy alcohol use, or not changing

drinking behavior after receiving the intervention, as well as the possibility that students who had

preexisting concerns about their drinking behavior could have self-selected into the study

(Terlecki et al, 2011).

This study is particularly important because it notes not only the high correlation between

social anxiety and substance use, but it provides information as to the types of programs that may

be helpful when working with students of different anxiety levels. Both social anxiety and

substance abuse are very commonly reported among college students; therefore, it is important to

! 12 Anxiety and Substance Abuse

know implications of practice, specifically the tactics and programs that actually do work when

attempting to decrease the regularity of these disorders.

Comparison of Past Study 1 and Past Study 2

The Wu et al. (2010) and Terlecki et al. (2011) studies are similar in that both articles

utilize the independent variable of social anxiety and the dependent variable of substance use,

acknowledging the high correlations that previous studies have proven. Each study presents an

additional variable to contribute to the uniqueness of their research. Wu focuses on gender,

whereas Terlecki introduces a training and control group and conducts an experiment. Wu also

did not include any information regarding reliability, causing some skepticism when reviewing

the displayed results. The ages of participants also differed slightly in each article. Wu

researches adolescents ages 9 through 17, while Terlecki focuses on those 18-24 years of age.

Although 18-24 is not necessarily considered adolescence, it is young adulthood, a time in which

much self discover occurs, especially when going away to college. When taking both articles

into consideration, it becomes clear that earlier developmental stages do influence future

development, and high social anxiety, especially in girls, puts adolescents and young adults at

greater risk of substance abuse. Implications include the importance of diagnosing and

appropriately treating anxiety disorders during childhood, therefore, preventing comorbid

substance use disorders and failed treatment methods during late adolescence and young

adulthood.

Conclusion

Although much research has been conducted in reference to anxiety disorders and

substance use, the objective of this paper is to not only to examine this relationship with the

! 13 Anxiety and Substance Abuse

assistance of two peer reviewed articles, but to consider the stage of development that

participants are facing during adolescence and young adulthood according to Erik Erikson’s

psychosocial theory. Despite the fact that every individual is unique and enters developmental

stages when appropriate, adolescents who experience high levels of social anxiety are at a greater

risk of substance abuse. This fact highlights the importance of adequately diagnosing and

treating children who struggle with social anxiety before they enter the stage of adolescence and

begin their period of exploration. The best method to prevent substance dependence and

addiction is to address the underlying difficulty at hand before allowing time for self-medication

or negative social interactions to occur.

!!!!!!!!!!! References !

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. ! Breaux, J. J. (2009). James Marcia and the four identity statuses theory. Helium, Inc. Retrieved from http://www.helium.com/items/1560359-marcias-four-identity-statuses. ! Brook, J. S., Cohen, P., & Brook, D. W. (1998). Longitudinal study of co-occurring psychiatric 
 disorders and substance use. Journal of the American Academy of Child and Adolescent 
 Psychiatry, 37(3), 322–330. !