20% of People With Social Anxiety Have Alcohol Use Disorder Too: Here’s Why

Social anxiety and alcohol use disorder are two of the most common behavioral health conditions in the United States. About 7% of Americans have a social anxiety disorder diagnosis, while 8.5% have an alcohol use disorder diagnosis.1

These conditions also have a high rate of co-occurrence. An estimated 20% of people with social anxiety disorder also have alcohol use disorder.2

How Are Social Anxiety and Alcohol Use Disorder Related?

Social anxiety disorder is characterized by several factors, including:1

  • Fear of one or more social situations
  • Fear of humiliation or embarrassment in a social setting
  • Social fears that are disproportionate to the actual threat of the situation
  • Social fears that cause significant distress and impairment in one’s life and last for six months or more

Social anxiety disorder may or may not include the presence of panic attacks

Many people experience nonclinical social anxiety, exhibiting some symptoms but not enough to meet the criteria for a diagnosis.1 This type of anxiety may occur before you attend a party where you don’t know many people or give a presentation to company executives. However, nonclinical social anxiety symptoms respond to the realities of the situation. You may relax once you start having a conversation at the party or get into the flow of your presentation.

Clinical social anxiety is disproportionate to the realities of a situation and, in these examples, may prevent you from attending parties even with close friends or collaborating on projects where you may be asked to present information to your coworkers.

An estimated 70-80% of people with social anxiety disorder meet the criteria for additional diagnoses, with alcohol use disorder being one of the most common.3 A diagnosis of social anxiety tends to come before other diagnoses. This pattern is thought to occur because the symptoms of social anxiety facilitate the onset of other symptoms.

With substance use disorders, for example, social anxiety may contribute to substance use and dependence that can develop into addiction.

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Self-Medication

A high number of people with social anxiety report using alcohol to cope with anxiety symptoms.2 This pattern of behavior is sometimes known as “self-medicating.” However, because chronic alcohol misuse can lead to physical and psychological dependence over time, self-medication may turn into a pattern of needing alcohol to feel that you can function normally rather than using alcohol to feel less anxious.

Tension Reduction Hypothesis

One theory about people’s motivations for alcohol consumption can help explain why social anxiety and alcohol use are so closely correlated.2 Called the tension reduction hypothesis, this theory speculates that alcohol provides negative reinforcement for social situations.2

In other words, when you use alcohol before or during fear-inducing social situations, you may have fewer unwanted feelings. This pattern of tension reduction makes it more likely that you will use alcohol to reduce fear and anxiety around social situations again in the future.2

Anxiety-Intoxication Loop

While alcohol is often used to self-medicate the symptoms of anxiety, some research suggests that the pharmacological makeup of alcohol could actually increase stress, not decrease it.2

Symptoms of intoxication or withdrawal such as slurred speech, impaired judgment, and trembling may even lead to further social anxiety.1

However, once you experience a sense of relief after consuming alcohol, you are more likely to consume alcohol in similar situations, possibly leading to problematic alcohol consumption.2 Additionally, drinking to intoxication could lead to increased anxiety due to a sense of loss of control and symptoms that may be anxiety-inducing such as impaired memory or unsteadiness.2

This relationship creates a loop in which social anxiety and alcohol use perpetuate each other.2

Who Is At Risk for Co-Occurring Social Anxiety and Alcohol Use Disorder?

Social anxiety and alcohol addiction often happen together.Social anxiety disorder is diagnosed between the ages of 8 and 15 in 75% of individuals diagnosed.1 While alcohol exposure occurs at various ages, the most common age of exposure is in the mid-teens. Additionally, while a person of any age can be evaluated for and diagnosed with alcohol use disorder, diagnosis often occurs in the late teens or 20s.2

When examining the relationship between social anxiety and alcohol use disorder, social anxiety is typically seen as a precursor as alcohol is a socially acceptable, legal mind-altering substance that is more available than many other substances that might otherwise be used to self-medicate social anxiety symptoms.

Even heavy alcohol use may be considered expected among teenagers and young adults in social situations, regardless of the legal drinking age, which can make alcohol readily available and allow struggling individuals to hide problem drinking patterns from peers or family. For example, high school and college students may use alcohol without any scrutiny from adults or peers in social settings.

There are several risk factors for developing a social anxiety disorder, including:1

  • Having a timid or nervous temperament that may be characterized by profound shyness, inhibition, or fear of criticism from others
  • Abuse, neglect, or mistreatment
  • Trauma
  • Adverse childhood experiences
  • Genetic predisposition, either by inheriting social anxiety disorder or by inheriting temperamental traits that may lead to social anxiety

Risk factors for developing alcohol use disorder include:1

  • Environmental factors such as cultural or family attitudes about alcohol consumption, availability of alcohol, and heavy alcohol consumption among peers
  • High level of stress and lack of learned coping skills for stress
  • Impulsivity
  • Family history, which is considered to have a genetic component and a behavioral component where individuals learn substance use behaviors in their home of origin
  • Adverse childhood experiences
  • Trauma
  • Abuse, neglect, or mistreatment
  • Existing mental health conditions—such as depression—and certain physical conditions—like chronic pain

Having multiple or overlapping risk factors can increase the risk of developing both social anxiety disorder and alcohol use disorder.2

For example, an individual who was diagnosed with social anxiety disorder has a higher than average risk of developing alcohol use disorder if they have a family history of alcohol use disorder, live in an environment in which alcohol consumption is encouraged, and have peers who use alcohol often.1

What Are the Risks of Co-Occurring Social Anxiety and Alcohol Use Disorder?

Having both social anxiety disorder and alcohol use disorder can increase the risk for side effects and greater functional impairment.3 Compared to individuals with social anxiety disorder alone, individuals with social anxiety disorder and other comorbid conditions are more likely to have difficulty fulfilling responsibilities at home or in other roles, are more likely to need medication to manage their symptoms, and are at higher risk of being hospitalized or dying after trying to take their own lives.3

The co-occurrence of alcohol use disorder among individuals with social anxiety disorder is also associated with:4

  • Less peer and social support
  • More stressful social relationships
  • Greater healthcare utilization
  • More physical health conditions
  • More mental health symptoms

Data shows that people with social anxiety disorder are more likely to be treated for a physical ailment than a mental health one. This failure to treat the source of their symptoms can lead to repeated healthcare encounters with minimal symptom relief.

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What Treatment Addresses Social Anxiety and Alcohol Use Disorder?

Initial treatment recommendations for comorbid social anxiety disorder and alcohol use disorder may depend on the type and severity of symptoms. For example, suicidal ideation or severe alcohol withdrawal may require hospitalization or medical management.1

The goal of treatment is to reduce the fear associated with social situations so that they are no longer avoided or are endured with minimal discomfort without using alcohol.2 Treatment options include: 2,3,5

  • Medication—Several classes of medications have been shown to be effective in treating social anxiety disorder, such as monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), and benzodiazepines. Several medications have also been approved to treat alcohol use disorder, such as acamprosate, disulfiram, and naltrexone.
  • Individual therapy—Psychotherapy for social anxiety disorder integrates several techniques such as role-playing, development of coping skills, exposure therapy, and challenging negative beliefs. Cognitive-behavioral therapy (CBT) is highly effective at treating anxiety disorders and may integrate skills training such as relaxation and social skills.
  • Group therapy—Cognitive-behavioral group therapy (CBGT) has been shown to reduce self-reported social anxiety. Providing therapy in a group format has many advantages, including vicarious learning, support from group members, availability of role-playing partners, and exposure to anxiety-inducing social situations in a safe and therapeutic environment.
  • Support groups—Mutual support groups, such as Alcoholics Anonymous, can be highly effective in providing a peer support aspect in treatment for alcohol use disorder and may also serve as social exposure and a therapeutic environment for utilizing social skills and managing anxiety.

When both disorders occur simultaneously, some treatment options may be contraindicated. For example, those taking MAOIs must avoid an ingredient found in some alcoholic beverages.2 Some medications, such as benzodiazepines, also have the potential for misuse and may not be appropriate for someone with alcohol use disorder.2

Group therapy or support groups like AA may be also be too anxiety-inducing initially and may not be a feasible treatment option until your social anxiety is better managed.2

Social anxiety disorder and alcohol use disorder are highly treatable even when they occur simultaneously.

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Resources

  1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association Publishing.
  2. National Institute on Alcohol Abuse and Alcoholism. (2002). Social Anxiety Disorder and Alcohol Use
  3. Barlow, David H. (2014). Clinical Handbook of Psychological Disorders. The Guilford Press.
  4. Buckner, J. D., Timpano, K. R., Zvolensky, M. J., Sachs-Ericsson, N., & Schmidt, N. B. (2008). Implications of comorbid alcohol dependence among individuals with social anxiety disorder. Depression and Anxiety, 25(12), 1028-1037.
  5. Substance Abuse and Mental Health Services Administration. (2021). MAT Medications, Counseling, and Related Conditions.
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