Anxiety sensitivity and substance-related disorders:a narrative review

Omid Saed, Sahel Khakpoor

Department of Clinical Psychology, Faculty of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran

Abstract

Anxiety sensitivity means fear of anxiety-related sensations which is one of the important factors in the development and maintenance of substance-related disorders. Studies support the underlying, mediating, and moderating role of this construct in the etiology of substancerelated disorders. This review suggests that anxiety sensitivity can play a role in this group of disorders in different ways, such as fear of body sensations, fear of cognitive dyscontrol, and fear of socially observable anxiety symptoms. Finally, high anxiety sensitivity can interfere with the treatment of substance-related disorders as an underlying vulnerability and increase the likelihood of relapse in this group of people.

Key words: alcohol use; anxiety sensitivity; review; substance-related disorders

INTRODUCTION

Substance-related disorders result from abnormal and unauthorized consumption of substances such as alcohol, opioids,and cannabis, and cause one's psychological or physiological substance dependency. These disorders are widespread among the general population and have imposed enormous economical and psychological costs on society (Grant et al., 2004;Azad and Saed, 2012). In recent decades, there has been a significant tendency towards the prevention of such high-risk behaviors in adolescents and adults. To this end, understanding the etiology of this multifaceted phenomenon and its related factors seems necessary, and research in this area can help to increase our understanding of the psychopathology of substance-related disorders and prevent its occurrence. Some studies on the etiology of substance-related disorders have focused on factors involved in emotional and psychological vulnerabilities such as anxiety sensitivity. Overall, anxiety sensitivity refers to the fear of anxiety-related sensations that appear to arise from one's beliefs about the adverse consequences of anxiety symptoms (Taylor, 1999; Deacon and Abramowitz, 2006). These perceived consequences include the three general categories of fear of body sensations, fear of cognitive dyscontrol, and fear of socially observable anxiety symptoms (Asmundson et al., 2011; Wheaton et al., 2012).Anxiety sensitivity constructs were initially raised in relation to panic disorder, but the results suggest that this vulnerability also plays a role in the pathology of other emotional disorders(Schmidt et al., 2008). In addition, Reiss (1991) suggested that anxiety sensitivity plays a role not only in the development and maintenance of anxiety disorders but also in substance-related disorders. This article aims to investigate the role of anxiety sensitivity as a moderating, mediating, and independent factor in substance-related disorders.

SEARCH STRATEGY AND SELECTION CRITERIA

Inclusion criteria for the current review were the following: a)articles had original and review formats b) anxiety sensitivity, substance use and alcohol were one of the main variables in the title of articles and c) full text of the article should be available. To identify studies which were appropriate for surveying anxiety sensitivity and substance use disorders,we conducted systematic searches of the electronic databases American Psychological Association (PsychInfo), PubMed,Scopus, and Google Scholar up to 2018. In order to identify anxiety sensitivity and substance use disorders studies the following parameters were searched: anxiety sensitivity and substance use disorders or alcohol or cigarette or nicotine or marijuana or cannabis or tobacco and mediation or moderation and treatment or intervention. In addition, reference sections of all identified papers were scrutinized for additional published papers in this area. We restricted searches to studies in English,relating to humans, published after January 1, 1990. The full electronic searches are shown in Table 1.

THE MODERATING, MEDIATING AND INDEPENDENT ROLES OF ANXIETY SENSITIVITY IN SUBSTANCE-RELATED DISORDERS

A review of the literature in this area shows that various studies have investigated the role of anxiety sensitivity in substancerelated disorders. These studies can be categorized into three general groups in terms of their role in considering anxiety sensitivity. The first group mainly emphasizes the moderating role of anxiety sensitivity in the relationship between anxiety and substance use. From this perspective, high anxiety sensitivity can increase the likelihood of drug use in anxious individuals(Stewart and Kushner, 2001). In Reiss's view, high anticipatory anxiety increases avoidant behaviors such as substanceuse and high anxiety sensitivity can exacerbate these behaviors(Reiss, 1991). The results revealed that anxiety sensitivity moderates the relationship between trait anxiety and alcohol use and smoking in adolescents (Comeau et al., 2001). Given that people with high anxiety sensitivity are more sensitive to tension-reduction effect, this vulnerability can exacerbate the anxiolytic effects of substance and alcohol in this group of people (MacDonald et al., 2000, 2001), In fact, anxiety sensitivity continues the consumption of substances use by increasing tension-reduction expectancies (MacDonald et al.,2001) and also by moderating the negative reinforcing effect of substance use (reducing anxiety symptoms).

Table 1: Database search strategy

The second group of studies supports the mediating role of anxiety sensitivity in substance use. For example, according to the McCaul et al. (2017) study, anxiety sensitivity can be considered as a mediating factor in the relationship between anxiety and alcohol consumption. Their results showed that high scores of anxiety and anxiety sensitivity scales are correlated with more frequent and a stronger desire for the alcohol consumption. In the other study Wolitzky-Taylor et al. (2015)showed that anxiety sensitivity is a mediating factor in the association of social anxiety disorder, generalized anxiety disorder, and panic disorder with alcohol consumption problems in adolescents. In their view, responding to anxiety symptoms,not the symptoms themselves, impels one to drink alcohol.

Finally, the third group assigns an independent role for anxiety sensitivity in substance use. According to this group of studies, anxiety sensitivity itself can predict the likelihood of substance use through mediators such as motivation to use,emotional disorders and negative affect. DeMartini and Carey(2011) proposed a model for explaining relationship between anxiety sensitivity and alcohol consumption. According to this model, anxiety sensitivity through a chain of mediators can affect alcohol consumption. Novak et al. (2003) suggested that individuals with high anxiety sensitivity getting involved substance to reduce negative affect symptoms. Considering anxiety sensitivity is seen in a wide range of disorders(Taylor, 1995; Khakpoor and Saed, 2018) and also anxiety disorders increase the likelihood of substance use (DeHaas et al., 2001), it can be concluded that anxiety sensitivity may affect substance use through emotional disorders. The results indicated that anxiety sensitivity affects alcohol consumption by affecting symptoms of generalized anxiety and depression(Lechner et al., 2014; Allan et al., 2015). In addition, some studies reported a positive association between anxiety sensitivity and drug and alcohol use in patients with panic disorder(Cox et al., 1993) and post-traumatic stress disorder (Naifeh et al., 2012). It seems that high anxiety sensitivity lead to more severe anxiety responses and increase the likelihood of substance use as a way to avoid these unpleasant emotions(Kushner et al., 2001). Motivation for use is another mediator of the relationship between anxiety sensitivity and substance use. Studies show that individuals turn to substance use based on four main motivations, including social, enhancement,coping, and conformity motivations and anxiety sensitivity is associated with substance use (Lejuez et al., 2006; Farris et al., 2016), smoking (Bilsky et al., 2016), and alcohol and marijuana use (Comeau et al., 2001; Bonn-Miller et al., 2007;Howell et al., 2010; DeMartini and Carey, 2011) through the coping and conformity motivations.

In addition to mediating variables, some factors can modulate the relationship between anxiety sensitivity and substance use. Some studies support the moderating role of gender in the relationship between anxiety sensitivity with alcohol consumption and the substance use motivation (DeMartini and Carey,2011). The results also show that perceived control moderates the relationship between anxiety sensitivity and alcohol consumption in adolescents (Kearns et al., 2018). In an experimental study, Telch et al. (1996) divided students with high anxiety sensitivity into two groups based on perceived control.According to their results, the group with low perceived control showed a stronger emotional response to caffeine.

Finally, in order to better understanding the relationship between anxiety sensitivity and substance-related disorders, it is important to pay attention to their different pharmaceutical effects. Since people with high anxiety sensitivity are concerned about anxiety-related physical symptoms, they appear to be more inclined to use or abuse substances such as alcohol,(Johnson et al., 2010). For example, Buckner et al. (2011)indicated that this dimension of anxiety sensitivity is associated with craving and problems associated with marijuana use. Because marijuana and hashish users are less tolerant of cognitive symptoms of craving experience, cognitive concerns can make the withdrawal of these substances harder. Guillot et al. (2016) investigated the dimensions of anxiety sensitivity among tobacco users. According to their results, cognitive concerns are associated with negative effect reduction motives and negatively reinforce the variables associated with tobacco use. This group of people believes that tobacco use can reduce their concentration and mood problems and increase their cognitive control. In fact, it seems that people's beliefs about uncontrollability and threat of thoughts can influence substance use (Saed et al., 2010, 2011).

It also should be noted that some studies suggest that there is no significant difference between the anxiety sensitivity dimensions related to substance use in particular, and only the total score of anxiety sensitivity could be the best predictor of this group of disorders (Schmidt et al., 2007). Against this background, given the heterogeneity of the results, it seems that this area needs further and more precise studies.

ANXIETY SENSITIVITY AND THE TREATMENT OF SUBSTANCE-RELATED DISORDERS

People with high anxiety sensitivity do not have the appropriate psychological resources to effectively accept, tolerate, or regulate their emotions. The similarity between withdrawal and anxiety symptoms (such as perspiration or palpitations)seems to make people with high anxiety sensitivity afraid of withdrawal symptoms as well as somatic sensations. On the other hand, anxiety sensitivity can cause a person to perceive withdrawal symptoms more severely than they are, thus resume using substance to reduce or avoid these symptoms (Stewart and Kushner, 2001).

Lack of attention to anxiety sensitivity in the treatment of patients with substance-related disorders may continue these fears. In such circumstances, attention to anxiety sensitivity seems to be useful in the treatment of this group of patients and in the prevention of substance use. Studies have supported the effects of anxiety sensitivity-based interventions on substance use (Worden et al., 2015) and smoking cigarette (Zvolensky et al., 2014). Studies show that cognitive-behavioral interventions for people with high anxiety sensitivity can reduce craving for heroin (Tull et al., 2007), expectations about the soothing effect of alcohol (Watt et al., 2006), as well as the amount of alcohol consumption (Conrod et al., 2000; Olthuis et al., 2015). These interventions reduce the use of substance(as a way of coping with anxiety) by decreasing anxiety sensitivity, thereby reducing the physical problems associated with substance use. In addition, some studies have pointed to the role of anxiety sensitivity in maintaining substance use as well as the increased risk of relapse after treatment. These studies suggest that anxiety sensitivity can interfere with the experience of withdrawal or craving symptoms and may increase the likelihood of leaving the treatment or relapse (Lejuez et al., 2008; Zvolensky et al., 2007).

Finally, since anxiety sensitivity seems to play a significant role in the maintenance, relapse, and treatment of substancesedative drugs, and opiates rather than stimulants. Various studies support the association between anxiety sensitivity and smoking (Bilsky et al., 2016), alcohol (Wolitzky-Taylor et al.,2015), marijuana (Comeau et al., 2001), heroin (Lejuez et al.,2006) and hashish use (Farris et al., 2016). The results suggest that people with high anxiety sensitivity are more likely to avoid using stimulants such as cocaine than other stimulants(Lader, 1996). However, studies did not report a significant relationship between the severity of anxiety sensitivity and the types of substance (McWilliams and Asmundson, 2001;Forsyth et al., 2003) and this area needs further and more precise investigation.

DIMENSIONS OF ANXIETY SENSITIVITY AND SUBSTANCE-RELATED DISORDERS

In order to better understanding the relationship between anxiety sensitivity and substance-related disorders, a group of studies examined the relationship between different dimensions of this construct with substance use. The results revealed that the fear of body sensations dimension is associated with alcohol dependency (Lechner et al., 2014), cannabis (Farris et al., 2016), and heroin use (Lejuez et al., 2006). On the other hand, some studies show that the association between this dimension and substance use is influenced by gender. For example, alcohol consumption is more related to physical concerns in women and more to cognitive and social concerns in men (DeMartini and Carey, 2011). The results also indicated that body-focused anxiety is associated with coping-related motives in smokers, especially women (Leyro et al., 2010;Bilsky et al., 2016).

In addition, some results suggest that fear of publicly observable anxiety symptoms are associated with substance use.The study results of Wolitzky-Taylor et al. (2015) showed that anxiety sensitivity is the main mediator of the association between social anxiety symptoms and alcohol use. Buckner et al. (2011) stated that the component of social concerns moderates the relationship between marijuana craving and use. It seems that people sometimes use coping strategies,such as using substance, to avoid negative evaluations or to avoid feeling embarrassed in the social situations. McDermott et al. (2009) showed that social concerns were more prevalent among crack/cocaine users with post-traumatic stress disorder.Social concerns increase the likelihood of avoiding symptoms of post-traumatic stress disorder (such as encountering people or places reminiscent of unpleasant memories) and substance use can make it easier to cope with these conditions. Another study found that social concerns component was also higher among heroin users (Lejuez et al., 2006). This group of consumers exhibits less impulsive and extroversion behaviors and are less involved in risky behaviors. In addition, it seems that this dimension of anxiety sensitivity can predict substance withdrawal rates among heroin users (Lejuez et al., 2008).Given that substance use treatment are often group-based programs, individuals appear to have less privacy and are more sensitive to social evaluations. In such circumstances, paying attention to social concerns can help improve this group of patients and their sustainability in treatment.

Finally, the results support the relationship between the fear of cognitive dyscontrol dimension and substance use related disorders, therapists need to be aware of this cognitive construct and its effects.

CONCLUSIONS

A review of literature in the field of substance-related disorders supports the role of anxiety sensitivity as a moderator or mediator. This construct can also be linked to substance use as an independent underlying vulnerability through factors such as motivation for consumption, emotional disorders and negative affect. On the other hand, the results show that anxiety sensitivity is a perpetuating factor in substance use.People with high anxiety sensitivity experience a noticeable decrease in anxiety symptoms when taking the substance or drinking alcohol, an issue that continues to increase substance use in this group of people and increase resistance to current treatments. Failures to do so can lead people with high anxiety sensitivity to substance use, fail to receive appropriate treatment, or a failure in the treatment. The role of this construct is highlighted especially in situations where substance use is comorbid with emotional disorders (such as anxiety or mood disorders).

Considering what has been said, it seems that studies to investigate the role of underlying vulnerabilities such as anxiety sensitivity in substance-related disorders, helps our understanding of the predisposing, perpetuating, and therapeutic factors in this group of disorders. In this regard, it is suggested that future studies using longitudinal, cross-sectional designs,or methods such as structural equation analysis, examine the relationship between anxiety sensitivity and substance use more precisely as well as the type of selected substance. Further, it is suggested that future studies, based on the underlying theories of substance use, develop an instrument that can specifically assess anxiety sensitivity in this group of individuals. Finally,considering the overlap between substance withdrawal symptoms and anxiety symptoms, it is recommended that existing evidence-based therapies consider anxiety sensitivity as one of the therapeutic targets in substance-related interventions or at least consider it as one of the effective factors in improving the therapeutic effects.

Acknowledgment

We would like to thank Dr. Alireza Shoghli (MD) Vice President for Deputy of Research and Technology of Zanjan University of Medical Sciences for his assistance in this work.

Author contributions

Conception and design of the work: OS; data collection and manuscript preparation: SK and OS. Both authors approved the final version of this manuscript for publication.

Conflicts of interest

None declared.

Financial support

None.

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Externally peer reviewed.

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