0145-6008/01/2502-0210$03.

00/0
ALCOHOLISM: CLINICAL AND EXPERIMENTAL RESEARCH

Vol. 25, No. 2

February 2001

Concurrent Alcoholism and Social Anxiety Disorder: A

First Step Toward Developing Effective Treatments
Carrie L. Randall, Suzanne Thomas, and Angelica K. Thevos

Background: Social anxiety disorder (also called social phobia) is an anxiety disorder in which affected
individuals fear the scrutiny of others. Clinical reports suggest that individuals with social anxiety disorder
often use alcohol to alleviate anxiety symptoms, a practice that leads to alcohol abuse and/or dependence
in approximately 20% of affected individuals. The present study investigated whether simultaneous treatment of social phobia and alcoholism, compared with treatment of alcoholism alone, improved alcohol use
and social anxiety for clients with dual diagnoses of social anxiety disorder and alcohol dependence.
Methods: The design was a two-group, randomized clinical trial that used 12 weeks of individual
cognitive behavioral therapy for alcoholism only (n 44) or concurrent treatment for both alcohol and
social anxiety problems (n 49). Outcome data were collected at the end of 12 weeks of treatment and at
3 months after the end of treatment.
Results: Results with intent-to-treat analyses showed that both groups improved on alcohol-related
outcomes and social anxiety after treatment. With baseline scores covaried, there was a significant effect of
treatment group on several drinking measures. Counter to the hypothesis, the group treated for both
alcohol and social anxiety problems had worse outcomes on three of the four alcohol use indices. No
treatment group effects were observed on social anxiety indices.
Conclusions: Implications for the staging of treatments for coexisting social phobia and alcoholism are
discussed, as well as ways that modality of treatments might impact outcomes.
Key Words: Alcoholism, Anxiety, Comorbidity, Social Phobia, CBT.

OCIAL ANXIETY DISORDER, also called as social

phobia*, is more than just shyness (Chavira and Stein,
1999; Hazen and Stein, 1995; Lamberg, 1998). It is the third
most common mental disorder, preceded only in prevalence by depression and alcoholism (Kessler et al., 1994).
The disorder is characterized by the persistent fear of
criticism in various social situations, or fear while performing behaviors in public such as eating or writing. People
with social phobia fear that their physiological signs of
anxiety, such as blushing or perspiring, will be noticed by
others and judged critically (Schneier, 1995). The fears are
so intense that, eventually, the individual avoids the situations or endures them with great distress. The chronicity of
these fears and subsequent avoidance interfere significantly
with the affected individuals performance at work or
school, the development of relationships, and the achievement of career goals (Schneier et al., 1994).
Social phobia typically has an onset around 15 years of
age (Ballenger et al., 1998), and it does not spontaneously
From the Alcohol Research Center, Medical University of South Carolina,
Charleston, South Carolina.
Received for publication June 19, 2000; accepted November 16, 2000.
Supported by Grant AA09751 (CLR) from the NIAAA.
Reprint requests: Carrie L. Randall, PhD, Center for Drug and Alcohol
Programs, Medical University of South Carolina, 67 President Street, Charleston, SC 29425; Fax: 843-792-5204: E-mail: randallc@musc.edu
*The terms social phobia and social anxiety disorder are used interchangeably throughout this report.
210

remit with age. It occurs slightly more frequently in women,

although men are more likely to be treated for it (Weinstock, 1999). There are two distinct forms of social phobia.
With the generalized type, the individual fears most social interaction and performance situations, whereas with
the nongeneralized type, the individual fears one or two
specific situations (e.g., giving a speech, writing a check).
The generalized type is more prevalent and also is considered more severe (Heimberg et al., 1993; Kessler et al.,
1998).
Social phobia often is accompanied by coexisting affective disorders and alcoholism (Ballenger et al., 1998; Moutier and Stein, 1999). The lifetime prevalence of alcohol
abuse or dependence among individuals with social phobia
is about 22% (Himle and Hill, 1991; Regier et al., 1990).
Prevalence rates of social phobia for individuals who seek
treatment for alcohol problems range from 2% to 54%
(Lepine and Pelissolo, 1998), with an average prevalence of
15%. In a large multisite sample of both inpatient and
outpatient alcoholics, Thomas et al. (1999) found that the
prevalence of social phobia (with current symptoms) was
23%. Non-treatment-seeking samples, such as the one in
the National Comorbidity Study, show a similar prevalence
of comorbidity. Approximately 25% of alcoholic individuals
met diagnostic criteria for social phobia in that sample,
although there was disparity across the sexes (19% of males
and 30% of females endorsed the comorbidity; Kessler et
Alcohol Clin Exp Res, Vol 25, No 2, 2001: pp 210 220

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ALCOHOLISM AND SOCIAL ANXIETY DISORDER

al., 1997). Together, these reports suggest that the prevalence rate of comorbidity is at least 20%.
Even though this particular dual diagnosis represents a
significant subpopulation of alcoholics, little is known
about these individuals, other than how they present to
treatment (Randall et al., 2000; Thevos et al., 1999;
Thomas et al., 1999). No prospective studies have investigated treatment outcomes for socially phobic alcoholics. If
individuals with social phobia use alcohol to self-medicate
anxiety symptoms, as they indicate they do (Chambless et
al., 1987; Kushner et al., 1990; Randall et al., 2000;
Schneier et al., 1989), then relapse after alcohol treatment
may be more likely without attention to social fears (Kushner et al., 2000). Also, clinical observation at our inpatient
treatment center shows that alcoholics with social phobia
have difficulty participating in traditional alcohol
treatment-related activities (e.g., group therapy, Alcoholic
Anonymous [AA] meetings). The available evidence, then,
suggests that untreated social phobia not only may hinder
the alcoholics ability to benefit from alcohol treatment
(especially if group activities are involved) but also may put
the affected individual at risk for relapse.
The previously mentioned clinical observation was the
primary impetus for the present study, which compares the
efficacy of treating both disorders (alcoholism and social
phobia) versus treating the alcohol problem only. It is, in
fact, the first prospective study to investigate treatment
outcomes in alcoholics with coexisting social anxiety disorder and the first to compare treatments in this population.
Consequently, there is no empirical evidence to show that
treating both disorders is more effective than treating the
alcohol problem alone in this population, or how these
treatments should be administered. However, one study
conducted on alcoholic inpatients with depression showed
that concurrent cognitive behavioral treatment for both
disorders was more effective in reducing drinking and depressive symptoms at follow-up than treatment for the
alcohol problem only (Brown et al., 1997).
Because of the marked order of onset of alcoholism and
social phobia, where social phobia symptoms typically predate alcoholism by a decade (Kushner et al., 1990; Schneier
et al., 1992), there is an even stronger rationale for addressing each disorder in the present study. That is, compared
with alcoholism and depression, where depressive symptoms may precede, coincide with, or result from the individuals alcohol problem, alcoholism and social phobia are
more distinct disorders, and separate treatments for each
problem probably are warranted. Also, because effective
manual-guided psychological treatments recently have
been developed for both social phobia (Antony, 1997; Masia and Schneier, 1999; Otto, 1999) and alcoholism (Project
MATCH Research Group, 1997), it is now possible to
systematically address this question.
In the present study we randomly assigned alcoholics
with coexisting social anxiety disorder to one of two treatments: alcohol only, or a combination of alcohol and social

phobia treatment (dual treatment group). Both treatments

were manual-driven and used 12 weeks of individual cognitive behavioral therapy (CBT). Clients were treated by a
skilled therapist experienced in manual-guided therapy.
Although individuals were assessed every 3 months after
the termination of treatment for a period of 9 months, only
the results from the end of 12 weeks of treatment and the
first 3 months of follow-up are presented in this report.
Outcome measures included both alcohol consumption and
social phobia indices. The primary hypothesis was that
concurrent alcohol and social phobia treatment would improve social anxiety and would improve drinking outcomes
more than alcohol-only treatment.
METHODS
Participants
Between March 1994 and March 1998, 187 individuals were screened
for possible participation in the trial. Participants were recruited from the
substance abuse unit of an academic medical center, an affiliated Veterans
Affairs Medical Center, and a county substance abuse treatment facility.
All participants recruited from these facilities sought outpatient treatment
for alcohol problems. Participants also were recruited through newspaper
advertisements and referrals. Of the 187 screened individuals, 110 met
inclusion criteria (see subsequent discussion), signed informed consent,
and were randomized to one of the two therapy treatment groups: the
alcohol-only treatment or the concurrent treatment for both alcohol and
social anxiety problems (dual group). Two participants (both female) were
derandomized, one because she moved out of state before the first therapy
session and the other because of a fatal accident unrelated to the trial that
occurred before the first therapy session. Six participants failed to attend
any therapy sessions. Because we decided a priori that the analysis would
be based on attendance at a minimum of one treatment visit, these
subjects were excluded from the analyses. Nine additional participants
moved away or failed to provide data at the end of treatment; consequently, their data were excluded from the analyses. Thus, there was a
final assessable sample of 93 individuals from the total of 110 randomized
(85%) who attended at least one therapy session and provided data at
baseline and at the end of treatment. A comparison of the excluded
subjects with those included in the analyses failed to show any baseline
group differences on age, sex, or any alcohol use or social anxiety measures (all p values 0.20). Of the final assessable sample, 44 participants
received alcohol-only treatment, and 49 received dual treatment.
Inclusion/Exclusion Criteria
Inclusion. Participants were required to be at least age 18 and to meet
current DSM-III-R (American Psychiatric Association, 1987) diagnostic
criteria for both alcohol dependence and social phobia. The alcohol use
disorder was assessed by a trained masters-level clinician who used the
Structured Clinical Interview (Spitzer and Williams, 1985) keyed to the
DSM-III-R. Social phobia, as well as other Axis I disorders, were assessed
with the computerized version of the Diagnostic Interview Schedule (CDIS) (Ottowa Civic Hospital, 1985). Participants had to indicate in a
nonprompted, open-ended question that they used alcohol to cope with
anxiety (100% positive response to this question), and they had to agree to
12 weeks of outpatient treatment for their alcohol problems.
Exclusion. Participants were required to have consumed alcohol in the
30 days before screening. That is, abstinence from alcohol was an exclusion criterion. Other exclusion criteria included concomitant drug dependence in the past 90 days on any substance other than marijuana or
nicotine, an untreated psychotic disorder, failure to provide a locator, lack
of transportation, or intent to relocate in the next 3 months. A total of 77
subjects failed to meet inclusion criteria for one or more of these reasons.

212

Procedure
Each potential participant was screened by telephone or in person by a
trained research assistant to gather demographic information and to
determine whether the individual was a probable candidate for participation. If an individual met preliminary inclusion criteria (current alcohol
dependence and social phobia) and did not meet exclusion criteria, she or
he was scheduled for a final eligibility assessment interview. Participants
were given a breathalyzer test and signed informed consent if the breath
alcohol measurement equaled 0.000 g/dl. All others were rescheduled.
Participants were assessed with the substance use and psychotic sections of the SCID to confirm the presence of alcohol dependence and the
absence of other substance use dependence and psychotic disorders. A
urine drug screen was given to confirm that participants were not currently
abusing psychoactive drugs, the use of which might undermine the reliability of the self-reported information provided.
Participants then were assessed with the C-DIS to confirm diagnosis of
social anxiety disorder and to assess the presence of other Axis I disorders.
The C-DIS is a fully structured diagnostic interview tool that is used widely
in diagnosing psychopathology in clinical research studies, which include
Project Matching Alcohol Treatments to Client Heterogeneity (MATCH).
The C-DIS has been reported to overdiagnose affective and anxiety
disorders in substance abusers (Ross et al., 1988), but in the present study,
the veracity of the social phobia diagnosis was supported by several
additional measures of social anxiety (described subsequently).
This assessment lasted approximately 6 hr (during which time baseline
data were collected if the client was eligible) and typically was divided into
two consecutive sessions. At the end of the second session, when eligibility
was confirmed, clients were randomized to one of the two treatment
conditions. After baseline assessment and randomization, the client met
with the therapist weekly and again met with the research assistant 12 to
14 weeks after the first therapy visit, which corresponded with the end of
treatment. The client returned at 3 month intervals for 9 months for
follow-up interviews. Several instruments, outlined subsequently, that
were related to alcohol use and social anxiety were administered at each
of these interviews, the data from which serve as the primary dependent
variables for this study. As with the baseline assessment interview, each
follow-up assessment was preceded by a breathalyzer test. Only data from
baseline, end of treatment, and the first follow-up (3 months after treatment completion) are reported here.
Quantity and frequency of alcohol use was obtained with the Form 90
(Miller, 1996), which assesses drinking over the past 90 days. The reliability of form 90 has been established (Tonigan et al., 1997). The four
outcome variables of interest were (1) number of standard drinks per
drinking day, (2) total number of drinks in the 90 day window, (3)
percentage days abstinent, and (4) percentage days heavy drinking (four or
more and six or more standard drinks for women and men, respectively).
The Form 90 was administered at baseline for the 90 days before entry
into the study and at each follow-up period for the preceding 90 days.
Collateral informants were contacted at each follow-up period to corroborate clients self-reports.
The primary social anxiety measure was the Social Phobia and Anxiety
Inventory (SPAI; Turner et al., 1989), which is a self-report questionnaire
with 45 items related to somatic symptoms and escape and avoidant
behaviors indicative of social phobia. The respondents score is calculated
such that it reflects the severity of the respondents social anxiety apart
from his or her symptoms of agoraphobia. The SPAI score ranges from 0
to 192, and a score around 80 typically reflects impairment (Turner et al.,
1989). The SPAI has sound psychometric properties, and it has shown
clinical utility as a treatment outcome measure (Beidel et al., 1993; Cox et
al., 1998).
The Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987) was incorporated into the battery of tests after recruitment had begun, so only a
subset (n 45) provided scores on the LSAS. This instrument typically is
administered by a clinician, but recent evidence supports its utility as a
self-report questionnaire (Coles et al., 1999; Cox et al., 1998), which was
the format used in this study. The LSAS contains two scales one for

RANDALL ET AL.

fear/anxiety and another for avoidance. There is also a total LSAS score,
which is the sum of the two scale scores. Individuals with generalized social
anxiety typically score around 40 on each scale and have a mean LSAS
total score around 80 (Stein et al., 1998). The LSAS has sound psychometric properties (Heimberg et al., 1999).
Two additional measures of social phobia severity included the
Thoughts and Beliefs scale (TBS; Johnson et al., 1995), which yields scores
from 29 to 145 (individuals with social phobia typically score around 100,
and controls score about 50). The Fear of Negative Evaluation (FNE;
Watson and Friend, 1969) was also used in the trial. Scores on the FNE
range from 0 to 30; higher scores reflect greater impairment.
Treatments
General Issues. The trial used two psychotherapy treatments: one for
alcohol problems only and the other for both alcohol problems and social
anxiety (referred to as the dual group). Recall that all clients had dual
diagnosis of alcohol dependence and social anxiety disorder. Both treatments were manual-guided to ensure standardization in content delivery,
to establish treatment goals and clinical care standards, to set standards
for training and evaluation of therapists, and to allow an objective comparison of two different psychotherapies (Carroll, 1997). The treatments
were delivered by trained clinicians in 12 individual sessions over a maximum of 14 weeks.
Both treatments were based on the principles of cognitive behavioral
therapy, an approach shown to be successful for the treatment of alcoholism (Project MATCH Research Group, 1997) as well as social phobia
(Masia and Schneier, 1999). We chose to deliver the therapy individually
to clients, rather than forming clients into groups, because individual
therapy would afford better control of experimental conditions, and manuals had been developed for individual CBT for alcoholism (Kadden et al.,
1992). Furthermore, given the nature of social anxiety disorder, where
social interactions are one of the greatest fears, we believed that individual
therapy would more attractive to participants. Although the literature on
the treatment of social phobia supports that group CBT is very successful
(Heimberg and Barlow, 1991; Heimberg and Juster, 1994), individual CBT
also has been shown to be efficacious (Butler, 1989; Stravynski and
Greenberg, 1998). Consistent with the CBT approach, both treatment
groups were given homework assignments that were reviewed at the next
session. Assignments involved practicing the skills that were taught in that
weeks module. Attendance at AA meetings was not given as a homework
assignment, nor was it expressly encouraged or discouraged during treatment sessions for either treatment group. We reasoned that if AA attendance was encouraged in one group but not the other, the alcohol outcomes might be confounded. Furthermore, encouraging AA attendance in
both groups might provide some similance of social anxiety treatment
(albeit not very good) for the alcohol-only group (via exposure to feared
situations) and thereby might compromise the alcohol-only treatment.
Therapists. Four therapists were used during the trial, although two
PhD-level clinical psychologists delivered therapy to nearly all (96%) of
the participants. Therapists were trained and supervised by one investigator (A.K.T.) who has extensive experience in supervision of manual guided
therapies and treatment outcome research. The supervisor trained the
therapists to deliver both alcohol-only and dual therapies, monitored the
delivery of therapy, and also conducted weekly supervision throughout the
study. All therapists and the therapy supervisor were skilled in behavior
therapy and had experience in treating clients with alcohol addiction and
anxiety disorders.
Therapist Training. Training of the therapists consisted of 2 hr of
didactic instruction that covered study aims, study procedures, use of the
treatment manuals, and general treatment philosophy. For the alcohol
treatment modules, which were used in both treatment conditions, videotapes and audiotapes were available from Project MATCH and were used
liberally for training. Therapists reviewed at least one audiotape or videotape for each of the various modules before delivering the module with
a pilot case client for the first time. For the social phobia treatment
modules (used only in the dual condition), no training tapes were available

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ALCOHOLISM AND SOCIAL ANXIETY DISORDER

for viewing. Therapist training for the delivery of the social phobia treatment modules involved a general overview of social anxiety and systematic
desensitization, a review of topics to be covered in the course of 12 weeks,
and familiarization of hierarchy setting. The therapist and therapy supervisor evaluated and discussed the pilot case every week during a regularly
scheduled therapy supervision meeting. In addition to the review of the
previous weeks session, the therapist reviewed the material to be covered
for the next therapy session, and any questions were addressed. All
therapists were required to have supervision and receive feedback on each
session of both of the manuals before they could provide therapy in the
trial.
Alcohol-Only Treatment. Clients who received treatment for alcohol
problems only (alcohol-only group, n 44) received CBT modeled directly from the CBT therapy manual (Kadden et al., 1992) used in Project
MATCH (Project MATCH Research Group, 1997). Sessions lasted approximately 60 min, including review of past sessions and homework
assignments. Review of past sessions occurred early in the session, new
material was presented, and homework assignments were given at the end
of the session. Before each treatment session, breath alcohol concentrations were obtained from the client, and the session was rescheduled if the
clients breath alcohol concentration was greater than 0.05 g/dl.
Table 1 indicates the types of material covered in the 12 alcohol
treatment sessions. As shown in the table, core sessions for the alcoholonly group included coping with cravings and urges to drink, managing
thoughts about alcohol, problem solving, drink refusal skills, and planning
for emergencies. After completion of the core sessions, clients had the
option to return to core sessions of particular relevance to them or to
select elective sessions. None of the elective topics addressed issues that
related to the clients social anxiety. If the client attempted to discuss
social anxiety problems with the therapist, dialogue was redirected to
return the focus to alcohol use and acquiring skills for abstinence. This
practice was done to ensure fidelity of treatment groups.
Dual Treatment. The dual experimental treatment condition addressed
both social phobia and alcoholism in each session (dual group, n 49).
After the breath alcohol level was assessed for the client (as in the
alcohol-only treatment), each session began with the manual-guided topic
appropriate for that session of alcohol treatment as outlined previously.
The second half of the session used the manual-guided CBT for social
anxiety (V Holmstrom and AK Thevos, unpublished data, 1993).
Because we needed to cover both alcohol and social phobia disorders
in a single session, the treatment sessions for the dual group were approximately 90 min, 30 min longer than for the alcohol-only group. That is, in
each treatment session, approximately half of the meeting time (45 min)
was used to address the alcohol problem and half was used to address
social anxiety. Because the alcohol-only group received 60 min of therapy
time, for clients in dual treatment, the therapist attempted to cover the
new content and homework assignment and reduced time spent reviewing
the past weeks homework by approximately 15 min. Thus, although the
dual group received less review of homework material than the alcoholonly group, all clients received the same amount of alcohol therapy from
the therapist in each session, regardless of treatment group assignment.
An outline of the session topics for the dual group is listed in Table 1.
After an introductory session and training in relaxation techniques in the

first few sessions, the 45 min of therapy for social anxiety (which was
provided only to clients in the dual group) used individualized hierarchical, cognitive behavioral intervention. That is, each client rank ordered his
or her most feared social situations. The therapist then targeted the
situations from the least feared to the most feared over the course of the
treatment. The treatment included discussion on the triggers of social
anxiety, and homework assignments included behavioral exposure to the
feared situations in a progressive and systematic fashion. The aim was for
the client to progress through a behavioral sequence that increased the
likelihood of successful social interactions as well as expectations for
future success. The components included in the modules were selected
based on empirical evidence to support their efficacy (Butler, 1989). The
goal of the social phobia treatment was to reduce social anxiety; concerning alcohol use, the goal of the dual group, like the alcohol-only group, was
to help clients achieve and maintain abstinence.
Treatment Integrity. All therapy sessions were audiotaped and were
monitored randomly by the therapy supervisor to ensure treatment integrity, treatment distinctiveness, and adherence to the therapy boundaries.
Because the same therapist delivered both therapies, it was critical to
determine that the treatments were, in fact, distinct and were delivered
with similar skill and enthusiasm. Thus, session tapes were monitored and
evaluated by the supervisor for treatment condition, empathy, and skill. In
all cases, the two treatments were distinguishable, and skill level was
acceptable. Monitoring also was used to prevent therapist drift from the
treatment model. Therapists attended weekly supervision with the therapy
supervisor. Any problems noted by the supervisor were addressed at these
meetings. Therapists completed therapy session forms after each session,
which were used to assess compliance with the treatment approach and to
summarize the key components of the session. These data were used for
supervision purposes only.

Statistical Methods
Of the 93 clients who attended at least one therapy session, five clients
were missing data at the 3 month follow-up visit. We used a last-pointcarried-forward approach to reconstruct data for these clients. Two sets of
analyses were conducted for all outcome variables. First, to test whether
end-of-treatment scores differed from baseline scores, paired samples t
tests were conducted for each treatment group separately. Significant t
values for these tests reflect significant differences between baseline and
end-of-treatment group means on the dependent variable of interest.
Second, analyses were conducted to test for the effects of treatment group
over time by using repeated measures analysis of covariance (ANCOVA).
The ANCOVA model included the main effects of treatment group and
time and the interaction between treatment group and time. The time
effect reflects changes in group means from the end of treatment to the 3
month follow-up. The baseline score on the dependent variable of interest
was held constant as the covariate in each ANCOVA. Where differences
were indicated by significant F values, post hoc comparisons were conducted with t tests for each time point. We used 2 tests of independence
to compare treatment groups on demographic and other categorical
variables.

Table 1. Topics Covered in Each Session for Both Treatment Conditions

Session
1
2
3
4
5
6
7
811
12
a

Alcohol-only treatment
Introduction
Coping with cravings & urges to drink
Managing thoughts about alcohol
Problem solving
Drink refusal skills
Planning for emergencies
Seemingly irrelevant decisions
Review or electivea
Graduation/future plans

Dual treatment (includes alcohol-only modules plus topics below)

Introduction; triggers
Anxiety self management; relaxation training
Construction of behavioral hierarchy
Introduction to in vitro desensitization/exposure treatment
Managing thoughts associated with social anxiety
Managing emergencies or crisis situations
Progress assessment with social phobia hierarchy
Progress assessment with social phobia hierarchy (review or electivea optional)
Graduation/future plans

Electives include: Awareness of anger; Anger management; Increasing pleasant activities; Managing depression; Spouse/partner session.

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RANDALL ET AL.

RESULTS

Demographics and Baseline Data

Participants were mostly male (69%), were an average of
38 years of age, and were mostly white (88%). Seventy
percent of the participants were married or separated/
divorced. The majority of the sample completed high
school, and 23% were college graduates. Most subjects
were employed full time (73%). There were no differences
between the treatment groups on demographic variables
(all p values 0.10).
The average age of onset of social phobia was in the early
teen years (mean 13.3, SD 8.1). Most clients (87%)
experienced the onset of social phobia before the onset of
alcohol problems. Twelve clients reported that social phobia symptoms coincided with (n 5) or followed (n 7)
the onset of alcohol problems. These clients were equally
distributed across the two treatment groups (five in
alcohol-only treatment; seven in dual treatment). Most
clients (95%) presented with social anxiety of the generalized type, whereby they feared most social situations.
Treatment groups did not differ on the severity of social
anxiety or on the types of situations that induced anxiety.
Baseline scores on standardized measures of social anxiety
are presented in Table 2.
The rate of comorbidity of depressive disorders and

additional anxiety disorders (as assessed by the C-DIS) was

high across both groups and did not differ between groups
(all p values for 2 tests 0.10). The percentage of each
group with additional comorbidity is shown in Table 2.
The percentages of clients in each treatment group who
reported severe anxiety for commonly feared situations are
presented in Table 3. Note that these situations might all
occur in the course of group therapy or in AA meetings. On
average, clients reported that the severity of their social
anxiety was markedly to severely disturbing; severity ratings
did not differ between treatment groups [t(91) 0.27, p
0.79].
In the 90 days before study enrollment, clients reported
drinking on 62% of days (SD 30.4) and drinking an
average of 14 standard drinks (SD 8.1) per drinking day.
Clients reported that they drank heavily on 53% of days
(SD 31) in the 3 months before enrollment. Heavy
drinking is defined in this study as four or more standard
drinks for women and six or more standard drinks for men.
There were no treatment group differences on any of these
drinking indices at baseline (all p values 0.10). The
average age of onset of alcohol dependence was 23.4 years
(SD 8.0), which was generally about 10 years after the
onset of social phobia. Age of onset of alcohol dependence
did not differ between treatment groups [t(91) 0.52, p

Table 2. Comparison of Treatment Groups on Demographic and Baseline Variables

Alcohol-only
group (n 44)
Demographics
Males, % (N)
Age, mean (SD)
Ethnicity, %(N)
White
African-American
Other
Never married, % (N)
Education, % (N)
12 years
Some college
College graduate
Employment, % (N)
Full-time
Other
Social phobia
Age onset social anxiety, mean (SD)
Severity rating (06) of social anxiety, mean (SD)
LSAS: total scores, mean (SD)
LSAS: fear score, mean (SD)
LSAS: avoidance, mean (SD)
SPAI, mean (SD)
Alcohol use
Age onset of alcohol dependence, mean (SD)
Physiologic dependence, % (N)
ASI alcohol severity score (01.0), mean (SD)
Percentage days abstinent in past 90 days, mean (SD)
Drinks per drinking day in past 90 days, mean (SD)
Percentage days heavy drinking in past 90 days, mean (SD)
Total number of drinks in past 90 days, mean (SD)
Other psychopathology
Beck Depression Inventory, mean (SD)
Percentage with past depressive disorders % (N)
Percentage with past anxiety disorders, % (N)
t tests and 2 revealed no differences between groups, all p values 0.10.

Dual group
(n 49)

61%
(27)
37.5 (8.3)

76%
(37)
39.5 (10.7)

84%
11%
5%
30%

(37)
(5)
(2)
(13)

92%
8%
31%

(45)
(4)
0
(15)

41%
32%
27%

(18)
(14)
(12)

37%
45%
18%

(18)
(22)
(9)

66%
34%

(29)
(15)

80%
20%

(39)
(10)

12.2
4.8
89.4
46.6
42.3
102.1

(7.0)
(1.1)
(21.1)
(11.1)
(13.6)
(24.8)

14.4
4.9
78.8
43.1
37.4
99.0

(8.9)
(1.1)
(22.2)
(11.7)
(12.0)
(29.2)

23.0 (7.6)
91%
(40)
0.54 (0.21)
39.6 (28.9)
14.6 (8.9)
54.27 (28.8)
815.7 (647.0)

23.9 (8.4)
82%
(40)
0.55 (0.21)
37.0 (31.9)
11.9 (7.1)
51.7 (33.0)
630.1 (468.7)

22.5 (10.4)
57%
(25)
43%
(19)

19.9 (10.3)
49%
(24)
35%
(17)

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ALCOHOLISM AND SOCIAL ANXIETY DISORDER

Table 3. Five Most Feared Social Situations and the Percentage Who
Endorsed Marked Anxiety When Faced With the Situation
Percentage who
endorsed marked
anxiety
Situation

Alcohol-only

Dual

Being the center of attention

Speaking in front of an audience
Talking to a stranger
Entering a room where others are seated
Working while being observed

90%
89%
84%
78%
76%

91%
87%
85%
73%
73%

0.60]. The majority of clients (86%) met criteria for physiological dependence, as evidenced by their endorsement of
tolerance or withdrawal. Almost half of the participants,
42% of the alcohol-only group and 46% of the dual group,
endorsed both tolerance and withdrawal, evidence of severe alcohol dependence. These rates did not differ between treatment groups [2 (1) 0.15, p 0.69]. Severity
of alcohol problems also was assessed by the Addiction
Severity Index (McLellan et al., 1992). Scores on the Addiction Severity Index (which range from 0 to 1.0) averaged
0.55 (SD 0.21). Analyses showed no differences in severity between the treatment groups [t(91) 0.23, p 0.82].
Thus, the sample overall was alcohol dependent with
marked comorbid social anxiety. Data partitioned by treatment groups are shown in Table 2.
Treatment Compliance
There were no differences between the two treatment
groups in treatment attendance [t(91) 0.31, p 0.76].
Fifty-five percent of clients attended at least 10 of the 12
treatment sessions (referred to as completers; n 23 and
n 28 for the alcohol-only and dual groups, respectively).
The average number of sessions attended overall was 8.0
(SD 4.4). The number of sessions attended by the
alcohol-only group was 7.8, and for the dual group it was
8.1. Fourteen subjects in the alcohol-only group (32%)
completed all 12 sessions, whereas 21 subjects in the dual
group (43%) did so. A total of 14 subjects, 7 in the alcoholonly group (16%) and 11 in the dual group (22%) dropped
out of treatment before the third session.
Therapist Effects
Therapist effects were assessed by comparing the two
therapists who provided treatment for the majority (96%)
of clients. There were no differences in attendance rates
between the groups of clients who were treated by each
therapist [F(1,85) 0.79, p 0.38], nor was there an
interaction between therapist and treatment group on attendance rates [F(1,85) 1.34, p 0.25]. There were also
no therapist effects or therapist by treatment group interactions on any of the outcome measures; consequently,
therapist was not included as a factor in the analyses reported on treatment outcomes.

Drinking Outcomes
Treatment groups did not differ at baseline on any drinking variables (Table 2). Comparisons of baseline to end-oftreatment scores (via the paired-samples t tests) showed
that clients in both treatment groups improved on drinking
measures after treatment (t values 3.44 8.88, all p values
0.001).
Repeated-measures ANCOVA (where baseline scores
were covaried) revealed a significant treatment group effect on three of the four drinking outcome variables. Specifically, clients who received the dual treatment had worse
drinking outcomes than clients in the alcohol-only treatment group. Treatment group differences were evident on
percentage of days abstinent [F(1,90) 6.74, p 0.01],
percentage of heavy drinking days [F(1,90) 4.56, p
0.04], and total number of drinks consumed [F(1,90)
4.03, p 0.04]. Post hoc t tests showed that the treatment
group effect was significant for all three drinking variables
at the 3 month follow-up and was significant at the end of
treatment for percentage of days abstinent (all p values
0.05). Group means and standard errors are presented for
these three drinking measures in Fig. 1. There was no effect
of treatment group on drinks per drinking day [F(1,90)
1.38, p 0.24]. There were no effects of time (i.e., there
was no change from the end-of-treatment time point to the
3 month follow-up), nor were there any significant interactions between treatment group and time on any of the
drinking measures.

Social Anxiety Outcomes

Analyses were conducted on six social anxiety indices
(SPAI, FNE, LSAS total score, LSAS fear score, LSAS
avoidance score, and TBS score) and on the Beck Depression Inventory (BDI; Beck et al., 1961). Treatment groups
did not differ at baseline on any social anxiety measures or
on the BDI (all p values 0.10). Comparisons of baseline
to end-of-treatment scores showed that clients improved on
all social anxiety measures and the BDI after treatment,
regardless of treatment group assignment (t values 1.98
6.37, all p values 0.05).
Repeated-measures ANCOVAs (where baseline scores
were covaried) revealed no main effects of treatment group
(all p values 0.40) and no significant treatment group by
time interactions on any of the social anxiety measures or
on the BDI. Treatment group means (and standard errors)
for the SPAI and total LSAS scores, which are representative of the other social anxiety outcome measures, are
presented in Fig. 2. There was a significant effect of time on
the SPAI [F(1,91) 6.82, p 0.01] and on the FNE
[F(1,91) 4.82, p 0.02], where 3 month follow-up scores
were lower than the end-of-treatment scores, regardless of
treatment group. This effect was not evident on the LSAS
scores, TBS, or BDI.

216

Fig. 1. Group means ( SEM) over time on percentage of days abstinent and
percentage days of heavy drinking days (four or more and five or more drinks per
day for women and men, respectively). The alcohol-only group had greater
percentage of days abstinent and fewer percentage days of heavy drinking than
the dual group both at the end of treatment and at the 3 month follow-up.

Relationship Between Social Phobias and

Drinking Outcomes
Difference scores were computed for the SPAI and the
four drinking variables by subtracting end-of-treatment
scores from baseline scores for each measure. Of interest
was the correlation between the change in SPAI scores and
the change in drinking indices. None of the Pearson correlation coefficients computed between the SPAI and drinking measures were statistically significant (rs 0.10 0.16,
all p values 0.10).
Collateral-Rated Improvement
Collaterals were phoned at the end of the clients treatment and were asked to provide information about the clients
drinking and anxiety. Fewer than half of the collaterals (40%)
reported that clients were abstinent during treatment, which

RANDALL ET AL.

Fig. 2. Group means ( SEM) over time on the Social Phobia and Anxiety
Inventory (SPAI) and the Liebowitz Social Anxiety Scale (LSAS). There were no
differences between treatment groups on either measure. Both treatment groups
improved over time (from the end of treatment to the 3-month follow up) on SPAI
scores, but not on LSAS scores.

did not differ across treatment groups [2(1) 0.002, p

0.96]. This percentage is slightly higher than the clients self
reports: only 20% of clients self-reported abstinence during
treatment18% in alcohol-only group, 20% in the dual group
[2(1) 0.07, p 0.79]. Collaterals also were asked whether
they thought the client had improved in drinking and/or anxiety after treatment. Regarding alcohol use, 82% of collaterals
reported that clients were improved or much improved. These
percentages did not differ across treatment groups (78% alcohol-only; 85% dual; 2(1) 0.33, p 0.56). Fewer
collaterals reported a similar opinion about clients improvement in anxiety 68% (alcohol-only) and 64%
(dual) said that clients anxiety was improved or much
improved. These rates also did not differ by treatment
group [2(1) 0.09, p 0.76].
AA Attendance
The number of days that clients attended an AA or other
12-step meeting was recorded for the 90 days that preceded

ALCOHOLISM AND SOCIAL ANXIETY DISORDER

baseline, during treatment, and at follow-up. It was expected that attendance at these meetings, which involves
social interaction and public speaking, would be fostered if
the clients social anxiety improved during treatment. Not
surprisingly, few clients ever attended any AA meetings,
either before or during treatment, so interval data were
transformed into categorical data for analysis. Percentage
of nonattenders (who attended 0 meetings), minimal attenders (110 meetings), and regular attenders ( 10 meetings) were compared by treatment group at all time points.
Treatment groups did not differ at any time in the percentages of each type of attender. At baseline, 75% and 78% of
the alcohol-only and dual groups were nonattenders, and
11% and 6% of the two groups, respectively, were regular
attenders [2(2) 0.87, p 0.65]. In the 90 days during
treatment, the number of regular attenders increased to
19% (alcohol-only) and 17% (dual), with no difference
between treatment groups [2(2) 0.48, p 0.79]. At
follow-up, this rate decreased again to 9% and 2%, respectively, with no difference between treatment groups [2(2)
2.31, p 0.32]. Although the number of regular attenders did improve from baseline, the majority of clients were
nonattenders at the end of treatment (68%) and at
follow-up (80%).
DISCUSSION

The present study addressed the efficacy of simultaneous

treatment of alcoholism and social anxiety disorder (with
CBT) versus treatment of the alcohol problem alone. The
results of this randomized clinical trial of treatment-seeking
socially phobic alcoholics failed to demonstrate any benefit
of simultaneous adjunctive treatment that targeted social
anxiety. Although both groups improved significantly from
baseline on all drinking outcome measures, the group who
received concurrent alcohol and social anxiety treatment
actually faired worse than the group who received only
alcohol treatment. That is, alcoholics in the dual group
drank more frequently, drank more total drinks, and experienced more frequent heavy drinking days than alcoholics
treated with alcohol-only treatment. When the analyses
were repeated by using only data from treatment completers (those clients who attended at least 10 sessions), the
group differences were similar to those from the intent-totreat analyses. These results were counter to the original
hypothesis, which was that the dual treatment would result
in better drinking outcomes, presumably because inclusion
of therapy for social phobia would decrease social anxiety
and thereby reduce the need to self-medicate.
It is not clear why the dual group showed worse drinking
outcomes than the alcohol-only group. One possibility is
that the homework assignments in the dual treatment,
which required exposure to feared situations, resulted in
drinking to cope. It is also possible that clients in the dual
group engaged in more social situations and had more
opportunities to drink. This is unlikely, however, because

217

avoidance scores on the LSAS did not indicate any differential improvement in avoidance between the groups. It is
also possible that the dual group did worse than the
alcohol-only group because they received less alcohol treatment. Although it is true that they received approximately
15 min less alcohol treatment each week, this was typically
limited to a review of homework assignments. It is unlikely
that such a minimal difference in treatment intensity was
responsible for the increase in drinking-related outcomes,
but it is still possible. Alternatively, the dual group might
have fared worse because of the longer treatment session
(90 min). Although no data are available to address
whether clients in dual treatment lost interest or had
poorer attention during treatment, attendance rates were
similar across treatment groups (and even slightly higher in
the dual group, though not significantly so). Although it is
improbable that the different lengths of therapy session
explain the treatment outcomes, future studies should be
designed to avoid this possible confound.
Although social anxiety was addressed only in the dual
treatment group, both groups improved equally in social
anxiety scores from baseline. The reason for the social
anxiety improvement in the alcohol-only group, as well as
the lack of more significant improvement in the dual group,
is not clear. It is possible that the skills taught in the alcohol
sessions that related to drink refusal, mood management,
and high-risk situations improved social anxiety in both
groups. Another possibility is that regardless of treatment
type, the therapy provided was beneficial for social anxiety
because it gave clients a safe therapeutic relationship with
a supportive person. Perhaps this relationship was just as
influential in improving clients social anxiety as the exposure therapy that targeted social anxiety specifically.
The amount of improvement, as measured by the six
social anxiety indices, was modest (averaging around 20%
improvement from baseline scores), and average end-oftreatment scores still indicated significant impairment. Improvement in social anxiety scores was similar to those
reported from other samples of nonalcoholic clients with
social phobia treated with CBT (Cox et al., 1998). They are
smaller, however, than those observed in recent pharmacotherapy trials in nonalcoholic clients with social phobia
(Pande et al., 1999; Stein et al., 1998). Pharmacotherapy
trials typically report 30% to 50% improvements on similar
social anxiety indices.
Interestingly, there was not a correlation between improvement in social anxiety (as measured by changes in
SPAI scores) and improvement in drinking, which indicates
that improvements in each realm were unrelated, at least in
this sample. Such a relationship might have been observed
if greater reductions in social anxiety had been achieved or
if the study had focused on clients with less severe alcohol
problems.
Although it is recognized that individuals with social
phobia typically present with multiple problems, which include coexisting alcoholism and depression, there is very

218

little information on treatment outcomes for these dually

diagnosed individuals. For example, most clinical trials for
social phobia exclude subjects with alcohol dependence
(Feske and Chambless, 1995; Gelernter et al., 1991; Pande
et al., 1999; Stein et al., 1998), so it is difficult to compare
our results with those from other treatment studies. It has
been suggested that more information is needed on treatment of the socially phobic patient who also has alcoholism
and/or depression (Herbert, 1995). It is not known if socially phobic alcoholics are more resistant to social phobia
treatment or whether the treatment delivered in this trial
would have been effective if alcohol problems had not also
been addressed. However, the form of therapy used is
standard for the treatment of social phobia. The therapy
was well-controlled, manual-guided, supervised and monitored to prevent therapist drift, and individualized to the
clients specific fears. Again, because of the exclusion of
multiproblem participants, there is no literature to show
whether socially phobic individuals with and without alcoholism respond differently to CBT for social phobia. However, it is possible that individuals who have coped with
social anxiety by using alcohol for a long period of time
(i.e., alcoholics) might have a more difficult time working
through their social fears and completing homework assignments without the aid of alcohol (Merikangas et al., 1998).
If clients in the dual group continued to drink, as indicated
by the data, alcohol may have retarded the extinction of
social anxiety, as it has done for simple phobias (Cameron
et al., 1987), and reduced the benefit of the exposure
therapy.
This study has many strengths and follows recommendations of new methods for treatment efficacy research (Carroll, 1997). Specifically, diagnostic criteria for alcohol use
disorders and social phobia were made by using standardized diagnostic criteria. Treatment manuals were used to
guide both types of psychotherapy, and therapy attendance
was recorded. Corroborative data were collected from collateral informants, and standardized assessment instruments with established reliability and validity were used.
Stringent quality control procedures were implemented for
both treatment delivery and data collection. Because the
data collection was separated in time from treatment provision (i.e., collected at baseline and at the end of 12 weeks
of treatment rather than weekly during treatment), this
minimized the possible perceived pressure to provide positive reports of treatment. Therapists did not collect research outcome data or talk to research assistants about the
client, again ensuring fidelity between research and treatment. With regard to data analysis, the study included all
patients randomized to treatment who had attended one
therapy session, regardless of whether they dropped out of
treatment or provided data at all follow-up assessments.
This ensured that the sample was not biased in favor of the
more adherent clients.
Although this study has these numerous strengths, it also
has many limitations. It is limited to a severe population of

RANDALL ET AL.

treatment-seeking alcoholics, to individualized manualguided treatment, and to a cognitive behavioral therapy

approach to both alcohol and social phobia. We do not
know, for example, whether group CBT that addressed
social anxiety would have been more successful than individual CBT. Another approach to management of social
anxiety, such as social effectiveness therapy, or pharmacological therapy might have been more efficacious than CBT
for this population. Two further limitations relate to the
way that the therapy was delivered. We recognize that time
with the therapist was not equated across groups, although
the group with the most therapy exposure time actually
performed worse. Also, the fact that each therapist delivered both treatments might have masked treatment differences if the therapist inadvertently delivered one treatment
better than the other. However, the therapists were monitored for effectiveness and adherence to manuals, so this is
unlikely.
Similarly, the study is limited because it did not compare
dual treatment to group therapy or to treatment that used
a traditional 12-step approach, which are the approaches
used in most clinical treatment facilities. Given that the
cardinal feature of social phobia is fear of speaking in
groups, traditional alcoholism treatment (where groups are
used and AA participation is encouraged) might not be
fully effective unless social fears are addressed in the course
of treatment. In this case, the benefits of dual treatment
might be more apparent. Also, if a period of abstinence had
been required before trial entry, we would have been able
to assess important time-to-event measures (e.g., time to
first drink, time to first heavy drinking day) that might have
shown differential treatment effects.
In summary, the results of this controlled clinical trial in
socially phobic alcoholics have important treatment implications. They highlight the need to attend to the staging of
the treatment interventions and not just treatment of both
disorders. It generally is accepted that it is important to
treat the comorbid psychiatric disorder as well as the alcohol problem in a dual-diagnosed population for best outcome (Litten and Allen, 1995; Moggi et al., 1999; Zweben,
1993), but there has been little attention to the order in
which this should be done. That is, should the alcohol
problem be addressed first, and then the psychiatric problem if it does not remit (Schuckit and Monteiro, 1988), or
should the disorders be treated simultaneously as was done
in this trial? If done simultaneously, should the psychiatric
treatment be adjunctive (as in this study), integrated, or
parallel to the alcohol treatment? Additionally, what combination of treatment modalities maximizes improvement
in both disorders (e.g., CBT for both social phobia and
alcohol, pharmacotherapy for social phobia and CBT for
alcohol, pharmacotherapy for both social phobia and alcohol, or CBT for social phobia and 12-step for alcohol)?
Finally, it will be important to know if anxiety disorders
such as social phobia require unique staging from other
comorbid disorders, not only of alcohol and social phobia

ALCOHOLISM AND SOCIAL ANXIETY DISORDER

disorder treatment but also of the components of the social

phobia treatment itself (Cottraux et al., 2000). These are all
important questions that need to be addressed in future
research.
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