A Peer Support Service for Patients with Alcohol Dependence & Social Anxiety

1. A Peer Support Service for Patients with Alcohol Dependence & Social Anxiety Matthew Gaskell Consultant Psychologist Leeds Addiction Unit SSA York 2013

3. Prevalence

4. Background / Context • Alcohol use disorders (AUD) & social anxiety disorder (SAD) among 5 most prevalent psychiatric diagnoses • Lifetime prevalence for AUD (inc abuse-dependence) range from 8.3 to 30.3% & for SAD from 5 to 12.1%; lifetime prevalence of co-morbid AUD & SUD in general population is 2.4% (Kessler et al. 2005) • AUD and SAD frequently co-occur, are highly co-morbid with other Axis I and II disorders, & are associated with severe morbidity & functional disability

5. Background / context Recovery from either disorder is compromised by failure to treat the other (Lucrubier, 1998; Moggi et al. 1999; Randall et al. 2001; Terra et al. 2006)

6. Early Onset (11-16)

7. Chicken or Egg?

8. “The course of SAD is typically chronic and unremitting. Left untreated it can lead to a downward spiral of impaired functioning.” • (Leahy, Holland & McGinn, 2012, p218)

9. Functional Impairment

10. Co-Morbidity 97% with co-morbid alcohol/SAD have at least one additional psychiatric disorder (a mean of 4.6 disorders) • Schneier et al 2010 – National Epidemiological Survey • Depression • Avoidant personality in severe cases

11. Barriers to Treatment • Both frequently go undetected and untreated, despite existence of efficacious treatments • A diagnostic challenge • Patients hide SA • Addiction professionals/services focused on the addiction problem • Popular addiction treatments such as AA and NA or other groups present social obstacles

12. What is Social Anxiety Like?

13. DSM-IV – Social Phobia • A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. • The feared social or performance situations are avoided or else are endured with intense anxiety or distress.

15. Common fears • Eating, writing, drinking or using the phone in public • Doing a task while being observed • Talking to strangers or authority figures • Offering an opinion or disagreeing • Talking about yourself • Social events • Blushing, shaking, sweating • Being introduced

18. Treatment Models • Randall et al. 2001: Integrated CBT for AUD and SAD yielded worse outcomes versus CBT for AUD alone • Watkins et al. 2004: Empirical support for integrated versus sequential or separate treatment is lacking • Buckner et al. 2008:Integrated MET with CBT. Preliminary data are encouraging.

19. The Leeds Addiction Unit Treatment Model for SAD and AUD

20. Treatment Model – Phase 1 • Based on integrated assessment, formulation & treatment in one service • Alcohol dependence addressed first • Detoxification & RP Pharmacotherapy • Relapse Prevention / SBNT • Initial 1:1 CBT Prep for SA

21. Phase 220 sessions of group CBT for Social Anxiety

22. Phase 3Weekly peer group meetings

23. Phase 4Peer activities & social events

24. Outcomes

25. Social Anxiety Group: Baseline and outcome dependence, psychological well being and social satisfaction measures n=6 participants; 4 dropped following first session LDQ scores 0-30; CORE score 0-40; SSQ scores 0-24

26. Service User Experiences

27. “I was isolated from any social situation and did not even go out of the door unless I had a friend or my support worker. I really thought I was crazy and that depression was my only problem. I felt a freak that stood out, and nobody understood my situation. Unlike AA we actually learned techniques to deal with day to day issues & evaluating them together to make behavioural changes. I would measure it up from having a lifestyle of seeing drinking buddies to having real friends.”

28. “I don’t generally do groups. But hearing people’s stories, first hand, past and present, was a revelation. I haven’t criticised myself for my apparent social ineptitude to half the extent I used to.”

29. “It was important for me to realise that other people view me completely differently from my own interpretation of self. We all share a common purpose and background. There is a genuine air of empathy. CBT gave me a foundation to assess situations honestly, rather than jumping to conclusions based on skewed historical fears.”

30. “I had the opportunity and potential to help others in the group. I could finally put something back – I seemed to have spent my life being part of the problem rather than part of the solution. I don’t drink. I am much less anxious. I am more able to talk to people and form relationships. When I joined the group I had a very negative self-image – I now feel more positive about myself which has improved all aspects of my life. The group are now my friends. They provide an anchor; stability that prevents me from slipping back to old ways. It has given me practice in being in and coping with social situations”

31. Summary • Prevalent co-morbid presentation • Highly comorbid with other problems • Early onset • Severe morbidity & functional impairment • Hidden disorder – frequently undetected & untreated • Treatment works & seems to be a worthwhile investment

32. Further Reading Clark, D.M. (2001). A Cognitive Perspective on Social Phobia. In Crozier, W.R. & Alden, L.E. (Eds) International Handbook of Social Anxiety: Concepts, Research and Interventions Relating to the Self and Shyness. John Wiley & Sons. Schneier, F.R., Foose, T.E., Hasin, D.S., Heimberg, R.G., Liu, S.-M, Grant, B.F. & Blanco, C. (2010). Social anxiety disorder and alcohol use co-morbidity in the National Epidemiologic Survey on Alcohol & Related Conditions. Psychological Medicine, 40, 6, 977-988.