Examination of anxiety sensitivity and distress tolerance as transdiagnostic mechanisms linking multiple anxiety pathologies to alcohol use problems in adolescents.

A number of anxiety disorders are associated with alcohol use problems (e.g., Grant et al., 2004) starting as early as young adolescence (e.g., Zimmermann et al., 2003). Compared to adolescents without these disorders, those with panic disorder (PD) and social anxiety disorder are nearly 6 and 4 times more likely to develop alcohol dependence by age 30, respectively (Buckner et al., 2008). Thus, there is a clear need to uncover the mechanisms explaining the relationship between anxiety and alcohol-related problems in adolescence to better understand the etiology of alcohol problems and their comorbidity with anxiety pathology. If the mechanisms linking anxiety and alcohol use problems are malleable individual characteristics that can be targeted in prevention interventions, such research may have beneficial effects in interventions for curbing the development of alcohol use disorders and improving mental health. Furthermore, if common factors that explain the anxiety–alcohol relation are observed across multiple forms of anxiety psychopathology, the results may inform interventions relevant to wide-spanning and symptomatically heterogeneous groups of adolescents with anxiety problems at risk for alcohol use disorders. We hypothesize that it is not the presence of anxiety symptoms and syndromes in and of themselves that entirely drive risk for alcohol use disorders, but rather, that it is the underlying traits present among those high in anxiety that enhance motivation to seek alcohol for relief. That is, transdiagnostic “reactive vulnerability” traits that reflect maladaptive responses to anxiety-related sensations (rather than anxiety symptoms per se) may be core processes underlying anxiety–alcohol comorbidity. These reactive vulnerabilities putatively underlie multiple forms of anxiety psychopathology by amplifying the maladaptive emotional and cognitive effects of various types of anxiety-related states and motivating avoidance behaviors, thereby maintaining anxiety states (see Barlow, 2004). Transdiagnostic reactive vulnerability traits may promote alcohol use behavior as a manifestation of the maladaptive tendency to execute behaviors aimed at avoiding, reducing, or eliminating anxiety symptoms, irrespective of the quality and severity of manifest anxiety symptoms. One such transdiagnostic variable that may account for the relationship between anxiety symptoms and alcohol use problems is anxiety sensitivity (AS). AS, sometimes referred to as “fear of fear,” is a fairly stable yet malleable trait characterized by the cognitive misappraisal of anxiety symptoms as having harmful or negative consequences. These perceived consequences fall into 3 factors: physical concerns, mental concerns, and social concerns. High-AS individuals perceive anxiety-related sensations as a sign of imminent harm. Consequently, they are likely to respond to anxiety-related experiences and other aversive internal states with elevated levels of anxiety, which in turn, may contribute to more threat-based cognitions and vicious cycles of fear and anxiety. AS plays a key role in the etiology and maintenance of many forms of anxiety psychopathology (Olatunji and Wolitzky-Taylor, 2009; Schmidt et al., 2006). Conceptual models posit that a fear of physical symptoms is most strongly linked to PD; a fear of showing publicly observable signs of anxiety is most strongly linked to social phobia (SP); and a fear of cognitive dyscontrol is most strongly linked to generalized anxiety disorder (GAD; see Olatunji and Wolitzky-Taylor, 2009). Furthermore, reductions in AS have been observed after treatment for anxiety disorders (Arch et al., 2013), and improvement from cognitive behavioral therapy (CBT) for certain anxiety disorders has been shown to be mediated by changes in AS (Smits, et al., 2004). A significant body of work has also demonstrated that AS is related to alcohol problems (for reviews, see Stewart et al., 1999; Stewart and Kushner, 2001) and greater coping-oriented motives for alcohol use (Stewart et al., 2001). Importantly, AS is incrementally related to coping-related drinking motives, as well as alcohol problems and (risk of) alcohol use disorder, over and above manifest anxiety and negative affect (Howell et al., 2010; Novak et al., 2003; Schmidt et al., 2007), suggesting that AS per se is an important affective mechanism underlying drinking independent of the quality or severity of anxiety symptoms. Indeed, AS may be elevated especially among those who use substances to dampen autonomic arousal (Lejuez et al., 2006), presumably because high-AS individuals are motivated to drink in order to avoid or delimit the experience of anxiety-related sensations that they perceive as personally dangerous. Moreover, brief CBT for high AS has been found to decrease emotional relief alcohol expectancies and problem drinking in young adults (Watt et al., 2006). Research on AS and alcohol problems in adolescents is scant, but the extant literature does suggest that although AS tends to be unrelated to drinking frequency or quantity in adolescence (Castellanos-Ryan et al., 2013; Woicik et al., 2009), it may be related to more severe alcohol problems (Lammers et al., 2013; Woicik et al., 2009). Given that AS is manifested in youths and plays a role in adolescent anxiety (for a review, see Silverman and Weems, 1999), it is possible that AS is an explanatory construct linking anxiety syndromes to alcohol problems in adolescents. Distress tolerance (DT) is another transdiagnostic construct that may explain why individuals high in anxiety symptoms use alcohol. Although nested conceptually within a broader network of risk and protective processes, DT is theorized to be related to, though conceptually distinct from, other transdiagnostic variables (e.g., avoidant coping, AS, emotion regulation, experiential avoidance; Leyro et al., 2010). DT is defined as (i) the perceived capacity to withstand negative emotional and/or other aversive states (e.g., physical discomfort), and (ii) the behavioral act of withstanding distressing internal states elicited by some type of stressor (Leyro et al., 2010). Individuals who perceive themselves to be lower in DT tend to report maladaptively responding to distressing states by avoiding distress-eliciting contexts, disapproving of their own ability to handle distress, and becoming cognitively absorbed and behaviorally incapacitated with the experience of distress. Importantly, DT is conceptually distinct from AS in 2 important ways: (i) DT reflects maladaptive reactivity to a broad range aversive experiences (including anxiety, but extending to other types of aversive states, such as sadness), whereas AS is focused on anxiety-related experiences; (ii) DT reflects a wider range of maladaptive reactions (including cognitive reactions, but extending to other types of reactions, such as behavioral), whereas AS is focused on cognitive expectations of negative consequences of anxiety. Factor analytic work further suggests that while DT and AS tap a common higher order construct of maladaptive emotional reactivity, they also reflect empirically distinct lower-order manifestations with unique patterns of correlation with theoretically relevant criterion variables (Bernstein et al., 2009). Hence, DT and AS appear to represent distinct transdiagnostic processes. DT is implicated in the etiology of several manifestations of anxiety, including panic, general worry, and social anxiety symptoms (Keough et al., 2010; Marshall-Berenz et al., 2010; Norr et al., 2013), perhaps because individuals with poorer DT do not engage in adaptive coping strategies in response to anxiety and instead execute avoidance behaviors that prevent habituation to anxiety as well as the development of adaptive coping mechanisms. A growing literature also documents a relation between low DT and the motivation to use alcohol to cope with negative affect (Howell et al., 2010; Marshall-Berenz et al., 2011; Vujanovic et al., 2011), which would be expected as a manifestation of the maladaptive response to distress in low-DT individuals. Further, poorer DT has been found to mediate the relation between depressive symptoms and alcohol problems in college students (Buckner et al., 2007). In addition, given recent evidence linking DT to alcohol use and anxiety in adolescents (O’Neil Rodriguez & Kendall, 2014; Winward et al., 2014), it is reasonable to suspect that poor DT may explain the association between multiple forms of adolescent anxiety and alcohol problems. The current cross-sectional study addresses the question, “If an adolescent has elevated symptoms of anxiety, what is it about that adolescent that makes her/him more likely to have alcohol use problems?” We explored AS and DT as 2 putative transdiagnostic factors linking the association between several types of anxiety pathologies and alcohol problems in a sample of 14- to 15-year-old high school students. To this end, we tested the hypothesis that AS and DT would account for (i.e., statistically mediate) relations between symptom levels of 3 types of anxiety syndromes (i.e., PD, GAD, and SP) and alcohol problem status. By doing so, we hoped to identify “key ingredients” that may underlie affective sources of alcohol use problems among adolescents with various types of anxiety.