The role of anxiety sensitivity and drinking motives in predicting alcohol use: A critical review
Research Highlights
►Evidence for a relationship between anxiety sensitivity and alcohol use. ►Strong support for a relationship between anxiety sensitivity and drinking motives. ►Gender is a likely moderator of these relationships. ►Proposed path model can provide a guide for future research on anxiety sensitivity.
Introduction
Anxiety sensitivity (AS) is a cognitive, individual difference variable that refers to the fear of arousal-related bodily sensations, including increased respiration, dizziness, and heart palpitation (Reiss, 1991). Persons with high AS fear these sensations because they believe the sensations are signs of impending catastrophic physical, psychological, or social events, including life-threatening illness, loss of control, or embarrassment (Stewart & Kushner, 2001). Although this construct is similar to trait anxiety, AS is a “lower order construct that denotes a general tendency to respond fearfully to one's own anxiety symptoms” (McNally, 1999, p. 9), while trait anxiety is a higher order construct that indicates a tendency to respond fearfully to stressors (McNally, 1999). In the expectancy theory of anxiety, AS was proposed as an anxiety-accelerating factor that would increase risk for the development of anxiety-related psychopathology (Reiss & McNally, 1985). Moreover, AS is considered to be a powerful motivator of avoidance behavior (Reiss, 1991).
This connection to avoidance behaviors has resulted in a surge of research on the potential importance of AS in the development and maintenance of substance use and addictions. Because AS functions as an anxiety-amplifier (Reiss, 1991), it could lead to use of any psychoactive drug, including alcohol, that has the capacity to reduce, control, or eliminate arousal, fear, or the tendency to catastrophize about anxiety sensations (Stewart, Samoluk, & MacDonald, 1999). Consistent with theory, patients with alcohol dependence are characterized by higher than average levels of AS (cf. Stewart et al., 1999). As a result, it has been hypothesized that AS functions as a risk factor for development of substance abuse and dependence.
A recent study provides the first prospective evidence that AS predicts alcohol use disorders (Schmidt, Buckner, & Keough, 2007). A sample of 404 participants with no current or recent psychiatric diagnoses was followed for up to 24 months to determine the effects of various risk factors, including AS, on the development of alcohol use disorders (AUDs). Higher levels of AS and male gender predicted AUD development. By 24-month follow-up, 6% of males and 2% of females with high AS had AUDs, whereas 3% of males and 0% of females with low AS had AUDs. These findings prompt questions about how AS increases risk for AUD.
Correlational research suggests that high AS is associated with higher levels of alcohol consumption. High AS has been significantly and positively correlated with self-reports of weekly alcohol consumption and with yearly excessive alcohol consumption (Stewart, Peterson, & Pihl, 1995). Compared to low AS participants, high AS participants consumed significantly more drinks per week (M = 2.2 vs. 7.4 drinks per week, respectively) (Stewart et al., 1995). Moreover, high AS women self-report drinking to legal intoxication more frequently than low AS women (M = 77.0 vs. 16.2 excessive drinking episodes per year, respectively) (Conrod, Stewart, & Pihl, 1997). Thus, high AS has been associated with elevated consumption on certain alcohol use indices.
This observed correlation has created an interest in constructs, including drinking motives, that help to explain the relationship between AS and consumption. The factor model of drinking motivations posits four drinking motives: (1) enhancement motives, characterized by internal, positive reinforcement; (2) social motives, characterized by external, positive reinforcement; (3) coping motives, characterized by internal, negative reinforcement; and (4) conformity motives, characterized by external, negative reinforcement (Cooper, 1994). Each has been shown to predict unique aspects of drinking behavior (cf. Carrigan et al., 1998, Cooper, 1994). Enhancement, coping, and conformity motives have been termed “risky” motives, because they are related to drinking problems (Cooper, 1994). In particular, the negative reinforcement motives — coping and conformity — predict drinking problems after controlling for level of alcohol consumption, whereas positive reinforcement motives do not. Thus, drinking motivated by a desire to escape negative consequences may serve a more maladaptive function compared to drinking for social reward (Cooper, 1994).
AS has been linked to selected drinking motives (cf. Stewart et al., 1999). AS has been found to independently predict both coping and conformity motives (e.g. Conrod et al., 1998, Stewart et al., 1997). Individuals with high AS report more drinking to cope with negative affect than do low AS controls (Stewart et al., 1997). Moreover, high AS individuals are more likely to report that their primary reason for drinking is to cope with negative affect and are less likely to report that their primary drinking motive is social. High AS individuals are also more likely to report increased conformity-motivated drinking than low AS individuals (e.g. Stewart, Zvolensky, & Eifert, 2001). Therefore, AS is associated with risky drinking motives, which are related to increased alcohol consumption and a greater incidence of alcohol problems (Stewart et al., 1999).
Initial research focused exclusively on the correlational relationships between AS and risky drinking motives, and the individual relationships with each and alcohol use and abuse. In the last decade, research has moved from correlational studies to ones that address how AS and drinking motives are functionally related as precursors to alcohol use. Both mediator and moderator statistical models have been proposed to explain the relationships between AS, use of alcohol to cope with negative affect, and consumption levels. In addition, investigators have employed experimental methods to test predictions about AS and factors influencing drinking behavior. Consequently, a review that integrates these literatures with the goal of developing a multivariate model that incorporates AS, drinking motives, and related variables is warranted. Such a model may inform interventions that target drinking reduction in individuals with AS.
The purpose of this review is twofold. The first aim is to summarize and integrate two lines of research that can contribute to a model of AS and alcohol use: (a) correlational studies demonstrating mediator or moderator relationships with AS and drinking motives, and (b) experimental studies of AS and negative affect. The second aim is to provide a methodological critique of the existing literature and to provide suggestions for future investigation into the nature of the relationship between AS and alcohol use. In order to accomplish this, this paper is organized into three sections. The first section reviews studies that have tested a statistically mediated or moderated model of AS and drinking or drinking motives. The next section examines findings produced by experimental, laboratory-based studies on the relationships between AS, negative affect, and alcohol consumption. These sections are followed by a methodological critique and a discussion of future research directions that will enhance understanding of the complex relationship between AS and drinking.
Section snippets
Literature review
A search of the literature from 1999 to 2008 was conducted using both MEDLINE and PsycINFO databases to identify published articles in peer-reviewed journals that examined anxiety sensitivity and motives for alcohol consumption. The AS literature was last reviewed a decade ago (Stewart et al., 1999), and we focus on research published since then. These newer studies allow an examination of how AS and motives, in combination, influence alcohol use, and therefore provide a more complex picture of
Discussion
The first goal of this review was to synthesize the findings from two lines of research, statistical mediator/moderator models and experimental studies, which address the relationship between anxiety sensitivity and alcohol consumption. This synthesis resulted in development of a model of the interrelationships between AS, alcohol consumption, and drinking motives. Fig. 1 provides a path diagram of the model that incorporates findings from multiple studies.
First, evidence exists for a
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