Psychology of Addictive Behaviors 2014, Vol. 28, No. 4, 1284 –1289
© 2014 American Psychological Association 0893-164X/14/$12.00 http://dx.doi.org/10.1037/a0037643
BRIEF REPORT
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Anxiety Sensitivity as a Moderator of the Relationship Between Trait Anxiety and Illicit Substance Use Laura J. Dixon
Erin N. Stevens
University of Mississippi Medical Center
Northern Illinois University
Andres G. Viana University of Mississippi Medical Center Anxiety and substance use problems are common and often comorbid, and past research has shown that young adults in particular are especially at risk for developing these disorders. To further delineate the relationship between anxiety and substance use, the current study evaluated anxiety sensitivity (AS)—a cognitive vulnerability factor—as a moderator of the association between trait anxiety and illicit substance use in a large sample of young adults (N ⫽ 845; M ⫽ 18.7 years, SD ⫽ 1.0). It was hypothesized that AS would moderate the association between trait anxiety and illicit substance use, such that trait anxiety would significantly predict illicit substance use among those with high, but not low, AS. Consistent with prediction, a significant trait Anxiety ⫻ AS interaction was found, 2(5) ⫽ 29.38, p ⬍ .001. Specifically, analyses of simple slopes revealed that for the high-AS group, as trait anxiety increased, so did frequency of illicit substance use (odds ratio [OR] ⫽ 1.03, p ⫽ .005; 95% confidence interval [CI] [1.01, 1.06]). The slope for the low AS was not significant (OR ⫽ 0.98, p ⫽ .100; 95% CI [0.95, 1.01]). Results also showed significant moderation effects for the AS physical concerns and cognitive concerns facets but not AS social concerns. These findings suggest that AS may be an important cognitive vulnerability that may help to identify those at particular risk for substance use, and that interventions should target AS reduction in anxiety-prone individuals to reduce and prevent substance abuse. Keywords: anxiety, illicit substance use, anxiety sensitivity, young adulthood, prevention
(de Girolamo, Dagani, Purcell, Cocchi, & McGorry, 2012). Among these, substance use and anxiety problems are particularly prevalent (Vida et al., 2009), comorbid (Conway, Compton, Stinson, & Grant, 2006), and a public health concern that warrants serious attention. Research suggests that anxiety disorders can increase risk for substance use among young adults, who often engage in substance use to reduce anxiety and its associated features (Cranford, Eisenberg, & Serras, 2009; Dawson, Grant, Stinson, & Chou, 2005). Likewise, high-risk substance users are often found to drink to cope with anxious states (Fitzgerald & Long, 2012). However, the specific mechanisms that contribute to the association between anxiety and substance use are still not fully understood. As a result, increased attention has been paid to individual difference factors that may help to clarify when anxiety and substance use may be most likely to covary. Among these, anxiety sensitivity (AS)—the belief that anxiety-related sensations can have catastrophic physical, social, and/or cognitive consequences (Reiss & McNally, 1985)— has received substantial empirical support for its role in substance use (Stewart, Samoluk, & MacDonald, 1999). Numerous studies have found that AS is associated with substance misuse, especially among anxiety-prone individuals (Stewart & Kushner, 2001). Alcohol use in college students is positively
It is well documented that young adults often engage in risky behaviors, particularly those who attend college (e.g., binge drinking, drug use; Bachman, Johnston, O’Malley, & Schulenberg, 1996). Research has found that substance use initiation commonly coincides with the transition to college, and lifetime prevalence rates of substance use have been found to increase from the end of high school to the sophomore year of college (Arria et al., 2013). Substance use in college is associated with a range of negative outcomes, including absenteeism, risky sex, and increased aggression (Cleveland, Mallett, White, Turrisi, & Favero, 2013; Martens, Brown, Donovan, & Dude, 2005). Moreover, this period is commonly associated with the onset of many psychological disorders
This article was published Online First August 18, 2014. Laura J. Dixon, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center; Erin N. Stevens, Department of Psychology, Northern Illinois University; Andres G. Viana, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center. Correspondence concerning this article should be addressed to Andres G. Viana, Department of Psychiatry and Human Behavior, School of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. E-mail: [email protected] 1284
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MODERATING EFFECT OF AS
related to high AS (Stewart & Zeitlin, 1995), and research has found that young adults with both high trait anxiety and high AS endorsed drinking to cope and avoid anxiety-related arousal (DeMartini & Carey, 2011). Studies examining the role of AS in illicit substance use in particular have also found positive associations between AS and illicit sedative use (Hearon et al., 2011), cocaine dependence (Buckner, Proctor, Reynolds, Kopetz, & Lejuez, 2011), problematic cannabis use (Buckner, Zvolensky, et al., 2011), and heroin use (Lejuez, Paulson, Daughters, Bornovalova, & Zvolensky, 2006). Extant research on the lower order facets of AS and illicit substance use, although limited, has also found that AS social and cognitive concerns predicted marijuana cravings (Buckner, Zvolensky, et al., 2011), whereas AS physical and social concerns were significantly associated with cocaine dependence (Buckner, Proctor, et al., 2011). Given associations of AS to both anxiety and illicit substance use, investigators have also examined whether AS may operate as a moderator of this relationship (e.g., Buckner, Leen-Feldner, Zvolensky, & Schmidt, 2009). In general, these studies have found that increased AS is indeed associated with greater levels of anxiety symptoms in substance users (McLeish, Zvolensky, & Bucossi, 2007; McLeish, Zvolensky, Yartz, & Leyro, 2008). Although more research is clearly needed, this literature suggests that the association between trait anxiety and substance use may be stronger for high (vs. low) AS individuals, who may have difficulty managing arousal and rely on illicit substances to regulate their distress. Young adults in college who have high AS may be especially at risk, due in part to their frequent exposure to anxietyprovoking situations (e.g., separation from family, academic demands) and the increased opportunities for relying on illicit substances to cope with distress. The aim of the current study was to evaluate the role of AS as a moderator of the relationship between trait anxiety and illicit substance use in a large sample of college-attending young adults. It was hypothesized that the association between trait anxiety and illicit substance use would be moderated by AS, such that increases in trait anxiety would be associated with increases in illicit substance use frequency among those with high (vs. low) AS. Consistent with existing recommendations, the higher order AS total factor was examined as a dimensional construct (cf. categorical; Broman-Fulks et al., 2010). Each AS lower order facet was also examined, given the limited research on the differential effect(s) of the AS facets on illicit substance use frequency. Accordingly, it was hypothesized that each AS facet (i.e., physical, social, cognitive) would significantly moderate the relationship between trait anxiety and illicit substance use, wherein increases in trait anxiety would be associated with increases in illicit substance use frequency among individuals evidencing high (vs. low) levels of AS physical, social, and cognitive concerns (respectively).
Method Participants and Procedure Undergraduate students (N ⫽ 885) from an introductory psychology participant pool at a large, public Northeastern university participated in the current study. Inclusionary criteria required that participants be between 18 and 22 years, as participants older than 22 years fell outside of accepted chronological boundaries of
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young adults (Steinberg, 2005). Participants provided informed consent and completed a battery of measures, all of which took place during a single, online assessment session. Course credit was given for participation. All procedures were approved by the institutional review board of the corresponding author’s former institution. Forty participants had missing data and were excluded from analyses. Univariate outliers which had a z score ⱖ3.3 (six cases; .08% of all data) were corrected to one unit larger or smaller than the next most extreme score in the distribution (Tabachnick & Fidell, 2007). Multivariate outliers were also examined, though no cases evidenced extreme Mahalanobis distances (Tabachnick & Fidell, 2007). To safeguard the validity of responses, the questionnaire packet also included the Jackson Infrequency Scale (Jackson, 1984), a measure designed to assess for infrequent responses. A score ⱖ4 on this measure suggests that a participant’s responses may be invalid. No participants scored ⱖ4 on this measure. The final sample (N ⫽ 845; 71% female) had a mean age of 18.7 years (SD ⫽ 1.0). Eighty-three percent of participants identified as White American, 7% as Asian American, 4% as Hispanic/Latino(a), 4% as African American, 1% as Pacific Islander, and 1% as another or unspecified racial/ethnic background. Given the relatively small number of ethnic/racial minorities, race and ethnicity were collapsed into a single dummy-coded variable for preliminary analyses (coded as White [n ⫽ 700, 83%] vs. non-White [n ⫽ 142, 17%]; see Results).
Measures State-Trait Anxiety Inventory–Trait Version (STAI-T; Spielberger, Gorsuch, & Lushene, 1970). The STAI-T is a 20-item self-report questionnaire that assesses chronic, crosssituational trait anxiety. Participants are asked to rate the frequency with which they experience a variety of anxiety symptoms (e.g., “I feel nervous and restless”) on a 4-point scale (1 ⫽ almost never to 4 ⫽ almost always). Total scores (range ⫽ 20 to 80) are computed by summing individual item scores; higher scores indicate higher trait anxiety (in this study, ␣ ⫽ .92). Anxiety Sensitivity Index – 3 (ASI-3; Taylor et al., 2007). The ASI-3 is an 18-item self-report questionnaire designed to assess fear of anxiety-related sensations. Participants are asked to rate the extent to which they agree with statements which assess fears about normal anxiety reactions on a 5-point scale (0 ⫽ very little to 4 ⫽ very much). Total scores are computed by summing responses to all items. Results from a factor analysis on the ASI-3 (Taylor et al., 2007) suggested a total score and three facets (each comprised of six items) related to physical, cognitive, and social concerns in this study (␣ ⫽ .80 to .89 across ASI-3 facets). Illicit substance use. A single item from a larger survey designed to assess substance use, risk factors for psychopathology, and overall psychological adjustment (see Viana, Gratz, & Rabian, 2011) was used to assess the frequency with which participants engaged in illicit substance use. The item was rated on a 6-point scale (1 ⫽ never, 2 ⫽ eleven or fewer times per year, 3 ⫽ once per month, 4 ⫽ two to three times per month, 5 ⫽ once per week, 6 ⫽ two or more times per week).
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Data Analytic Approach T tests and correlations were examined to determine whether there were main effects of the demographic variables (i.e., gender, race/ethnicity, age) on all other study variables. Holm’s (1979) modified Bonferroni correction was used to control for increases in the probability of making a Type I error as a result of conducting multiple comparisons (Jaccard & Guilamo-Ramos, 2002). This step-down procedure is one in which, first, the critical p value (i.e., ␣ ⫽ .05) is divided by k, where k is the number of tests. Then, all obtained p values are ranked from least to greatest magnitude; the most significant p value is compared with .05/k and, if the result is significant, the next most significant p value obtained is compared with .05/(k⫺1). If the result is significant, the next p value in the rank is compared with .05/(k⫺2), and so on. The procedure continues until a nonsignificant result is observed. Demographic variables with significant associations with the dependent variables were added as covariates in subsequent multivariate analyses. An ordinal regression model was used to examine AS total scores as a moderator of the association between trait anxiety and illicit substance use. To examine the independent contributions of each AS facet (i.e., physical, social, cognitive), three ordinal regressions were conducted using each AS facet as a moderator in the association between trait anxiety and illicit substance use, while controlling for the other AS facets. For each regression, control variables, trait anxiety, AS, and an interaction term comprised of the product of trait anxiety and AS were entered as predictor variables. Predictor variables were mean-centered (Aiken & West, 1991). Significant interactions were probed using simple slopes analyses (i.e., at high and low [⫾ 1.5 SD from the mean] values of AS) corresponding to clinical and nonclinical levels of AS (cf. Taylor et al., 2007).
Results Preliminary Analyses and Descriptive Statistics Age was significantly positively associated with substance use, and males reported greater frequency of substance use than females, t(839) ⫽ 4.67, p ⬍ .001 (M ⫽ 1.92, SD ⫽ 1.63, and M ⫽
1.47, SD ⫽ 1.09, respectively). Race/ethnicity was not significantly associated with illicit substance use frequency. Means, standard deviations, and correlations for study variables are presented in Table 1. Trait anxiety was significantly associated with AS total score (p ⬍ .001), as well as the three AS facets (ps ⬍ .001). Illicit substance use frequency was significantly associated with the AS total score (p ⫽ .036), as well as the AS-Physical Concerns subscale (p ⫽ .029). Illicit substance use frequency was not significantly associated with trait anxiety (p ⫽ .237), nor was it associated with either the AS-Social Concerns (p ⫽ .289) or AS-Cognitive Concerns (p ⫽ .131) subscales.
Moderation Analyses The first regression examined associations between trait anxiety, AS total score, and illicit substance use frequency. The overall model was significant, 2(5) ⫽ 29.38, p ⬍ .001, Nagelkerke R2 ⫽ .041. There was a significant interaction between AS and trait anxiety in predicting illicit substance use (odds ratio [OR] ⫽ 1.002, p ⫽ .006; 95% confidence interval [CI] [1.001, 1.003]). Simple slopes analysis revealed a significant, positive relationship between trait anxiety and illicit substance use frequency for high-AS individuals (OR ⫽ 1.03, p ⫽ .005; 95% CI [1.01, 1.06]), but a nonsignificant relationship for low-AS individuals (OR ⫽ 0.98, p ⫽ .100; 95% CI [0.95, 1.01]; see Figure 1). Three additional ordinal linear regressions examined associations between trait anxiety, AS facets, and illicit substance use frequency (see Table 2). All models were significant (ps ⬍ .001, Nagelkerke R2 ⫽ .039 to .043). Significant interactions emerged between trait anxiety and both AS physical concerns (OR ⫽ 1.004, 95% CI [1.001, 1.007], p ⫽ .011) and AS cognitive concerns (OR ⫽ 1.004, 95% CI [1.001, 1.008], p ⫽ .009). The interaction between AS social concerns and trait anxiety was not significant (OR ⫽ 1.002, 95% CI [1.000, 1.005], p ⫽ .095). Simple slopes analyses revealed a significant, positive relationship between trait anxiety and illicit substance use frequency for individuals with high AS physical concerns (OR ⫽ 1.03, 95% CI [1.01, 1.06], p ⫽ .022), but a nonsignificant relationship for individuals with low AS physical concerns (OR ⫽ 0.98, 95% CI [0.95, 1.01], p ⫽ .186). Similarly, there was a significant, positive relationship between
Table 1 Correlations Among Variables of Interest Variable name 1. 2. 3. 4. 5. 6. 7. 8. 9.
Age Gender Ethnicity Trait anxiety Anxiety sensitivity AS-Physical Concerns AS-Social Concerns AS-Cognitive Concerns Illicit substance use
M
SD
1
2
3
4
5
6
7
8
9
18.71 71%a 83%b 39.34 15.67 4.14 8.57 2.98 75%c
0.95 — — 9.47 11.59 4.72 5.19 4.05 —
— ⫺.16ⴱⴱⴱ ⫺.08ⴱ .01 .01 .03 ⫺.02 .01 .12ⴱⴱⴱ
— .03 .04 ⫺.06 ⫺.00 ⫺.08ⴱ ⫺.05 ⫺.12ⴱⴱⴱ
— ⫺.04 ⫺.06 ⫺.05 ⫺.02 ⫺.10ⴱⴱ .05
— .51ⴱⴱⴱ .36ⴱⴱⴱ .42ⴱⴱⴱ .51ⴱⴱⴱ .04
— .86ⴱⴱⴱ .82ⴱⴱⴱ .84ⴱⴱⴱ .07ⴱ
— .51ⴱⴱⴱ .68ⴱⴱⴱ .08ⴱ
— .50ⴱⴱⴱ .04
— .05
—
Note. N ⫽ 845. Trait anxiety ⫽ State-Trait Anxiety Inventory; Anxiety sensitivity(AS) ⫽ Anxiety Sensitivity Index – 3. a For gender, 71% of the sample was females and 29% was males. b Race and ethnicity were collapsed into a single dummy-coded variable for preliminary analyses, coded as White (83%) vs. minority (17%). c Reported correlations between illicit substance use and continuous variables are Spearman. For illicit substance use, 75% of the sample reported never having used, 11% reported ⬍ 12⫻/year, 4% reported 1⫻/month, 5% reported 2–3⫻/month, 2% reported 1⫻/week, and 4% reported ⬎ 1⫻/week. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.
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MODERATING EFFECT OF AS
Figure 1. The relationship between trait anxiety and illicit substance use frequency for individuals at high and low levels of the AS total score (⫹1.5 SD above and below the mean of AS, respectively). The relationship between trait anxiety and illicit substance use frequency for individuals high in AS was significant (OR ⫽ 1.03, p ⫽ .005; 95% CI [1.01, 1.06]); it was nonsignificant for those low in AS (OR ⫽ 0.98, 95% CI [0.95, 1.01], p ⫽ .100).
trait anxiety and illicit substance use frequency for individuals with high AS cognitive concerns (OR ⫽ 1.03, 95% CI [1.01, 1.06], p ⫽ .021), but a nonsignificant relationship for individuals with low AS cognitive concerns (OR ⫽ 0.98, 95% CI [0.95, 1.01], p ⫽ .170).
Discussion The aim of the current study was to investigate the moderating role of AS in the association between anxiety and illicit substance in a large sample of young college-attending adults. Consistent with our hypothesis, high anxiety was positively associated with substance use frequency among young adults who evidenced high (clinical), but not low (nonclinical), levels of AS. Although the magnitude of this effect was indeed small, findings provide direct empirical support for theoretical models of AS as a moderator of the anxiety-illicit substance use association (e.g., Stewart & Kushner, 2001), and suggest that the association between anxiety and illicit substance use is especially problematic among individuals with clinical levels of AS (see Taylor et al., 2007).
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A unique aspect of the current evaluation was the differential examination of the lower order facets of AS. Trait anxiety was modestly but significantly associated with increased illicit substance use among young adults with higher levels of two of the three AS facets (i.e., physical and cognitive). In line with selfmedication and negative affect reduction theories of substance use (Kushner, Abrams, & Borchardt, 2000), findings suggest that young adults with heightened anxiety may use illicit substances to cope with anxiety-related physiological cues (e.g., increased heart rate, sweating) or cognitive dyscontrol (e.g., disassociation, mind racing, losing control) that are perceived as potentially catastrophic. Although this strategy may serve to reduce uncomfortable physiological and cognitive sensations in the short term through negative reinforcement, the likelihood of future illicit substance use may actually increase (Stewart & Kushner, 2001). Interestingly, a significant moderator effect was not found for AS social concerns, suggesting that young adults with high trait anxiety engage in illicit substance use primarily to manage one’s internal anxiety experience (i.e., physical, cognitive cues) rather than to cope with or reduce socially observable anxiety sensations. Taken together, findings provide support for the role of AS as an important, individual difference factor that may influence the association between anxiety and illicit substance use. Given that individuals with high AS are at risk for coping-motivated substance misuse (Robinson, Sareen, Cox, & Bolton, 2011), findings highlight the importance of increased utilization of prevention programs focused on AS reduction in young adults at risk for substance use. For example, past research suggests that cognitive– behavioral, school-based intervention programs targeting AS (and several other risk factors for alcohol misuse), through psychoeducation, cognitive coping skills training, and behavioral coping skills training, lead to both short- and long-term reductions in problematic substance use among adolescents (Conrod, Stewart, Comeau, & Maclean, 2006). These interventions may be particularly appealing in the context of a college setting, as they are brief, cost-effective, and easily implemented (i.e., delivered in group format, master’s-level therapists). Finally, in addition to increasing the utilization of preventionbased treatments, findings suggest that AS should be a treatment target for individuals presenting with comorbid substance and anxiety, as reductions in AS may decrease risk for substance
Table 2 Summary of Ordinal Regression Analyses and Odds Ratios for Variables Predicting Illicit Drug Use Anxiety sensitivity moderator variables Variable
Physical OR [95% CI]
Cognitive OR [95% CI]
Social OR [95% CI]
Gender Age Trait anxiety Anxiety sensitivity – Physical Anxiety sensitivity – Cognitive Anxiety sensitivity – Social Trait Anxiety ⫻ Anxiety Sensitivity moderator Nagelkerke R2
1.75 [1.25, 2.45]ⴱⴱⴱⴱ 1.23 [1.06, 1.45]ⴱⴱⴱ 1.03 [0.98, 1.07] 0.99 [0.94, 1.05] 0.99 [0.95, 1.03] 1.01 [0.99, 1.03] 1.004 [1.001, 1.007]ⴱⴱ .043ⴱⴱⴱⴱ
1.78 [1.27, 2.50]ⴱⴱⴱⴱ 1.23 [1.06, 1.44]ⴱⴱⴱ 1.04 [1.00, 1.09]ⴱ 0.97 [0.91, 1.03] 0.99 [0.95, 1.03] 1.01 [0.99, 1.03] 1.004 [1.001, 1.008]ⴱⴱⴱ .043ⴱⴱⴱⴱ
1.75 [1.25, 2.45]ⴱⴱⴱⴱ 1.23 [1.05, 1.44]ⴱⴱⴱ 1.04 [0.99, 1.09]ⴱ 1.00 [0.94, 1.06] 0.99 [0.95, 1.02] 1.01 [0.99, 1.03] 1.002 [1.000, 1.005]ⴱ .039ⴱⴱⴱⴱ
Note. N ⫽ 845. OR ⫽ odds ratio; CI ⫽ confidence interval; Trait anxiety ⫽ State-Trait Anxiety Inventory; Anxiety sensitivity ⫽ Anxiety Sensitivity Index – 3. ⴱ p ⬍ .10. ⴱⴱ p ⬍ .05. ⴱⴱⴱ p ⬍ .01. ⴱⴱⴱⴱ p ⬍ .001.
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utilization. Extant research has demonstrated the effectiveness of brief stand-alone or integrated interventions for AS reduction (e.g., Keough & Schmidt, 2012), in the treatment of substance withdrawal (e.g., Otto, Pollack, Meltzer-Brody, & Rosenbaum, 1992), and the inclusion of cognitive– behavioral strategies for AS in substance-use treatment has been found to reduce distress associated with substance misuse (Tull, Schulzinger, Schmidt, Zvolensky, & Lejuez, 2007). Likewise, integrative treatments targeting both AS and substance use through cognitive– behavioral strategies have yielded positive outcomes related to smoking-cessation behaviors and AS reductions (Feldner, Zvolensky, Babson, LeenFeldner, & Schmidt, 2008; Zvolensky, Brandt, & Bernstein, 2011). Given these findings, we propose that such interventions could be similarly effective for decreasing AS and illicit substance use in young adults with anxiety and/or substance use difficulties. As expected, this study is not without limitations. First, the study utilized a cross-sectional study design; therefore, the direction or temporal order of the associations reported here cannot be determined and may differ from our predictions. Specifically, although several longitudinal studies have established that anxiety often precedes illicit substance use (Wolitzky-Taylor, Bobova, Zingbarg, Mineka, & Craske, 2012), it may be that illicit substance use also leads to increased anxiety. Longitudinal studies are needed to clarify the precise nature of the associations examined here and whether there are any (and we suspect there are) bidirectional influences between trait anxiety, AS, and illicit substance use over time. Second, the sample was comprised of nonclinical college-attending young adults, most of whom were White American females. Likewise, although moderation analyses did test associations between trait anxiety and substance use at clinical levels of the moderator (AS total score ⫽ 33; see Taylor et al., 2007), the extent to which results generalize to other young adults or to clinical populations evidencing greater levels of severity (e.g., substance dependence) remains unclear. In addition, given the degree of substance use in our sample, replication of these associations among heavy users is needed. Finally, an additional limitation was the lack of specificity with regard to type of illicit substance used by participants, which was not assessed. Given that marijuana is the most commonly utilized illicit substance among college students (Substance Abuse and Mental Health Services Administration, 2011), we suspect that marijuana was likely the illicit substance of choice for many participants. However, caution is warranted until results are replicated in investigations specifically assessing for various types of illicit substances. Despite limitations, the current findings further our understanding of the associations among anxiety, AS, and substance use, and highlight the role of AS as an important cognitive vulnerability that may influence illicit substance use among young adults. Given that young adulthood is a period of change and stressful developmental transitions, identifying factors that may increase risk for maladaptive behaviors in this population is of paramount importance. Likewise, findings highlight the importance of differential examination of the facets of AS. Given the different properties of substances and their differential effects on the body (e.g., cognitive effects vs. physiological effects), it is likely that examining specific AS facets may facilitate the identification of young adults at risk for specific types of substances.
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MODERATING EFFECT OF AS Fitzgerald, K., & Long, C. G. (2012). The influence of drinking motives and anxiety on low-moderate- and high-risk drinkers. Journal of Substance Use, 17, 240 –248. doi:10.3109/14659891.2011.565109 Hearon, B. A., Calkins, A. W., Halperin, D. M., McHugh, R. K., Murray, H. W., & Otto, M. W. (2011). Anxiety sensitivity and illicit sedative use among opiate-dependent women and men. The American Journal of Drug and Alcohol Abuse, 37, 43– 47. doi:10.3109/00952990.2010 .535581 Holm, S. (1979). A simple sequentially rejective multiple test procedure. Scandinavian Journal of Statistics, 6, 65–70. Jaccard, J., & Guilamo-Ramos, V. (2002). Analysis of variance frameworks in clinical child and adolescent psychology: Advanced issues and recommendations. Journal of Clinical Child and Adolescent Psychology, 31, 278 –294. doi:10.1207/S15374424JCCP3102_13 Jackson, D. N. (1984). Personality research form manual (3rd ed.). Port Heron: Research Psychologists Press. Keough, M. E., & Schmidt, N. B. (2012). Refinement of a brief anxiety sensitivity reduction intervention. Journal of Consulting and Clinical Psychology, 80, 766 –772. doi:10.1037/a0027961 Kushner, M. G., Abrams, K., & Borchardt, C. (2000). The relationship between anxiety disorders and alcohol use disorders: A review of major perspectives and findings. Clinical Psychology Review, 20, 149 –171. doi:10.1016/S0272-7358(99)00027-6 Lejuez, C. W., Paulson, A., Daughters, S. B., Bornovalova, M. A., & Zvolensky, M. J. (2006). The association between heroin use and anxiety sensitivity among inner-city individuals in residential drug use treatment. Behaviour Research and Therapy, 44, 667– 677. doi:10.1016/j .brat.2005.04.006 Martens, M. P., Brown, N. T., Donovan, B. M., & Dude, K. (2005). Measuring negative consequences of college student substance use: A psychometric evaluation of the core alcohol and drug survey. Measurement and Evaluation in Counseling and Development, 38, 164 –175. McLeish, A. C., Zvolensky, M. J., & Bucossi, M. M. (2007). Interaction between smoking rate and anxiety sensitivity: Relation to anticipatory anxiety and panic-relevant avoidance among daily smokers. Journal of Anxiety Disorders, 21, 849 – 859. doi:10.1016/j.janxdis.2006.11.003 McLeish, A. C., Zvolensky, M. J., Yartz, A. R., & Leyro, T. M. (2008). Anxiety sensitivity as a moderator of the association between smoking status and anxiety symptoms and bodily vigilance: Replication and extension in a young adult sample. Addictive Behaviors, 33, 315–327. doi:10.1016/j.addbeh.2007.09.018 Otto, M. W., Pollack, M. H., Meltzer-Brody, S., & Rosenbaum, J. F. (1992). Cognitive-behavioral therapy for benzodiazepine discontinuation in panic disorder patients. Psychopharmacology Bulletin, 28, 123– 130. Reiss, S., & McNally, R. J. (1985). Expectancy model of fear. In S. Reiss & R. R. Bootzin (Eds.), Theoretical issues in behavior therapy (pp. 107–121). San Diego, CA: Academic Press. Robinson, J. A., Sareen, J., Cox, B. J., & Bolton, J. M. (2011). Role of self-medication in the development of comorbid anxiety and substance use disorders: A longitudinal investigation. Archives of General Psychiatry, 68, 800 – 807. doi:10.1001/archgenpsychiatry.2011.75
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Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). The StateTrait Anxiety Inventory: Test manual. Palo Alto, CA: Consulting Psychologist Press. Steinberg, L. (2005). Cognitive and affective development in adolescence. Trends in Cognitive Sciences, 9, 69 –74. doi:10.1016/j.tics.2004.12.005 Stewart, S. H., & Kushner, M. G. (2001). Introduction to the special issue on “anxiety sensitivity and addictive behaviors.” Addictive Behaviors, 26, 775–785. doi:10.1016/S0306-4603(01)00236-2 Stewart, S. H., Samoluk, S., & MacDonald, A. B. (1999). Anxiety sensitivity and substance use and abuse. In S. Taylor (Ed.), Anxiety sensitivity: Theory, research, and treatment of the fear of anxiety (pp. 287–319). Mahwah, NJ: Erlbaum. Stewart, S. H., & Zeitlin, S. B. (1995). Anxiety sensitivity and alcohol use motives. Journal of Anxiety Disorders, 9, 229 –240. doi:10.1016/08876185(95)00004-8 Substance Abuse and Mental Health Services Administration. (2011). Results from the 2010 National Survey on Drug Use and Health: Summary of national findings. NSDUH Series H-41, HHS Publication No. (SMA) 11– 4658. Rockville, MD: Substance Abuse and Mental Health Services Administration. Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics. Needham, MA: Allyn & Bacon. Taylor, S., Zvolensky, M. J., Cox, B. J., Deacon, B., Heimberg, R. G., Ledley, D. R., . . . Cardenas, S. J. (2007). Robust dimensions of anxiety sensitivity: Development and initial validation of the Anxiety Sensitivity Index-3. Psychological Assessment, 19, 176 –188. doi:10.1037/10403590.19.2.176 Tull, M. T., Schulzinger, D., Schmidt, N. B., Zvolensky, M. J., & Lejuez, C. W. (2007). Development and initial examination of a brief intervention for heightened anxiety sensitivity among heroin users. Behavior Modification, 31, 220 –242. doi:10.1177/0145445506297020 Viana, A. G., Gratz, K. L., & Rabian, B. (2011). Cumulative versus multiple-risk models in the prediction of anxiety symptoms. Journal of Experimental Psychopathology, 2, 354 –370. Vida, R., Brownlie, E. B., Beitchman, J. H., Adlaf, E. M., Atkinson, L., Escobar, M., . . . Bender, D. (2009). Emerging adult outcomes of adolescent psychiatry and substance use disorders. Addictive Behaviors, 34, 800 – 805. doi:10.1016/j.addbeh.2009.03.035 Wolitzky-Taylor, K., Bobova, L., Zingbarg, R. E., Mineka, S., & Craske, M. G. (2012). Longitudinal investigation of the impact of anxiety and mood disorders in adolescence on subsequent substance use disorder onset and vice versa. Addictive Behaviors, 37, 982–985. doi:10.1016/j .addbeh.2012.03.026 Zvolensky, M. J., Brandt, C., & Bernstein, A. (2011). Panic psychopathology and substance use disorders. Annals of Psychotherapy & Integrative Health, 14, 28 – 41.
Received September 24, 2013 Revision received June 13, 2014 Accepted July 3, 2014 䡲
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BRIEF REPORT
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Anxiety Sensitivity as a Moderator of the Relationship Between Trait Anxiety and Illicit Substance Use Laura J. Dixon
Erin N. Stevens
University of Mississippi Medical Center
Northern Illinois University
Andres G. Viana University of Mississippi Medical Center Anxiety and substance use problems are common and often comorbid, and past research has shown that young adults in particular are especially at risk for developing these disorders. To further delineate the relationship between anxiety and substance use, the current study evaluated anxiety sensitivity (AS)—a cognitive vulnerability factor—as a moderator of the association between trait anxiety and illicit substance use in a large sample of young adults (N ⫽ 845; M ⫽ 18.7 years, SD ⫽ 1.0). It was hypothesized that AS would moderate the association between trait anxiety and illicit substance use, such that trait anxiety would significantly predict illicit substance use among those with high, but not low, AS. Consistent with prediction, a significant trait Anxiety ⫻ AS interaction was found, 2(5) ⫽ 29.38, p ⬍ .001. Specifically, analyses of simple slopes revealed that for the high-AS group, as trait anxiety increased, so did frequency of illicit substance use (odds ratio [OR] ⫽ 1.03, p ⫽ .005; 95% confidence interval [CI] [1.01, 1.06]). The slope for the low AS was not significant (OR ⫽ 0.98, p ⫽ .100; 95% CI [0.95, 1.01]). Results also showed significant moderation effects for the AS physical concerns and cognitive concerns facets but not AS social concerns. These findings suggest that AS may be an important cognitive vulnerability that may help to identify those at particular risk for substance use, and that interventions should target AS reduction in anxiety-prone individuals to reduce and prevent substance abuse. Keywords: anxiety, illicit substance use, anxiety sensitivity, young adulthood, prevention
(de Girolamo, Dagani, Purcell, Cocchi, & McGorry, 2012). Among these, substance use and anxiety problems are particularly prevalent (Vida et al., 2009), comorbid (Conway, Compton, Stinson, & Grant, 2006), and a public health concern that warrants serious attention. Research suggests that anxiety disorders can increase risk for substance use among young adults, who often engage in substance use to reduce anxiety and its associated features (Cranford, Eisenberg, & Serras, 2009; Dawson, Grant, Stinson, & Chou, 2005). Likewise, high-risk substance users are often found to drink to cope with anxious states (Fitzgerald & Long, 2012). However, the specific mechanisms that contribute to the association between anxiety and substance use are still not fully understood. As a result, increased attention has been paid to individual difference factors that may help to clarify when anxiety and substance use may be most likely to covary. Among these, anxiety sensitivity (AS)—the belief that anxiety-related sensations can have catastrophic physical, social, and/or cognitive consequences (Reiss & McNally, 1985)— has received substantial empirical support for its role in substance use (Stewart, Samoluk, & MacDonald, 1999). Numerous studies have found that AS is associated with substance misuse, especially among anxiety-prone individuals (Stewart & Kushner, 2001). Alcohol use in college students is positively
It is well documented that young adults often engage in risky behaviors, particularly those who attend college (e.g., binge drinking, drug use; Bachman, Johnston, O’Malley, & Schulenberg, 1996). Research has found that substance use initiation commonly coincides with the transition to college, and lifetime prevalence rates of substance use have been found to increase from the end of high school to the sophomore year of college (Arria et al., 2013). Substance use in college is associated with a range of negative outcomes, including absenteeism, risky sex, and increased aggression (Cleveland, Mallett, White, Turrisi, & Favero, 2013; Martens, Brown, Donovan, & Dude, 2005). Moreover, this period is commonly associated with the onset of many psychological disorders
This article was published Online First August 18, 2014. Laura J. Dixon, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center; Erin N. Stevens, Department of Psychology, Northern Illinois University; Andres G. Viana, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center. Correspondence concerning this article should be addressed to Andres G. Viana, Department of Psychiatry and Human Behavior, School of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. E-mail: [email protected] 1284
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MODERATING EFFECT OF AS
related to high AS (Stewart & Zeitlin, 1995), and research has found that young adults with both high trait anxiety and high AS endorsed drinking to cope and avoid anxiety-related arousal (DeMartini & Carey, 2011). Studies examining the role of AS in illicit substance use in particular have also found positive associations between AS and illicit sedative use (Hearon et al., 2011), cocaine dependence (Buckner, Proctor, Reynolds, Kopetz, & Lejuez, 2011), problematic cannabis use (Buckner, Zvolensky, et al., 2011), and heroin use (Lejuez, Paulson, Daughters, Bornovalova, & Zvolensky, 2006). Extant research on the lower order facets of AS and illicit substance use, although limited, has also found that AS social and cognitive concerns predicted marijuana cravings (Buckner, Zvolensky, et al., 2011), whereas AS physical and social concerns were significantly associated with cocaine dependence (Buckner, Proctor, et al., 2011). Given associations of AS to both anxiety and illicit substance use, investigators have also examined whether AS may operate as a moderator of this relationship (e.g., Buckner, Leen-Feldner, Zvolensky, & Schmidt, 2009). In general, these studies have found that increased AS is indeed associated with greater levels of anxiety symptoms in substance users (McLeish, Zvolensky, & Bucossi, 2007; McLeish, Zvolensky, Yartz, & Leyro, 2008). Although more research is clearly needed, this literature suggests that the association between trait anxiety and substance use may be stronger for high (vs. low) AS individuals, who may have difficulty managing arousal and rely on illicit substances to regulate their distress. Young adults in college who have high AS may be especially at risk, due in part to their frequent exposure to anxietyprovoking situations (e.g., separation from family, academic demands) and the increased opportunities for relying on illicit substances to cope with distress. The aim of the current study was to evaluate the role of AS as a moderator of the relationship between trait anxiety and illicit substance use in a large sample of college-attending young adults. It was hypothesized that the association between trait anxiety and illicit substance use would be moderated by AS, such that increases in trait anxiety would be associated with increases in illicit substance use frequency among those with high (vs. low) AS. Consistent with existing recommendations, the higher order AS total factor was examined as a dimensional construct (cf. categorical; Broman-Fulks et al., 2010). Each AS lower order facet was also examined, given the limited research on the differential effect(s) of the AS facets on illicit substance use frequency. Accordingly, it was hypothesized that each AS facet (i.e., physical, social, cognitive) would significantly moderate the relationship between trait anxiety and illicit substance use, wherein increases in trait anxiety would be associated with increases in illicit substance use frequency among individuals evidencing high (vs. low) levels of AS physical, social, and cognitive concerns (respectively).
Method Participants and Procedure Undergraduate students (N ⫽ 885) from an introductory psychology participant pool at a large, public Northeastern university participated in the current study. Inclusionary criteria required that participants be between 18 and 22 years, as participants older than 22 years fell outside of accepted chronological boundaries of
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young adults (Steinberg, 2005). Participants provided informed consent and completed a battery of measures, all of which took place during a single, online assessment session. Course credit was given for participation. All procedures were approved by the institutional review board of the corresponding author’s former institution. Forty participants had missing data and were excluded from analyses. Univariate outliers which had a z score ⱖ3.3 (six cases; .08% of all data) were corrected to one unit larger or smaller than the next most extreme score in the distribution (Tabachnick & Fidell, 2007). Multivariate outliers were also examined, though no cases evidenced extreme Mahalanobis distances (Tabachnick & Fidell, 2007). To safeguard the validity of responses, the questionnaire packet also included the Jackson Infrequency Scale (Jackson, 1984), a measure designed to assess for infrequent responses. A score ⱖ4 on this measure suggests that a participant’s responses may be invalid. No participants scored ⱖ4 on this measure. The final sample (N ⫽ 845; 71% female) had a mean age of 18.7 years (SD ⫽ 1.0). Eighty-three percent of participants identified as White American, 7% as Asian American, 4% as Hispanic/Latino(a), 4% as African American, 1% as Pacific Islander, and 1% as another or unspecified racial/ethnic background. Given the relatively small number of ethnic/racial minorities, race and ethnicity were collapsed into a single dummy-coded variable for preliminary analyses (coded as White [n ⫽ 700, 83%] vs. non-White [n ⫽ 142, 17%]; see Results).
Measures State-Trait Anxiety Inventory–Trait Version (STAI-T; Spielberger, Gorsuch, & Lushene, 1970). The STAI-T is a 20-item self-report questionnaire that assesses chronic, crosssituational trait anxiety. Participants are asked to rate the frequency with which they experience a variety of anxiety symptoms (e.g., “I feel nervous and restless”) on a 4-point scale (1 ⫽ almost never to 4 ⫽ almost always). Total scores (range ⫽ 20 to 80) are computed by summing individual item scores; higher scores indicate higher trait anxiety (in this study, ␣ ⫽ .92). Anxiety Sensitivity Index – 3 (ASI-3; Taylor et al., 2007). The ASI-3 is an 18-item self-report questionnaire designed to assess fear of anxiety-related sensations. Participants are asked to rate the extent to which they agree with statements which assess fears about normal anxiety reactions on a 5-point scale (0 ⫽ very little to 4 ⫽ very much). Total scores are computed by summing responses to all items. Results from a factor analysis on the ASI-3 (Taylor et al., 2007) suggested a total score and three facets (each comprised of six items) related to physical, cognitive, and social concerns in this study (␣ ⫽ .80 to .89 across ASI-3 facets). Illicit substance use. A single item from a larger survey designed to assess substance use, risk factors for psychopathology, and overall psychological adjustment (see Viana, Gratz, & Rabian, 2011) was used to assess the frequency with which participants engaged in illicit substance use. The item was rated on a 6-point scale (1 ⫽ never, 2 ⫽ eleven or fewer times per year, 3 ⫽ once per month, 4 ⫽ two to three times per month, 5 ⫽ once per week, 6 ⫽ two or more times per week).
DIXON, STEVENS, AND VIANA
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Data Analytic Approach T tests and correlations were examined to determine whether there were main effects of the demographic variables (i.e., gender, race/ethnicity, age) on all other study variables. Holm’s (1979) modified Bonferroni correction was used to control for increases in the probability of making a Type I error as a result of conducting multiple comparisons (Jaccard & Guilamo-Ramos, 2002). This step-down procedure is one in which, first, the critical p value (i.e., ␣ ⫽ .05) is divided by k, where k is the number of tests. Then, all obtained p values are ranked from least to greatest magnitude; the most significant p value is compared with .05/k and, if the result is significant, the next most significant p value obtained is compared with .05/(k⫺1). If the result is significant, the next p value in the rank is compared with .05/(k⫺2), and so on. The procedure continues until a nonsignificant result is observed. Demographic variables with significant associations with the dependent variables were added as covariates in subsequent multivariate analyses. An ordinal regression model was used to examine AS total scores as a moderator of the association between trait anxiety and illicit substance use. To examine the independent contributions of each AS facet (i.e., physical, social, cognitive), three ordinal regressions were conducted using each AS facet as a moderator in the association between trait anxiety and illicit substance use, while controlling for the other AS facets. For each regression, control variables, trait anxiety, AS, and an interaction term comprised of the product of trait anxiety and AS were entered as predictor variables. Predictor variables were mean-centered (Aiken & West, 1991). Significant interactions were probed using simple slopes analyses (i.e., at high and low [⫾ 1.5 SD from the mean] values of AS) corresponding to clinical and nonclinical levels of AS (cf. Taylor et al., 2007).
Results Preliminary Analyses and Descriptive Statistics Age was significantly positively associated with substance use, and males reported greater frequency of substance use than females, t(839) ⫽ 4.67, p ⬍ .001 (M ⫽ 1.92, SD ⫽ 1.63, and M ⫽
1.47, SD ⫽ 1.09, respectively). Race/ethnicity was not significantly associated with illicit substance use frequency. Means, standard deviations, and correlations for study variables are presented in Table 1. Trait anxiety was significantly associated with AS total score (p ⬍ .001), as well as the three AS facets (ps ⬍ .001). Illicit substance use frequency was significantly associated with the AS total score (p ⫽ .036), as well as the AS-Physical Concerns subscale (p ⫽ .029). Illicit substance use frequency was not significantly associated with trait anxiety (p ⫽ .237), nor was it associated with either the AS-Social Concerns (p ⫽ .289) or AS-Cognitive Concerns (p ⫽ .131) subscales.
Moderation Analyses The first regression examined associations between trait anxiety, AS total score, and illicit substance use frequency. The overall model was significant, 2(5) ⫽ 29.38, p ⬍ .001, Nagelkerke R2 ⫽ .041. There was a significant interaction between AS and trait anxiety in predicting illicit substance use (odds ratio [OR] ⫽ 1.002, p ⫽ .006; 95% confidence interval [CI] [1.001, 1.003]). Simple slopes analysis revealed a significant, positive relationship between trait anxiety and illicit substance use frequency for high-AS individuals (OR ⫽ 1.03, p ⫽ .005; 95% CI [1.01, 1.06]), but a nonsignificant relationship for low-AS individuals (OR ⫽ 0.98, p ⫽ .100; 95% CI [0.95, 1.01]; see Figure 1). Three additional ordinal linear regressions examined associations between trait anxiety, AS facets, and illicit substance use frequency (see Table 2). All models were significant (ps ⬍ .001, Nagelkerke R2 ⫽ .039 to .043). Significant interactions emerged between trait anxiety and both AS physical concerns (OR ⫽ 1.004, 95% CI [1.001, 1.007], p ⫽ .011) and AS cognitive concerns (OR ⫽ 1.004, 95% CI [1.001, 1.008], p ⫽ .009). The interaction between AS social concerns and trait anxiety was not significant (OR ⫽ 1.002, 95% CI [1.000, 1.005], p ⫽ .095). Simple slopes analyses revealed a significant, positive relationship between trait anxiety and illicit substance use frequency for individuals with high AS physical concerns (OR ⫽ 1.03, 95% CI [1.01, 1.06], p ⫽ .022), but a nonsignificant relationship for individuals with low AS physical concerns (OR ⫽ 0.98, 95% CI [0.95, 1.01], p ⫽ .186). Similarly, there was a significant, positive relationship between
Table 1 Correlations Among Variables of Interest Variable name 1. 2. 3. 4. 5. 6. 7. 8. 9.
Age Gender Ethnicity Trait anxiety Anxiety sensitivity AS-Physical Concerns AS-Social Concerns AS-Cognitive Concerns Illicit substance use
M
SD
1
2
3
4
5
6
7
8
9
18.71 71%a 83%b 39.34 15.67 4.14 8.57 2.98 75%c
0.95 — — 9.47 11.59 4.72 5.19 4.05 —
— ⫺.16ⴱⴱⴱ ⫺.08ⴱ .01 .01 .03 ⫺.02 .01 .12ⴱⴱⴱ
— .03 .04 ⫺.06 ⫺.00 ⫺.08ⴱ ⫺.05 ⫺.12ⴱⴱⴱ
— ⫺.04 ⫺.06 ⫺.05 ⫺.02 ⫺.10ⴱⴱ .05
— .51ⴱⴱⴱ .36ⴱⴱⴱ .42ⴱⴱⴱ .51ⴱⴱⴱ .04
— .86ⴱⴱⴱ .82ⴱⴱⴱ .84ⴱⴱⴱ .07ⴱ
— .51ⴱⴱⴱ .68ⴱⴱⴱ .08ⴱ
— .50ⴱⴱⴱ .04
— .05
—
Note. N ⫽ 845. Trait anxiety ⫽ State-Trait Anxiety Inventory; Anxiety sensitivity(AS) ⫽ Anxiety Sensitivity Index – 3. a For gender, 71% of the sample was females and 29% was males. b Race and ethnicity were collapsed into a single dummy-coded variable for preliminary analyses, coded as White (83%) vs. minority (17%). c Reported correlations between illicit substance use and continuous variables are Spearman. For illicit substance use, 75% of the sample reported never having used, 11% reported ⬍ 12⫻/year, 4% reported 1⫻/month, 5% reported 2–3⫻/month, 2% reported 1⫻/week, and 4% reported ⬎ 1⫻/week. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.
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MODERATING EFFECT OF AS
Figure 1. The relationship between trait anxiety and illicit substance use frequency for individuals at high and low levels of the AS total score (⫹1.5 SD above and below the mean of AS, respectively). The relationship between trait anxiety and illicit substance use frequency for individuals high in AS was significant (OR ⫽ 1.03, p ⫽ .005; 95% CI [1.01, 1.06]); it was nonsignificant for those low in AS (OR ⫽ 0.98, 95% CI [0.95, 1.01], p ⫽ .100).
trait anxiety and illicit substance use frequency for individuals with high AS cognitive concerns (OR ⫽ 1.03, 95% CI [1.01, 1.06], p ⫽ .021), but a nonsignificant relationship for individuals with low AS cognitive concerns (OR ⫽ 0.98, 95% CI [0.95, 1.01], p ⫽ .170).
Discussion The aim of the current study was to investigate the moderating role of AS in the association between anxiety and illicit substance in a large sample of young college-attending adults. Consistent with our hypothesis, high anxiety was positively associated with substance use frequency among young adults who evidenced high (clinical), but not low (nonclinical), levels of AS. Although the magnitude of this effect was indeed small, findings provide direct empirical support for theoretical models of AS as a moderator of the anxiety-illicit substance use association (e.g., Stewart & Kushner, 2001), and suggest that the association between anxiety and illicit substance use is especially problematic among individuals with clinical levels of AS (see Taylor et al., 2007).
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A unique aspect of the current evaluation was the differential examination of the lower order facets of AS. Trait anxiety was modestly but significantly associated with increased illicit substance use among young adults with higher levels of two of the three AS facets (i.e., physical and cognitive). In line with selfmedication and negative affect reduction theories of substance use (Kushner, Abrams, & Borchardt, 2000), findings suggest that young adults with heightened anxiety may use illicit substances to cope with anxiety-related physiological cues (e.g., increased heart rate, sweating) or cognitive dyscontrol (e.g., disassociation, mind racing, losing control) that are perceived as potentially catastrophic. Although this strategy may serve to reduce uncomfortable physiological and cognitive sensations in the short term through negative reinforcement, the likelihood of future illicit substance use may actually increase (Stewart & Kushner, 2001). Interestingly, a significant moderator effect was not found for AS social concerns, suggesting that young adults with high trait anxiety engage in illicit substance use primarily to manage one’s internal anxiety experience (i.e., physical, cognitive cues) rather than to cope with or reduce socially observable anxiety sensations. Taken together, findings provide support for the role of AS as an important, individual difference factor that may influence the association between anxiety and illicit substance use. Given that individuals with high AS are at risk for coping-motivated substance misuse (Robinson, Sareen, Cox, & Bolton, 2011), findings highlight the importance of increased utilization of prevention programs focused on AS reduction in young adults at risk for substance use. For example, past research suggests that cognitive– behavioral, school-based intervention programs targeting AS (and several other risk factors for alcohol misuse), through psychoeducation, cognitive coping skills training, and behavioral coping skills training, lead to both short- and long-term reductions in problematic substance use among adolescents (Conrod, Stewart, Comeau, & Maclean, 2006). These interventions may be particularly appealing in the context of a college setting, as they are brief, cost-effective, and easily implemented (i.e., delivered in group format, master’s-level therapists). Finally, in addition to increasing the utilization of preventionbased treatments, findings suggest that AS should be a treatment target for individuals presenting with comorbid substance and anxiety, as reductions in AS may decrease risk for substance
Table 2 Summary of Ordinal Regression Analyses and Odds Ratios for Variables Predicting Illicit Drug Use Anxiety sensitivity moderator variables Variable
Physical OR [95% CI]
Cognitive OR [95% CI]
Social OR [95% CI]
Gender Age Trait anxiety Anxiety sensitivity – Physical Anxiety sensitivity – Cognitive Anxiety sensitivity – Social Trait Anxiety ⫻ Anxiety Sensitivity moderator Nagelkerke R2
1.75 [1.25, 2.45]ⴱⴱⴱⴱ 1.23 [1.06, 1.45]ⴱⴱⴱ 1.03 [0.98, 1.07] 0.99 [0.94, 1.05] 0.99 [0.95, 1.03] 1.01 [0.99, 1.03] 1.004 [1.001, 1.007]ⴱⴱ .043ⴱⴱⴱⴱ
1.78 [1.27, 2.50]ⴱⴱⴱⴱ 1.23 [1.06, 1.44]ⴱⴱⴱ 1.04 [1.00, 1.09]ⴱ 0.97 [0.91, 1.03] 0.99 [0.95, 1.03] 1.01 [0.99, 1.03] 1.004 [1.001, 1.008]ⴱⴱⴱ .043ⴱⴱⴱⴱ
1.75 [1.25, 2.45]ⴱⴱⴱⴱ 1.23 [1.05, 1.44]ⴱⴱⴱ 1.04 [0.99, 1.09]ⴱ 1.00 [0.94, 1.06] 0.99 [0.95, 1.02] 1.01 [0.99, 1.03] 1.002 [1.000, 1.005]ⴱ .039ⴱⴱⴱⴱ
Note. N ⫽ 845. OR ⫽ odds ratio; CI ⫽ confidence interval; Trait anxiety ⫽ State-Trait Anxiety Inventory; Anxiety sensitivity ⫽ Anxiety Sensitivity Index – 3. ⴱ p ⬍ .10. ⴱⴱ p ⬍ .05. ⴱⴱⴱ p ⬍ .01. ⴱⴱⴱⴱ p ⬍ .001.
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utilization. Extant research has demonstrated the effectiveness of brief stand-alone or integrated interventions for AS reduction (e.g., Keough & Schmidt, 2012), in the treatment of substance withdrawal (e.g., Otto, Pollack, Meltzer-Brody, & Rosenbaum, 1992), and the inclusion of cognitive– behavioral strategies for AS in substance-use treatment has been found to reduce distress associated with substance misuse (Tull, Schulzinger, Schmidt, Zvolensky, & Lejuez, 2007). Likewise, integrative treatments targeting both AS and substance use through cognitive– behavioral strategies have yielded positive outcomes related to smoking-cessation behaviors and AS reductions (Feldner, Zvolensky, Babson, LeenFeldner, & Schmidt, 2008; Zvolensky, Brandt, & Bernstein, 2011). Given these findings, we propose that such interventions could be similarly effective for decreasing AS and illicit substance use in young adults with anxiety and/or substance use difficulties. As expected, this study is not without limitations. First, the study utilized a cross-sectional study design; therefore, the direction or temporal order of the associations reported here cannot be determined and may differ from our predictions. Specifically, although several longitudinal studies have established that anxiety often precedes illicit substance use (Wolitzky-Taylor, Bobova, Zingbarg, Mineka, & Craske, 2012), it may be that illicit substance use also leads to increased anxiety. Longitudinal studies are needed to clarify the precise nature of the associations examined here and whether there are any (and we suspect there are) bidirectional influences between trait anxiety, AS, and illicit substance use over time. Second, the sample was comprised of nonclinical college-attending young adults, most of whom were White American females. Likewise, although moderation analyses did test associations between trait anxiety and substance use at clinical levels of the moderator (AS total score ⫽ 33; see Taylor et al., 2007), the extent to which results generalize to other young adults or to clinical populations evidencing greater levels of severity (e.g., substance dependence) remains unclear. In addition, given the degree of substance use in our sample, replication of these associations among heavy users is needed. Finally, an additional limitation was the lack of specificity with regard to type of illicit substance used by participants, which was not assessed. Given that marijuana is the most commonly utilized illicit substance among college students (Substance Abuse and Mental Health Services Administration, 2011), we suspect that marijuana was likely the illicit substance of choice for many participants. However, caution is warranted until results are replicated in investigations specifically assessing for various types of illicit substances. Despite limitations, the current findings further our understanding of the associations among anxiety, AS, and substance use, and highlight the role of AS as an important cognitive vulnerability that may influence illicit substance use among young adults. Given that young adulthood is a period of change and stressful developmental transitions, identifying factors that may increase risk for maladaptive behaviors in this population is of paramount importance. Likewise, findings highlight the importance of differential examination of the facets of AS. Given the different properties of substances and their differential effects on the body (e.g., cognitive effects vs. physiological effects), it is likely that examining specific AS facets may facilitate the identification of young adults at risk for specific types of substances.
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Received September 24, 2013 Revision received June 13, 2014 Accepted July 3, 2014 䡲
