Understanding the relationship between social anxiety and alcohol use in college students: A meta-analysis

Addictive Behaviors 38 (2013) 2690–2706

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Addictive Behaviors

Review

Understanding the relationship between social anxiety and alcohol use in college students: A meta-analysis Amie R. Schry ⁎, Susan W. White Virginia Tech, Department of Psychology, 109 Williams Hall (0436), Blacksburg, VA 24061, United States

H I G H L I G H T S • • • • •

Meta-analysis examining social anxiety and alcohol variables in college students. Social anxiety (SA) was negatively related to alcohol use. SA was positively related to alcohol-related problems. Drinking motives and alcohol outcome expectancies were positively related to SA. Clinicians should be aware of these relationships for treatment and assessment.

a r t i c l e Keywords: Social anxiety Alcohol Undergraduates Meta-analysis

i n f o

a b s t r a c t Many college students use alcohol, and most of these students experience problems related to their use. Emerging research indicates that socially anxious students face heightened risk of experiencing alcohol-related problems, although the extant research on alcohol use and social anxiety in this population has yielded inconsistent findings. This meta-analysis was conducted to examine the relationship between social anxiety and alcohol variables in college students. A literature search was used to identify studies on college students that included measures of social anxiety and at least one of the alcohol variables of interest. All analyses were conducted using random effects models. We found that social anxiety was negatively correlated with alcohol use variables (e.g., typical quantity and typical frequency), but significantly positively correlated with alcohol-related problems, coping, conformity, and social motives for alcohol use, and positive and negative alcohol outcome expectancies. Several moderators of effect sizes were found to be significant, including methodological factors such as sample ascertainment approach. Given that social anxiety was negatively related to alcohol use but positively related to alcohol-related problems, research is needed to address why individuals high in social anxiety experience more problems as a result of their alcohol use. Avoidance of social situations among socially anxious students should also be taken into account when measuring alcohol use. The primary limitation of this study is the small number of studies available for inclusion in some of the analyses. © 2013 Elsevier Ltd. All rights reserved.

Contents 1.

2.

Introduction . . . . . . . . . . . . . . . . . . . . . 1.1. Social anxiety and alcohol . . . . . . . . . . . 1.2. Potential mediators: Drinking motives and alcohol 1.3. Potential moderators . . . . . . . . . . . . . 1.4. Hypotheses . . . . . . . . . . . . . . . . . . Materials and methods . . . . . . . . . . . . . . . . 2.1. Operational definitions . . . . . . . . . . . . 2.2. Literature search . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . outcome expectancies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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⁎ Corresponding author at: Department of Psychology, Virginia Tech, 109 Williams Hall (0436), Blacksburg, VA 24061, United States. Tel.: +1 540 231 6744; fax: +1 540 231 3652. E-mail addresses: [email protected] (A.R. Schry), [email protected] (S.W. White). 0306-4603/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.addbeh.2013.06.014

A.R. Schry, S.W. White / Addictive Behaviors 38 (2013) 2690–2706

2.3. 2.4.

Study inclusion criteria and resulting pool of studies Study coding . . . . . . . . . . . . . . . . . . . 2.4.1. Categorical moderators . . . . . . . . . . 2.4.2. Continuous moderators . . . . . . . . . . 2.5. Effect sizes . . . . . . . . . . . . . . . . . . . . 2.6. Statistical analyses . . . . . . . . . . . . . . . . 3. Results . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Mean effect sizes and homogeneity analyses . . . . 3.2. Analyses of moderator variables . . . . . . . . . . 4. Discussion . . . . . . . . . . . . . . . . . . . . . . . 4.1. Limitations . . . . . . . . . . . . . . . . . . . . 4.2. Recommendations for future research . . . . . . . 4.3. Clinical implications . . . . . . . . . . . . . . . 4.4. Conclusions . . . . . . . . . . . . . . . . . . . Role of funding sources . . . . . . . . . . . . . . . . . . . . Contributors . . . . . . . . . . . . . . . . . . . . . . . . . Conflict of interest . . . . . . . . . . . . . . . . . . . . . . Acknowledgments . . . . . . . . . . . . . . . . . . . . . . Appendix A. . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . .

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1. Introduction Alcohol is, by far, the most widely used drug among college students, with 60.8% of students reporting alcohol use in the past month (Substance Abuse & Mental Health Services Administration, 2012). In 2009, 61.5% of college students reported that they had been intoxicated at least once in the past year, with 42.4% reporting that they had been intoxicated in the past 30 days (Johnston, O'Malley, Bachman, & Schulenberg, 2010). Approximately 37 to 44% of college students reported that they binge drank at least once in the past two weeks to month (Hingson, Heeren, Winter, & Wechsler, 2005; Johnston et al., 2010; Wechsler et al., 2002). Alcohol use can lead to a wide range of problems (e.g., involvement in risky sexual situations, driving under the influence, hangovers, nausea and vomiting, and aggression). Due to the high levels of alcohol consumption and the contexts in which college students typically consume alcohol (e.g., parties where excessive drinking is the norm), along with no parental oversight and monitoring, this population may be particularly likely to experience alcohol-related problems (ARPs). Of college students who drank at least once per week during their first year of college, 80% experienced more than one ARP during their first year, and 34% reported that they had experienced six or more ARPs during that time (Mallett et al., 2011). 1.1. Social anxiety and alcohol It is important for practitioners who work with this population to be aware of other problems that may be associated with, or lead to, problematic alcohol use in order to best treat students, even when ARPs are not the primary presenting concern. Social anxiety, defined as a fear of being observed or negatively evaluated by others (American Psychiatric Association [APA], 2000), has been studied in relation to alcohol use among college students. For individuals with high levels of social anxiety, fear of negative evaluation may play a role in their alcohol use, as they may “use substances to avoid potential scrutiny from substance-using peers and/or because they believe substance use is a common (and thus socially acceptable) strategy for dampening their anxiety in social situations” (Buckner, 2011, p. 4). Multiple theoretical models (e.g., Appraisal-Disruption Model (Sayette, 1993), Attention Allocation Model (Steele, Southwick, & Pagano, 1986), and Avoidance-Coping Model (Bacon & Ham, 2010)) suggest that alcohol use can result in decreased anxiety for at least some individuals. In light of the

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dampening effect of alcohol on social anxiety and because college students are likely to be in situations where drinking, often to excess, is the social norm, understanding relationships among social anxiety and alcohol-related variables may be particularly relevant. Social anxiety disorder (SAD) and alcohol use disorders (AUDs) are frequently comorbid (see Morris, Stewart, and Ham (2005), for a review). Approximately 13% of adults with past-year SAD met criteria for a comorbid AUD, and of adults with lifetime SAD, 48.2% met criteria for an AUD (Grant et al., 2005). This relationship appears to be due to a greater likelihood of having comorbid alcohol dependence (characterized by tolerance, withdrawal, or compulsive alcohol consumption (APA, 2000); OR = 2.26 to 2.7) rather than alcohol abuse (characterized by a pattern of negative consequences that result from alcohol use (APA, 2000); OR = 1.2 to 1.23; Buckner, Timpano, Zvolensky, Sachs-Ericsson, & Schmidt, 2008; Grant et al., 2005). Both retrospective and longitudinal studies have shown that when SAD and AUD co-occur, SAD typically precedes the onset of the AUD (Buckner, Schmidt, et al., 2008; Buckner, Timpano, et al., 2008; Buckner & Turner, 2009; Falk, Yi, & Hilton, 2008). Consistent with studies of adults, Kushner and Sher (1993) found that 43% of college freshmen with SAD met diagnostic criteria for an AUD while only 26% of college freshman without SAD met criteria for an AUD. Overall, however, research on the relationship between social anxiety and alcohol use among college students has revealed very mixed findings (see Morris et al. (2005), for a review). Some laboratory studies have demonstrated that socially anxious participants drink more in anticipation of both interaction (Higgins & Marlatt, 1975) and speech tasks (Kidorf & Lang, 1999), whereas others (e.g., Holroyd, 1978) have found that socially anxious students drink significantly less alcohol than non-socially anxious peers during informal laboratory-based “get togethers.” Survey studies of college students have either failed to find a relationship between social anxiety and alcohol consumption, or have found an inverse relationship between social anxiety and alcohol consumption (e.g., Buckner, Schmidt, & Eggleston, 2006; Gilles, Turk, & Fresco, 2006; Ham & Hope, 2006; Lewis et al., 2008). One possible reason for the lack of a positive relationship between social anxiety and alcohol use is that socially anxious students may avoid social situations and only use alcohol to cope with anxiety in social situations when they cannot be avoided (Norberg, Norton, & Olivier, 2009; Stewart, Morris, Mellings, & Komar, 2006). Despite the fact that many studies have found a negative relationship, or no relationship at all, between social anxiety and alcohol use,

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many studies have found that social anxiety is positively associated with ARPs (e.g., Buckner, Ecker, & Proctor, 2011; Buckner & Heimberg, 2010; Buckner et al., 2006; Gilles et al., 2006; Norberg et al., 2009). A significant relationship between social anxiety and ARPs may be particularly important, because AUDs are defined by problems resulting from the use of alcohol rather than simply the quantity and frequency of use (Buckner et al., 2006). However, not all studies have found a significant relationship between social anxiety and ARPs (e.g., Ham, Zamboanga, Bacon, & Garcia, 2009; LaBrie, Pedersen, Neighbors, & Hummer, 2008).

1.2. Potential mediators: Drinking motives and alcohol outcome expectancies When examining the relationship between social anxiety and alcohol use, it is important to consider variables through which social anxiety may affect alcohol use variables (i.e., mediators), such as drinking motives (DMs) and alcohol outcome expectancies (AOEs). DMs, defined as the reasons why people choose to consume alcohol (Grant, Stewart, & Mohr, 2009), have been conceptualized as the pathways through which more distal risk factors, such as anxiety, depression, and sensation seeking, influence alcohol use at a given time (Cooper, 1994). Typically, four DMs are examined: enhancement of positive mood motives are internally motivated and related to positive reinforcement (e.g., drinking to get a pleasant feeling or because a person finds it fun to drink); social rewards motives are externally motivated and positively reinforcing (e.g., drinking to be more sociable or to celebrate an event or occasion with others); conformity motives are externally motivated and negatively reinforcing (e.g., drinking to fit in with others or due to pressure from others); and coping with negative emotions motives are internally motivated and negatively reinforcing (e.g., drinking to dealing with negative mood states such as depression or anxiety; Cooper, 1994). AOEs are defined as outcomes that an individual expects to occur as a result of consuming alcohol (Jones, Corbin, & Fromme, 2001). AOEs are learned through individuals' own alcohol use as well as the effects that they observe and learn about from others' experiences with alcohol (Jones et al., 2001). Studies with both non-college and college student samples have shown that individuals high in social anxiety are more likely to use alcohol as a way to reduce their anxiety in social situations, and they tend to avoid social situations where alcohol is not available, compared to individuals with low social anxiety (Buckner & Heimberg, 2010; Thomas, Randall, & Carrigan, 2003). DMs have been shown to predict alcohol use and ARPs (e.g., Cooper, Frone, Russell, & Mudar, 1995; Gonzalez, Bradizza, & Collins, 2009; Grant et al., 2009; Ham & Hope, 2003; Park & Levenson, 2002). Using alcohol to cope with negative emotions appears to be particularly problematic and has been found to be correlated with suicidal ideation, depression, alcohol use, binge drinking, and ARPs (Gonzalez et al., 2009; Park & Levenson, 2002). Ham and Hope (2003) suggested that coping motives may be associated with drinking problems because individuals who use alcohol as a mechanism to cope with negative emotions lack safer, more effective, and longer-lasting coping mechanisms. In support of this hypothesis, students who drink to cope have been found to possess lower coping abilities and higher positive alcohol expectancies (Park & Levenson, 2002). Therefore, social anxiety may increase the likelihood that individuals will drink alcohol for specific reasons, especially coping motives, which may in turn increase the likelihood of experiencing ARPs and, in turn, of developing AUDs in the future. In fact, coping motives have been found to partially mediate the relationship between social anxiety and both ARPs (Buckner & Heimberg, 2010; Norberg, Norton, Olivier, & Zvolensky, 2010) and symptoms of alcohol dependence (Ham et al., 2009). In another study,

enhancement motives mediated the relationship between social anxiety and ARPs (Buckner et al., 2006). A number of different AOEs have been assessed in the literature (e.g., tension reduction, sociability, and impairment). Although there are a variety of expectancies, they can all be classified as either positive or negative, depending on whether it would be a desirable or undesirable outcome (Jones et al., 2001). Social anxiety may be related to both positive and negative AOEs, as socially anxious individuals may drink because they expect certain positive outcomes (e.g., being more sociable) but not drink to excess due to fears about negative outcomes (e.g., doing something embarrassing out of impairment from alcohol). AOEs have been shown to predict alcohol use (e.g., Ham, Stewart, Norton, & Hope, 2005; Zamboanga & Ham, 2008; Zamboanga, Schwartz, Ham, Borsari, & Van Tyne, 2010). Ham (2009) found that social anxiety was positively related to positive social AOEs, which were positively related to hazardous alcohol use, and positive social AOEs partially mediated the relationship between social anxiety and hazardous alcohol use. Other studies have also found that social anxiety has an indirect effect on ARPs through AOEs (Ham & Hope, 2005, 2006). 1.3. Potential moderators The discrepant findings in the literature could be due to differences in study characteristics. There are a number of possible variables that could affect study results, perhaps the most obvious being participant characteristics. A recent study found that the relationship between social anxiety and ARPs may be moderated by gender (Norberg, Olivier, Alperstein, Zvolensky, & Norton, 2011; Norberg et al., 2009), so the proportion of the sample that is female should be considered. Since no studies have examined race or ethnicity as a potential moderator, it is important to consider the possibility that the relationship between social anxiety and alcohol-related variables may vary by race. Additionally, the way participants were recruited and selected (e.g., if advertisements were targeted to obtain certain individuals) could affect the characteristics of the sample. Ascertainment approach could result in a restricted range on a given variable (i.e., social anxiety or an alcohol variable), but it is also possible that these variables moderate the relationship, as they may be stronger in certain subgroups (e.g., those high in social anxiety or those who drinking heavily and have been referred for problematic use). The method of data collection is also important because inperson studies may result in a somewhat different sample than on-line studies. For example, individuals high in social anxiety may try to avoid in-lab studies in order to avoid the required social interaction. Additionally, because published studies often have larger effect sizes and are more likely to report significant effects than nonpublished studies (Cooper, 2010; Lipsey & Wilson, 2001), it is important to consider the possibility of publication bias when conducting a metaanalysis. Finally, characteristics of the measures used are important possible moderators. A variety of self-report questionnaire measures of social anxiety have been developed, and they differ in their relative focus on cognitive (e.g., fear of negative evaluation), behavioral (e.g., avoidance), and physiological symptoms. Furthermore, measures differ on the types of social situations (e.g., performance and interaction) they include. Similarly, assessments of ARPs assess different types of consequences (e.g., social consequences, risk behaviors, and personal consequences). Distinct aspects of social anxiety may be differentially related to alcohol-related variables. For example, avoidance of social situations may be negatively correlated with many alcohol-related variables because a person may have few opportunities to drink alcohol socially and, in turn, experience certain ARPs. In contrast, worry about negative evaluation (without avoidance) may relate differently, as the person may use

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alcohol to reduce their anxiety in social situations and experience ARPs as a result. Furthermore, one study found that the relationship between social anxiety and ARPs differs by type of consequence (Norberg et al., 2011). Finally, the amount of time individuals were asked to consider in their reporting could affect results. While shorter time frames are more accurate due to less demand on memory, these shorter timeframes could be more affected by sporadic changes in alcohol use (e.g., attending a major sporting event) if they fall in the reporting timeframe. 1.4. Hypotheses In light of inconsistent findings in the extant literature on the relationship between social anxiety and various alcohol-related variables in college students, we undertook a meta-analysis to clarify the nature of the relationship between social anxiety and alcohol variables among college students. Specifically, we sought to examine the relationship between social anxiety and four alcoholrelated variables: alcohol use, ARPs, DMs, and AOEs. Morris et al. (2005) completed a qualitative review of the literature on social anxiety and alcohol use disorders and included separate sections on the research in college students. However, a number of studies on the topic have been conducted since publication of that review. Because we found no previously published meta-analyses on this topic, we believe this is the first meta-analysis to examine the relationship between social anxiety and alcohol-related variables in college students. It is hoped that this meta-analysis will help to summarize the existing literature in order to help researchers plan future studies to further clarify this relationship. Although alcohol may be used to decrease anxiety, it is important to note that most college students consume alcohol in social situations (e.g., parties), and one frequently used coping technique for managing social anxiety is avoidance of situations that evoke fear and anxiety (APA, 2000). Therefore, we hypothesized that social anxiety would be (1) positively correlated with the amount of alcohol consumed per drinking episode, but (2) negatively correlated with the frequency of alcohol use. Furthermore, we hypothesized that (3) social anxiety would be positively related to ARPs, given the high rates of comorbidity between SAD and AUDs. Secondarily, we examined the relationships between social anxiety and DMs and social anxiety and AOEs in order to examine potential mediators of the relationship between social anxiety and alcohol use or ARPs. It was expected that social anxiety would be (4) positively related to coping and conformity motives for consuming alcohol. It was expected that college students high in social anxiety would use alcohol to cope with their anxiety in social situations, where drinking is likely to occur. Additionally, because socially anxious individuals are generally less assertive than non-socially anxious peers (APA, 2000; Chambless, Hunter, & Jackson, 1982; LeSure-Lester, 2001), they may be more likely to drink for conformity motives, as they may not be able to say no to alcohol when others pressure them to drink. Finally, it was hypothesized that (5) social anxiety would be positively related to both positive and negative alcohol expectancies. It was anticipated that individuals with social anxiety would expect alcohol to have positive outcomes, such as increased assertiveness or sociability. However, it was also expected that individuals with social anxiety would also report higher negative alcohol expectancies due to concerns about evaluation due to negative behaviors and, therefore, heightened concern about these outcomes. Most moderator analyses were exploratory, without a priori hypotheses. However, given the results of Norberg et al. (2009, 2011), we expected the percentage of the sample that was female to be positively related to the effect size (i.e., when there were more females, the effect size would be larger), particularly for analyses of ARPs. Due to concerns about publication bias, we hypothesized

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that effect sizes would be larger in published studies compared to unpublished studies. 2. Materials and methods 2.1. Operational definitions Social anxiety was defined as anxiety in, or avoidance of, social and performance situations, including anxiety related to evaluation by others in these situations (APA, 2000). Alcohol use was defined as any measure of the consumption of beverages containing alcohol. Frequency of alcohol use was defined as the number of times a person consumed alcohol during a given period of time; whereas quantity of alcohol use was defined as the number of standard alcoholic drinks consumed per drinking episode or per day. If the number of alcoholic drinks consumed over a period of time (e.g., a week or a month) was measured, this variable was considered a frequency by quantity index, because both number of drinks consumed per episode and frequency of consumption affect this variable. Finally, the frequency of binge drinking was also included as an alcohol use variable. Binge drinking was defined as five or more drinks in a single sitting for males and four or more drinks in a single sitting for females (per the National Institute on Alcohol Abuse and Alcoholism's Council Work Group's definition of binge drinking (NIAAA, 2003)). ARPs were defined as problems or negative consequences that resulted from the consumption of alcohol. Finally, DMs were defined as reasons for consuming alcohol, while AOEs were defined as expectations about the outcomes of alcohol use. It is important to note that motives are distinct from alcohol expectancies, as alcohol expectancies are the outcomes individuals anticipate will result from consuming alcohol regardless of whether an individual consumes alcohol in order to achieve these outcomes. 2.2. Literature search Studies for this review were obtained through (a) computer searches of PsycNET and PubMed using the terms social anxiety, alcohol, and college students/undergraduates in any field through June 10, 2012; (b) a manual search of the table of contents of Addiction, Addictive Behaviors, Behavior Therapy, College Student Journal, Depression and Anxiety, Journal of American College Health, Journal of Anxiety Disorders, Journal of College Student Development, Journal of Studies on Alcohol and Drugs, and Psychology of Addictive Behaviors in the 36 months prior to the study (i.e., from to June 2009 to the most recent issue available on-line as of June 10, 2012, including advanced on-line publication of articles that will be published in future issues, if available); (c) a manual search of the reference lists of studies identified by the electronic and manual searches that met inclusion criteria for the meta-analysis; (d) personal communications with researchers who were the first author of at least three reports that met inclusion criteria asking if they knew of additional studies or unpublished data; and (e) e-mail requests sent to Division 28 (Psychopharmacology and Substance Abuse) of the American Psychological Association and the Anxiety Disorders Special Interest Group (SIG) and the Addictive Behaviors SIG of the Association for Behavioral and Cognitive Therapies requesting relevant, unpublished studies. 2.3. Study inclusion criteria and resulting pool of studies In order to be included in the meta-analysis, a report had to (a) be published in English or be available in English; (b) be empirically based (e.g., theoretical and review articles not including new data were not included); (c) only include college students, defined as students enrolled in two-year or four-year undergraduate programs with a mean age of 18.0 to 24.0 years, as participants or have reported

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219 total reports identified

3 reports excluded because they were not available in English

10 reports excluded because they were not original empirical studies

25 reports excluded because sample was not college sample/ did not meet mean age requirement

112 reports excluded because social anxiety and/or at least one alcohol variable of interest not measured

18 reports excluded because the correlation coefficient was not reported

10 studies included in SA and DMs analyses (7 measured all 4 motives)

15 studies included in SA and AOEs analyses (15 measured positive AOEs and 9 measured negative AOEs)

50 total reports included

44 separate studies identified

23 studies included in SA and AU quantity analyses

23 studies included in SA and AU frequency analyses

19 studies included in SA and AU frequency X quantity analyses

30 studies included in SA and ARPs analyses

Fig. 1. Flowchart illustrating the selection process and characteristics of included studies.

results separately for college students; (d) measure social anxiety and at least one alcohol-related variable of interest (i.e., alcohol use, ARPs, DMs, or AOEs); and (e) report the correlation of social anxiety with the alcohol-related variable or provide sufficient information for the correlation to be computed. For studies identified by computer searches, the abstract was reviewed for inclusion criteria; for the manual searches of table of contents and reference lists, titles were reviewed followed by an abstract review, if appropriate. Inclusion criteria were evaluated sequentially (e.g., if the sample did not include college students, the report was not included and other inclusion criteria were not evaluated). If all inclusion criteria except (e) were met, we attempted to contact the corresponding author of the report to obtain the needed data. A study was defined as a set of data collected on a given sample. Because a single study can span multiple publications or reports, multiple reports on a single study were coded together as a single study. A total of 219 reports (i.e., journal articles, doctoral dissertations, etc.) were obtained using the search criteria described above. The first author, a doctoral student in a clinical psychology program, reviewed all identified reports for inclusion. Of these reports, 50 met the inclusion criteria, resulting in a sample of 44 separate studies (see Fig. 1 for a flow chart of the inclusion and exclusion of studies in the meta-analysis).

2.4. Study coding All 44 studies were coded by the first author, ten of which were randomly selected for reliability coding. A total of three raters were trained by the first author in the coding of the reports; two raters were undergraduate research assistants in psychology and one is a PhD level clinical psychologist. After reviewing the coding manual and joint coding of studies to establish initial consistency, the selected studies were coded independently by each reliability coder. Discussion to reach a consensus was used when there was a disagreement in codes. For continuously coded items (e.g., sample size, percentages for gender and ethnicity), intraclass correlation coefficients (ICCs) were computed as a measure of reliability, and reliability for categorical items was assessed using kappa. Using Landis and Koch's (1977) classification, kappa was fair for one (10%), substantial for four (40%), and

almost perfect for five (50%) of the categorical variables. A table containing descriptions of each study is included in Appendix A. 2.4.1. Categorical moderators The categorical moderators were: recruitment/selection criteria for the sample; data collection method (or type of assessment); publication status; and the measures used to assess variables of interest (e.g., social anxiety and ARPs). Studies were coded for whether they recruited or selected participants high in social anxiety (e.g., treatment seeking sample, stating in recruitment materials that they were seeking individuals who feel anxious in social situations), low in social anxiety, or high and low social anxiety (i.e., the researchers sought to exclude individuals with moderate levels of social anxiety; κ = .390). Because no studies recruited or selected participants low in social anxiety, only two studies recruited or selected participants high in social anxiety, and five studies recruited or selected participants high and low in social anxiety, this variable was dichotomized for the purposes of analyses based on whether the study

Table 1 Mean effect sizes for correlations between social anxiety and alcohol variables. Alcohol variable

Mean ES

AU − Quantity AU — Frequency AU — Frequency of Binge Drinking AU — Frequency × Quantity Index ARPs DMs — Coping DMs — Conformity DMs — Enhancement DMs — Social AOEs — Positive AOEs — Negative

−.0696⁎⁎⁎ −.0962 to −.0429 −.1045⁎⁎⁎ −.1310 to −.0779 −.0777⁎⁎⁎ −.1122 to −.0430

36.9347 (22)⁎ 35.0271 (22)⁎ 2.3803 (5)

−.1081⁎⁎⁎ −.1473 to −.0686

40.7634 (18)⁎⁎

Note. ⁎ p b 0.05. ⁎⁎ p b 0.01. ⁎⁎⁎ p b 0.001.

.0530⁎ .2363⁎⁎⁎ .2379⁎⁎⁎ .0318 .0838⁎⁎⁎ .1457⁎⁎⁎ .1604⁎⁎⁎

95% CI

.0126 to .0933 .1847 to .2866 .1746 to .2993 −.0528 to .1160 .0437 to .1236 .1036 to .1872 .1091 to .2108

Homogeneity analysis Q (df)

112.1600 (29)⁎⁎⁎ 23.1441 (9)⁎⁎ 18.0091 (6)⁎⁎ 29.5495 (6)⁎⁎⁎ 7.0943 (6) 33.5424 (14)⁎⁎ 19.8318 (8)⁎

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Table 2 Tests of categorical moderators. Alcohol Variable

Variable and Class

Between-Class Effect QB

AU–Quantity

Recruited/selected for social anxietya Not recruited/selected based on social anxiety Recruited/selected based on social anxiety Recruited/selected for alcohol use/ARPs Not recruited/selected based on AU/ARPs Non-drinkers excluded Recruited/selected for high AU/ARPs Data Collection Methodb In person Other Published/Peer-Reviewedc No Yes Social Anxiety Measure Social Interaction Anxiety Scale (SIAS) Other Multiple Recruited/selected for social anxiety Not recruited/selected based on social anxiety Recruited/selected based on social anxiety Recruited/selected for alcohol use/ARPs Not recruited/selected based on AU/ARPs Non-drinkers excluded Recruited/selected for high AU/ARPs Data Collection Method In person Other Published/Peer-Reviewed No Yes Social Anxiety Measure Social Interaction Anxiety Scale (SIAS) Other Multiple Recruited/selected for social anxiety Not recruited/selected based on social anxiety Recruited/selected based on social anxiety Recruited/selected for alcohol use/ARPs Not recruited/selected based on AU/ARPs Non-drinkers excluded Recruited/selected for high AU/ARPs Data Collection Method In person Other Published/Peer-Reviewed No Yes Social Anxiety Measured Social Interaction Anxiety Scale (SIAS) Other Multiple Recruited/selected for social anxiety Not recruited/selected based on social anxiety Recruited/selected based on social anxiety Recruited/selected for alcohol use/ARPse Not recruited/selected based on AU/ARPs Non-drinkers excluded Recruited/selected for high AU/ARPs Data Collection Method In person Other Published/Peer-Reviewed No Yes ARP Measure Rutgers Alcohol Problems Index (RAPI) Alcohol Use Disorders Identification Test (AUDIT) Other Social Anxiety Measuref Social Interaction Anxiety Scale (SIAS) Other Multiple

2.8834

AU – Frequency

AU – Frequency X Quantity Index

ARPs

k

Effect Size by Class

Within-Class Effect QW

17 6

−.0778⁎⁎⁎ −.0021

11.1948 14.1457⁎

6 11 6

−.0938⁎⁎⁎ −.0708⁎⁎ .0174

1.6480 8.9424 12.2348⁎

11 10

−.0371 −.0807⁎⁎⁎

20.3505⁎ 3.4809

8 15

−.0480⁎ −.0823⁎⁎⁎

2.0656 24.1458⁎

7 7 9

−.0698⁎⁎ −.0733⁎⁎ −.0612⁎

5.0867 18.1344⁎⁎ 1.7321

17 6

−.1098⁎⁎⁎ −.0616

13.0455 13.1141⁎

8 11 4

−.0941⁎⁎⁎ −.1281⁎⁎⁎ .0630

8.6160 4.4075 8.8322⁎

11 9

−.0437 −.1252⁎⁎⁎

17.1990 3.0719

8 15

−.1183⁎⁎⁎ −.0950⁎⁎⁎

5.6678 20.0630

8 7 8

−.1132⁎⁎⁎ −.0794⁎⁎ −.1110⁎⁎⁎

1.8228 16.5456⁎ 5.8186

16 3

−.1191⁎⁎⁎ .0633

14.1515 6.7166⁎

8 3 7

−.1044⁎⁎ −.1257⁎⁎ −.0780

5.3660 .5188 14.7582⁎

12 6

−.1224⁎⁎⁎ −.0795⁎

19.3049 2.6431

6 13

−.1094⁎⁎ −.1068⁎⁎⁎

3.7576 19.3020

3 7 9

−.0465 −.1369⁎⁎⁎ −.1150⁎⁎⁎

1.2691 16.2949⁎ 4.1272

25 5

.0355 .1773⁎⁎

31.4357 2.5226

14 10 5

.0281 .0712⁎ .1386⁎

14.2537 7.7173 8.4025

17 11

.0352 .0840⁎

19.4128 10.7396

10 20

−.0079 .0819⁎⁎⁎

12.8096 20.0950

11 4 15

.0692 .0863 .0356

16.7837 1.8331 13.1513

8 9 13

.1197⁎⁎ −.0044 .0526

5.6870 7.2939 18.3437

6.3585⁎

1.8489

1.5328

.1192

1.2455

7.6226⁎

7.3927⁎⁎

.6380

.9887

4.8010⁎

.5473

.9872

.0033

2.8373

5.5085⁎

3.0330

1.1586

4.5616⁎

.8850

5.8295

(continued on next page)

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Table 2 (continued) Alcohol Variable

Variable and Class

Between-Class Effect QB

DMs – Coping

Recruited/selected for social anxiety Not recruited/selected based on social anxiety Recruited/selected based on social anxiety Data Collection Method In person Other Published/Peer-Reviewed No Yes Social Anxiety Measureg Social Interaction Anxiety Scale (SIAS) Other Multiple Recruited/selected for social anxiety Not recruited/selected based on social anxiety Recruited/select based on social anxiety Data Collection Method In person Other Published/Peer-Reviewed No Yes AOEs measure Comprehensive Effects of Alcohol Scale (CEOA) Other Multiple

8.4138⁎⁎

AOEs – Positive

k

Effect Size by Class

Within-Class Effect QW

8 2

.2142⁎⁎⁎ .4101⁎⁎⁎

7.7337 .0196

4 5

.2047⁎⁎⁎ .2693⁎⁎⁎

6.0298 3.4113

3 7

.2285⁎⁎⁎ .2416⁎⁎⁎

.3371 9.9422

3 3 4

.2603⁎⁎⁎ .1627⁎⁎⁎ .2799⁎⁎⁎

5.6721 .7733 1.9890

13 2

.1288⁎⁎⁎ .2845⁎⁎⁎

14.2559 .2211

7 5

.1260⁎⁎⁎ .1609⁎⁎⁎

5.7786 5.8274

3 12

.0965⁎ .1589⁎⁎⁎

.5770 14.8239

4 5 6

.0668 .1908⁎⁎⁎ .1548⁎⁎⁎

3.1487 4.8800 3.1724

1.2424

.0481

4.7139

6.3901⁎

.4548

1.4684

4.6290

Note. ⁎ p b 0.05. ⁎⁎ p b 0.01. ⁎⁎⁎ p b 0.001. a Q(1) = 4.4417, p = .0351; Did not recruit/select based on social anxiety: mean ES = −.0890, p b .001, Qw(16) = 17.0144, p = .3847; Recruited/selected based on social anxiety: mean ES = −.0035, p = .9297, Qw(5) = 15.4785, p = .0085. b Q(1) = 4.6941, p = .0303; In-person: mean ES = −.0411, p = .0641, Qw(10) = 24.7053, p = .0059; Other: mean ES = −.0927, p b .001, Qw(9) = 7.0540, p = .6315. c Q(1) = 4.7407, p = .0295; Not published/peer-reviewed: mean ES = −.0510, p = .0042, Qw(7) = 2.8875, p = .8952; Published/peer-reviewed: mean ES = −.0939, p b .001, Qw(14) = 29.3064, p = .0095. d Q(2) = 7.5034, p = .0235; SIAS: mean ES = −.0536, p = .0364, Qw(2) = 3.2406, p = .1978; Other: mean ES = −.1364, p b .001, Qw(6) = 22.5319, p = .0010; Multiple: mean ES = −.1276, p b .001, Qw(8) = 7.4874, p = .4851. e Q(2) = 8.5224, p = .0141; Did not recruit/select based on alcohol use/ARPs: mean ES = .0077, p = .5945, Qw(13) = 54.3965, p b .001; Non-drinkers excluded: mean ES = .0474, p = .0023, Qw(9) = 25.8041, p = .0022; Recruited/selected for high alcohol use/ARPs: mean ES = .1066, p = .0020, Qw(4) = 20.1040, p b .001. f Q(2) = 16.8759, p b .001; SIAS: mean ES = .0936, p b .001, Qw(7) = 19.5073, p = .0067; Other: mean ES = −.0126, p = .4641, Qw(8) = 26.3988, p b .001; Multiple: mean ES = .0248, p = .1139, Qw(12) = 49.3781, p b .001. g Q(2) = 9.1218, p = .0105; SIAS: mean ES = .2606, p b .001, Qw(2) = 9.5358, p = .0085; Other: mean ES = .1689, p b .001, Qw(2) = 1.4695, p = .4796; Multiple: mean ES = .2704, p b .001, Qw(3) = 3.0170, p = .3890.

recruited or selected based on social anxiety. Studies were also coded for whether they excluded non-drinkers, recruited or selected participants high in alcohol use/ARPs (e.g., students referred to campus offices for campus alcohol violations), recruited or selected participants low in alcohol use/ARPs (e.g., excluding students referred to campus offices for campus alcohol violations), or recruited or selected participants high and low alcohol use/ARPs (κ = .674). Because only one study recruited or selected participants low in alcohol use/ARPs (Ham, 2003; Ham & Hope, 2006), this study was excluded from the moderator analyses for recruitment/selection based on alcohol use/ARPs. The data collection method was coded as occurring in-person (e.g., in a lab or classroom setting) or not in-person (e.g., internet surveys and mail questionnaires). If any portion of the relevant data collection was in-person, then the data collection method was coded as “in-person” (κ = .747). Whether or not any portion of the study was published in a peer-reviewed source (i.e., not published, published–not peer-reviewed, or published–peer-reviewed) was coded (κ = .726). All included studies were either not published or were published in a peer-reviewed journal. The self-report measures of social anxiety (κ = .901), ARPs (κ = 1.000), DMs (κ = 1.000), and AOEs (κ = 1.000) were coded. The Social Interaction Anxiety Scale (SIAS; Mattick & Clarke, 1998) was the most commonly used single measure of social anxiety (used in 29.5% of studies). Due to the wide range of other measures used, this code was collapsed to SIAS, other measure, or multiple

measures for the purposes of analyses. The Rutgers Alcohol Problems Index (RAPI; White & Labouvie, 1989) and Alcohol Use Disorders Identification Test (AUDIT; Babor, Higgins-Biddle, Saunders, & Monteiro, 2001) were the most commonly used measures of ARPs (used in 27.3% and 18.2% of studies, respectively), and this variable was collapsed to RAPI, AUDIT, or other for the purposes of analyses. The Drinking Motives Questionnaire or Drinking Motives Questionnaire — Revised (DMQ-R; Cooper, 1994) were the most commonly used measures of DMs, and only two studies reporting motives did not use the DMQ or DMQ-R. Therefore, this variable was not analyzed as a potential moderator. Finally, the Comprehensive Effects of Alcohol Scale (CEOA; Fromme, Stroot, & Kaplan, 1993) was the most commonly used single measure of AOEs (used in 11.4% of studies); this variable was collapsed into CEOA, other measure, and multiple measures for the purposes of analyses. 2.4.2. Continuous moderators Continuous moderators assessed were gender, race/ethnicity, and reporting timeframe. The percentage of the sample that was female was coded for each study (ICC = 1.000). The race and ethnicity of the study samples were coded as percentages of the sample that identified as various racial/ethnic groups. However, because which racial/ethnic categories were reported across studies varied, only the percentage of the sample that was Caucasian/European was used in analyses (ICC for percentage Caucasian/European = .754).

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The reporting timeframe for alcohol use (κ = 1.000) and ARPs (κ = .728) was coded in days (however, because most studies used standard reporting timeframes, rater agreement was assessed with kappa). Reporting timeframe was defined as the period of time participants were asked to think about when completing the measures (e.g., if a participant was told to report the average number of drinks consumed each day of the week over the past month, this was coded as 30 days). 2.5. Effect sizes Pearson zero-order correlations were used as the effect size indicators. If the correlation coefficient was not included in the report but sufficient information was included to estimate the correlation coefficient, the Practical Meta-Analysis Effect Size Calculator was used to compute the estimate (Lipsey & Wilson, 2001). If correlation coefficients were reported separately for males and females, then the correlations were transformed using Fisher's Zr-transformation (Hedges & Olkin, 1985), weighted by their inverse variance weight (Lipsey & Wilson, 2001), averaged, and then transformed back to a correlation to obtain the overall correlation between the two variables for the sample. If the study used multiple measures of social anxiety, the average correlation for each alcohol variable was computed using the same procedure described above. Average effect sizes were computed in these cases because effect sizes in a meta-analysis are assumed to be independent. Therefore, when multiple effect sizes are reported for a single relationship, an average effect size can be computed to prevent inclusion of dependent effect sizes in the meta-analysis (Cooper, 2010). If a study reported alcohol use or ARPs for multiple timeframes, only the correlation for the longest timeframe was coded in order to allow for assessment of the effect of reporting timeframe in moderator analyses. 2.6. Statistical analyses All data were entered into Predictive Analytics Software Statistics 18.0 (PASW Statistics 18.0) for analysis, and macros designed for meta-analyses (Wilson, 2010) were used to conduct the analyses. Before being analyzed, correlations were transformed using Fisher's Zr-transformation (Hedges & Olkin, 1985) and weighted by their inverse variance weight (i.e., n − 3; Lipsey & Wilson, 2001). The MeanES macro (Wilson, 2010) was used to compute the mean effect size for each relationship, the p-value for the mean effect size, and the 95% confidence interval of the mean effect size. The random effects model estimates were computed. Homogeneity analyses were also conducted using this macro in order to determine whether the variance in effect sizes for each relationship is statistically different from what would be expected if only sampling error accounted for variability in the effect sizes (Cooper, 2010). The effects of categorical moderator variables were tested using the MetaF macro (Wilson, 2010), an analog to an ANOVA (Lipsey & Wilson, 2001). This macro computes the between-class effects (QB), which tests the homogeneity of studies between groups, and the within-class variability (QW), which tests the homogeneity within the classes. If the between-class effect is significant (i.e., homogeneity between classes is rejected), and the within-class variability is not significant, then the moderator adequately explains the variability observed in the effect sizes; however, if the within-class variability is significant, the moderator explains some of the variability, but there is still significant variability remaining that was not explained by that particular moderator (Lipsey & Wilson, 2001). The effects of continuous moderator variables were tested using the MetaReg macro (Wilson, 2010), which runs a weighted regression analysis. In these analyses, the homogeneity test for the regression model (QR) evaluates whether the set of predictors explains a significant proportion of the variability in effect sizes, and the homogeneity test of the residual (QE) evaluates whether the unexplained variance

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exceeds what would be expected from sampling error alone (Lipsey & Wilson, 2001). The significance of individual predictors is evaluated by examining the significance of the regression coefficients. Due to the significant heterogeneity in effect sizes for almost all relationships tested, mixed effects models were used to test the effects of moderator variables (Cooper, 2010; Lipsey & Wilson, 2001). However, because of the small number of studies that met inclusion criteria and the fact that mixed effects models have lower statistical power (i.e., are more stringent) to detect the effects of moderator variables (Lipsey & Wilson, 2001), when a fixed effects model resulted in a significant effect and the mixed effects model did not, we have noted these effects with a footnote in the table. 3. Results 3.1. Mean effect sizes and homogeneity analyses Mean effect sizes and results of the homogeneity analyses are presented in Table 1. Social anxiety was significantly negatively correlated with all measures of alcohol use (i.e., quantity, frequency, frequency of binge drinking, and frequency by quantity indices). In contrast, the mean correlation between social anxiety and ARPs was significant and positive. Additionally, social anxiety was significantly, positively correlated with three of the four DMs (i.e., coping, conformity, and social motives), but it was not significantly correlated with enhancement motives. Finally, the mean correlation between social anxiety and both positive and negative AOEs was significant and positive. The homogeneity analyses for the majority of the effect sizes were significant, indicating that there is a significant amount of heterogeneity and the amount of variability exceeds what would be expected simply by sampling error (Lipsey & Wilson, 2001). However, the homogeneity test was not significant for the relationships between social anxiety and frequency of binge drinking and social anxiety and social motives. 3.2. Analyses of moderator variables Moderator effects were only examined for those effect sizes reported in at least ten studies, due to concerns about power to find a significant effect, if present, and concerns about having a sufficient number of studies per group when categorical variables were examined. Therefore, moderator variables were not examined for the relationships between social anxiety and frequency of binge drinking, conformity motives, enhancement motives, social motives, or negative expectancies. Tests of categorical moderators could only be run when there were at least two studies per group; therefore, some moderators could not be tested for some outcomes. Results of the tests for categorical moderators are presented in Table 2, and the results of the tests for continuous moderators are presented in Table 3. All potential moderators that were explored are included in the respective tables. When the correlation between social anxiety and alcohol use quantity was examined, only recruitment/selection based on alcohol use and/or ARPs was a significant moderator. While studies that did not recruit or select participants based on alcohol use and/or ARPs and studies that only excluded non-drinkers had a significant negative mean correlation, studies that recruited or selected participants high in alcohol use and/or ARPs had a non-significant mean correlation, suggesting that the relationship was stronger for studies that did not recruit or select participants for elevated levels of alcohol use and problems. Recruitment/selection based on alcohol use/ARPs and data collection method were significant moderators of the size of the correlation between social anxiety and alcohol use frequency. As with the analyses of alcohol use quantity, studies that recruited participants high in alcohol use/ARPs did not have a significant mean correlation,

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Table 3 Tests of continuous moderators. Alcohol variable

Predictors

AU — Quantity

Regression model homogeneity (QR)

Residual homogeneity (QE)

4.1792

20.8590

Alcohol use reporting timeframe % of sample female % of sample Caucasian AU — Frequency

.3133 −.1623 .2251 5.8268

14.7150

Alcohol use reporting timeframe % of sample female % of sample Caucasian AU — Frequency × Quantity Index

.3018 −.6047⁎ .0219 1.3893

10.6829 −.1219 −.3995 −.2059

Alcohol use reporting timeframe % of sample female % of sample Caucasian ARPs

6.7195

16.0180 −.4665⁎ .2802 .0818

ARPs reporting timeframe % of sample female a % of sample Caucasian DMs — Coping

1.3620

8.8857

% of sample female % of sample Caucasian AOEs — Positive

β

.1682 −.3423 .0084

10.7794 −.0149 .0171

% of sample female % of sample Caucasian Note. ⁎ p b 0.05. a Q(3) = 22.7845, p b .001; β = .3747, p = .0034.

while studies that did not recruit or select participants based on alcohol variables or that excluded non-drinkers had significant negative mean correlations. Studies that did not require participants to complete measures in-person had a significant negative mean effect, but studies that did require in-person participation did not have a significant mean effect. Additionally, percentage of the sample that was female was a significant moderator, even though the regression model did not explain a significant amount of the variance in effect sizes. The effect size was larger in studies that included a larger percentage of female participants. It is important to note that the relationship between social anxiety and frequency of alcohol use was negative. As such, studies using samples with more females found a stronger, inverse relationship between social anxiety and frequency of alcohol use. When the correlation between social anxiety and frequency by quantity indices of alcohol use was examined, only recruitment or selection based on social anxiety was a significant moderator. Studies that did not recruit or select participants based on level of social anxiety had a significant negative mean effect size, while those that did resulted in a non-significant mean correlation. Recruitment/selection based on social anxiety and publication status were significant moderators of the effect size for the relationship between social anxiety and ARPs. Studies that did recruit or select participants based on their level of social anxiety had a significant positive mean correlation, while those studies that did not had a non-significant mean correlation. Additionally, published studies had a mean effect size that was significant and positive, while unpublished studies did not have a significant mean effect size. Although the overall regression model was not significant, reporting timeframe for ARPs was a significant moderator of effect size, with a negative relationship between reporting timeframe and effect size. When moderators of the relationship between social anxiety and coping motives were examined, only recruitment/selection based

on social anxiety was significant. While both types of studies had significant positive mean effect sizes, studies that recruited or selected participants based on social anxiety had a larger mean effect size. Finally, when the relationship between social anxiety and positive AOEs was examined, only recruitment/selection based on social anxiety was a significant moderator. Similar to the results of the analyses with coping motives, both types of studies resulted in a significant positive mean effect size, but the mean effect size for studies that did recruit or select participants based on level of social anxiety was larger. 4. Discussion This study examined the relationship between social anxiety and alcohol variables in college students. The mean effect size of the relationship between social anxiety and all measures of alcohol use (i.e., quantity, frequency, frequency of binge drinking, and frequency by quantity indices) was significant and negative. These findings indicate that socially anxious college students consume less in a typical drinking episode, drink alcohol less frequently, binge drink less frequently, and consume fewer drinks over periods of time (e.g., a typical week or month) than their less socially anxious peers. The mean effect size for alcohol use quantity was in the opposite direction as hypothesized. It may be that individuals who are socially anxious consume only enough alcohol to reduce their anxiety; they may intentionally not drink in excess due to concerns about excessive alcohol use negatively affecting their social performance. Even if socially anxious individuals do not consume more drinks per episode, they may still drink to reduce their anxiety. Therefore, for college students who are high in social anxiety, number of alcoholic drinks consumed may not be elevated, particularly compared to college peers, since heavy alcohol use is common among college students (e.g., Benton et al., 2004; Johnston et al., 2010). The finding that social anxiety was negatively related to frequency of alcohol use supported our hypothesis. The importance of avoidance as a coping strategy must be considered in the relationship between

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social anxiety and alcohol use. A vast majority of drinking situations, particularly for college students, are in social settings (e.g., parties, meeting friends at a bar, and tailgating). Individuals high in social anxiety may choose to avoid these situations the majority of the time and only use alcohol as a coping technique when they either choose to be in the situation or feel they cannot avoid the situation. It is interesting to note that social anxiety had a small, but significant, positive mean correlation with ARPs, despite being negatively related to alcohol use. This finding is important, as AUDs are defined not only by alcohol use but primarily by problems resulting from use (APA, 2000; Buckner et al., 2006). Therefore, this positive correlation is consistent with the prior research suggesting high rates of comorbidity of SAD and AUDs (see Morris et al. (2005), for a review). Consistent with our hypotheses, the mean correlations between social anxiety and coping motives and social anxiety and conformity motives were significant and positive. College students high in social anxiety were expected to endorse more coping motives because it was expected that they would drink to reduce their anxiety in social situations. Furthermore, individuals with SAD have higher rates of other anxiety disorders and mood disorders than individuals without SAD (Grant et al., 2005), and social anxiety in college students is positively associated with self-reported depression and general worry (Schry, Roberson-Nay, & White, 2012). The high rates of comorbidity may further result in more endorsement of coping motives, as individuals with SAD may also be more likely to consume alcohol to cope with multiple types of negative affect (e.g., related to co-occurring depression). The positive correlation with conformity motives is consistent with the notion that individuals with SAD struggle to be assertive (APA, 2000; Chambless et al., 1982; LeSure-Lester, 2001). Since alcohol use, and even heavy alcohol use, is arguably normative among college students (Johnston et al., 2010), it is likely that students in situations where alcohol is consumed perceive social pressure to consume alcohol. Socially anxious individuals may be more likely to give in to this social pressure due to their poor assertion skills. Although not predicted, when examining the content of questions that assess social motives, it is not surprising that there was a significant and positive mean correlation with social anxiety, as these items ask about drinking alcohol to make social gatherings more fun and being more sociable (Cooper, 1994). For individuals who are high in social anxiety, reducing their social anxiety may be related to making social situations more enjoyable and being more sociable (i.e., if they feel less anxious and inhibited, they can be more sociable). Finally, as hypothesized, social anxiety was positively related to both positive and negative AOEs. Although intuitively contradictory, the finding that social anxiety was significantly and positively related to both types of AOEs is consistent with prior research that many types of AOEs are positively correlated, including positive and negative AOEs (e.g., Ham & Hope, 2006; Ham et al., 2005). Given that social anxiety is positively associated with both coping and social motives, it is not surprising that social anxiety is positively related to positive AOEs, as it may be argued that in order to be motivated to use alcohol for a certain reason, a person must expect that alcohol use will result in the positive, desired outcome. Consistent with concerns about negative evaluation as a defining feature of SAD (APA, 2000), we also found a significant positive relationship with negative AOEs. It is possible that these negative AOEs may mediate the negative relationship between social anxiety and alcohol use quantity, as socially anxious individuals may drink less due to concerns about negative outcomes, particularly social outcomes. Multiple moderator variables had significant effects on the observed effect sizes. Whether a study recruited or selected

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participants based on social anxiety was a significant moderator of effect size in studies of the relationship between social anxiety and frequency by quantity indices, ARPs, coping motives, and positive AOEs. For studies that examined ARPs, coping motives, and positive AOEs, when participants were recruited or selected based on social anxiety, the effect size was larger. Many of the studies that recruited or selected participants based on social anxiety sought a group of participants high in social anxiety and a group of participants low in social anxiety; methodologically, creating extreme groups may have enhanced their ability to detect an effect. In contrast, when the outcome was the relationship between social anxiety and frequency by quantity indices of alcohol use, a larger negative effect was found when studies did not recruit or select participants based on social anxiety, suggesting that having a full range of social anxiety in the sample enhances the ability to find an effect. Consistent with the finding that recruiting or selecting participants based on social anxiety decreased the overall effect size between social anxiety and frequency by quantity indices of alcohol use, data collection method was a significant moderator of the relationship between social anxiety and frequency of alcohol use. Studies that did not require in-person participation resulted in a significant negative mean effect, while in-person studies did not have a significant mean effect. It is possible that socially anxious individuals avoid in-person studies due to fears of interacting with the researcher, which could restrict the range of social anxiety in the sample and decrease power to find an effect. Recruitment or selection based on alcohol use or ARPs was a significant moderator in studies that examined the relationship between social anxiety and quantity of alcohol use and frequency of alcohol use. In both cases, when studies recruited or selected a sample that was high in alcohol use or ARPs, the mean effect size was not significant, but studies that either did not recruit or select in this way or that only excluded individuals that did not drink resulted in a significant negative effect. These results indicate that when only individuals with possible problematic use are included, social anxiety is not related to alcohol use. When the relationship between social anxiety and ARPs was examined, whether or not the study was published significantly moderated the relationship between social anxiety and ARPs, with published studies having a significant positive mean effect size and unpublished studies having a non-significant mean effect size. Therefore, concerns about publication bias are only present for studies of social anxiety and ARPs. In most analyses, the continuous moderators examined did not have a significant effect. However, the timeframe used for reporting of ARPs was a significant moderator of the relationship between social anxiety and ARPs. It is interesting to note that the regression coefficient was negative, indicating that as the reporting timeframe increased, the effect size decreased. It is possible that longer reporting timeframes dilutes the effect because there is significant variability in college student drinking (e.g., students may drink less when they go home on extended breaks), and longer timeframes may be more likely to include these times. It is also possible that college students struggle to recall drinking information, particularly ARPs for extended periods, since college students experience high rates of problems (Mallett et al., 2011); this difficulty may lead to less accurate reporting for extended time periods. The percentage of the sample that was female was only a moderator of the relationship between social anxiety and frequency of alcohol use, with the effect size being larger (i.e., more negative) when the percentage of females was greater. The fact that males tend to drink more than females (Ham & Hope, 2003) may explain this finding, as males may be more likely to see alcohol use as normative and therefore socially anxious male undergraduates may be

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more likely to go out drinking, while socially anxious female undergraduates may avoid these situations more. 4.1. Limitations Only 44 studies were included, and the number of studies in any given analysis was even smaller, ranging from six (for frequency of binge drinking) to 30 (for ARPs). However, Lipsey and Wilson (2001) indicate that meaningful meta-analyses can be conducted with as few as two or three studies. As a result, it is important to keep in mind that although many of the moderators examined were not significant, we may not have had sufficient power to detect significant effects, particularly in mixed effects models, which have lower power than fixed effects models. Additionally, the fact that measures of social anxiety had to be trichotomized into one group of studies that used the most commonly used measure of social anxiety (i.e., SIAS; Mattick & Clarke, 1998), a group of studies that used a single other measure, and a group of studies that used multiple measures was a significant limitation. It is likely that different measures of social anxiety result in different effect sizes (e.g., measures that focus on behavioral avoidance, as opposed to fear of negative evaluation, may result in stronger negative correlations for alcohol use frequency), but the number of different measures used and the low frequency with which some measures were used did not allow for this type of analysis. Using the percentage of the sample that was female to examine the moderating effect of gender poses a third limitation. It would have been ideal to examine the correlation coefficients separately for males and females, but too few studies reported the effect sizes separately for each gender. The percentage of females in the sample may not have affected the overall correlations sufficiently for an effect to be detected, even if the effects do differ for the two genders. 4.2. Recommendations for future research Researchers should consider the role of social avoidance when examining the relationship between social anxiety and alcohol variables. There is a social component to the use of many substances, and this may be particularly true for alcohol use in college students. Failure to consider behavioral avoidance of social situations may lead to misleading conclusions about the relationship between social anxiety and alcohol use. For example, it may be that social anxiety is negatively related to frequency of alcohol use, but socially anxious individuals may be more likely to drink alcohol when they are in social situations or prior to social events. Therefore, it may be important to examine the percentage of times an individual consumes alcohol out of the total number of times he/she was in a situation where others were drinking. It may also be important to examine the relationship between social anxiety and drinking prior to social events, which may be related to ARPs (Nitka & O'Connor, 2011). It may also be important to consider other situations in which socially anxious individuals may be likely to drink prior to the event (e.g., prior to presentations or tests), which may be related to ARPs even if alcohol consumption is not excessive. It is also recommended that studies should be powered to examine the potential moderating effects of gender. In addition to the fact that males and females differ on alcohol variables (Ham & Hope, 2003), recent research suggests that the relationship between social anxiety and substance use problems may vary by gender (e.g., Buckner, Heimberg, & Schmidt, 2011; Buckner & Turner, 2009; Norberg et al., 2009). While some studies control for gender, if the effects are different, simply entering gender as a covariate will not allow the researcher to detect these differences.

Researchers should also attempt to determine why social anxiety is positively related to ARPs despite being negatively related to alcohol use. If individuals high in social anxiety are not drinking more than less socially anxious peers, it is important that we determine what about social anxiety makes individuals more vulnerable to ARPs. One important step is to determine whether social anxiety is positively related to all types of ARPs, or if it is differentially related to ARPs based on type (e.g., subjectively perceived problems such as doing something embarrassing). 4.3. Clinical implications It is important for clinicians who work with college students to note that although social anxiety is negatively associated with measures of alcohol use, it appears to be positively associated with ARPs. Therefore, clinicians should consider asking about ARPs regardless of an individual's level of alcohol consumption because they may be experiencing significant problems related to alcohol use, even in the absence of heavy use, particularly if they have SAD. Social anxiety is also significantly related to drinking motives. Coping motives appear to particularly problematic (e.g., Cooper et al., 1995; Gonzalez et al., 2009; Park & Levenson, 2002) and have been shown to mediate the relationship between social anxiety and ARPs (Buckner & Heimberg, 2010; Norberg et al., 2010). It is likely that by helping individuals to develop other coping techniques and reducing their coping motives for alcohol use, clinicians could help individuals high in social anxiety to reduce the number of ARPs they experience or prevent them from experiencing ARPs. 4.4. Conclusions This quantitative review examined the relationship between social anxiety and alcohol variables in college students. While many of the average effect sizes are small, the relationship between social anxiety and alcohol variables is still important both clinically and scientifically because of the pattern of the results. Specifically, despite the fact that social anxiety was negatively related to quantity and frequency of alcohol use, quantity by frequency measures of alcohol use, and frequency of binge drinking, it was positively related to ARPs. Therefore, research on this phenomenon is necessary to identify interventions to reduce the increased number of ARPs experienced by those high in social anxiety, since their level of alcohol use is not elevated. Social anxiety was also positively related to coping, conformity, and social motives for alcohol use, which may put socially anxious college students at risk for problematic use. There was also a positive relationship with positive and negative outcome expectancies. Both DMs and AOEs are important variables to continue to examine in research as possible mediators of the relationship between social anxiety and alcohol variables. Role of funding sources This study was not funded. Contributors Amie R. Schry was responsible for writing the coding manual, conducting the literature search, coding all studies, conducting the analyses, and writing the first draft of the manuscript. Susan W. White consulted on the design and coding protocol, served as a reliability coder, and assisted in writing the manuscript. Conflict of interest The authors declare that they have no conflicts of interest. Acknowledgments We would like to thank Danny Axsom, PhD, Bethany C. Bray, PhD, and Robert Stephens, PhD, for consultation on the planning and design of this study. We would also like to thank Elmira Hamidi and Caitlyn Berry for serving as reliability coders.

Appendix A Characteristics of studies included in the meta-analysis. Report information

Sample size

Rec./sel.

% Female

% Caucasian

Data coll. method

Pub./ peer-review

SA meas.

AU time-frame report

ARP meas.

ARP time-frame

Motive meas.

AOEs meas.

Correlations

None

76%

72%

In person

Yes

SAS-A

n/a

PAI

Not rep.

n/a

n/a

ARP = .09

413

None

34%

Not rep.

In person

Yes

WMH-CIDI

Not reported

n/a

Not rep.

n/a

n/a

AU Freq. = .05

172

76%

87%

Other

Yes

SIAS

Month

RAPI

Month

n/a

n/a

Buckner and Heimberg (2010)

120

High/low SA Non-drinkers excluded High/low SA; Non-drinkers excluded

81%

85%

Other

Yes

SIAS

Month

RAPI

Month

DCSAS

n/a

Buckner and Matthews (2012)

232

High/low SA

Not rep.

Not rep.

Other

Yes

SIAS

Month

RAPI

Month

n/a

SIDS

Buckner et al. (2006)

293

Non-drinkers excluded

58%

86%

In person

Yes

SIAS

Month

RAPI

Month

DMQ

n/a

High alcohol use/ problems Non-drinkers excluded

59%

Not rep.

In person

Yes

IAS

Month

n/a

n/a

n/a

n/a

60%

66%

Not rep.

Yes

SAD

Month

YAAPST

Year

DMQ

n/a

AU Quant. = −.07 AU Freq. = −.05 ARP = .26 AU Quant. = −.14 AU Freq. = −.15 ARP = .21 Cope = .42 AU Freq. = −.16 ARP = .18 Pos. = .31 Neg. = .31 AU Quant. = −.08 AU Freq. = −.06 ARP = .17 Cope = .13 Enh. = .18 Soc. = .13 AU Freq. = −.18 AU FQ = −.13 AU Quant. = −.11 AU Freq. = −.16 AU FQ = −.16 ARP = −.04 Cope = .18 Conf. = .19 Enh. = −.11 Soc. = .02 AU FQ = −.08 ARP = −.03 Pos. = .15 Neg. = .17 AU Freq. = −.12 AU Binge = −.12 ARP = .11 Pos. = .22 Neg. = .19 AU FQ = −.04 ARP = .23 Pos. = .04 AU FQ = −.19 ARP = −.06 AU FQ = −.17 ARP = −.09 Pos. = −.06 Neg. = .09 AU FQ = −.19 ARP = .04 Pos. = .14 Neg. = .03

Burke and Stephens (1997) Clerkin and Barnett (2012)

73 730

Dhuse (2005)

334

None

69%

Not rep.

In person

No

SIAS and SAD

2 weeks

YAAPST

Year

n/a

AEQ and EDA

Eggleston, Woolaway-Bickel, and Schmidt (2004)

284

Non-drinkers excluded

58%

86%

Not rep.

Yes

SIAS

1 week

RAPI

Month

n/a

CEOA and AESES

Gilles (2005), Gilles et al. (2006)

118

None

61%

86%

Other

Yes

SIAS/SPS total

Not rep.

AUDIT

Not rep.

n/a

CEOA

Ham (2003), Ham and Hope (2005) Ham (2003), Ham and Hope (2006)

316

High alcohol use/problems Low alcohol use/problems

38%

90%

In person

Yes

IAS

Month

RAPI

6 months

n/a

n/a

39%

91%

In person

Yes

Comp. of SPAI/IAS

Month

RAPI

6 months

n/a

CEOA

69%

13%

In person

Yes

SIAS/SPS total

Not rep.

AUDIT

Not rep.

n/a

AESES and DEQ

Ham (2009)

228

610

None

(continued on next page)

2701

215

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Bagner, Storch, and Preston (2007) Bella and Omigbodun (2009) Buckner, Ecker, et al. (2011)

2702

Appendix (continued)A

(continued)

Report information

Ham, Bonin, and Hope (2007)

Sample size

239

% Female

% Caucasian

Data coll. method

Pub./ peer-review

SA meas.

AU time-frame report

ARP meas.

ARP time-frame

Motive meas.

AOEs meas.

Correlations

Non-drinkers excluded

59%

90%

In person

Yes

SPAI

Month

RAPI

6 months

DMQ

n/a

High alcohol use/problems

31%

81%

In person

Yes

SIAS/SPS total

Week

RAPI

6 months

n/a

n/a

AU Quant. = −.23 AU Freq. = −.13 ARP = −.07 Cope = .10 Conf. = .05 Enh. = −.06 Soc. = .01 AU Quant. = −.02 AU Freq. = .02 ARP = .34 AU FQ = .03 ARP = .11 Pos. = .23 Neg. = .22 AU FQ = −.08 ARP = .02 Cope = .28 Conf. = .30 Enh. = .12 Soc. = .13 Pos. = .15

Ham, Casner, Bacon, and Shaver (2011)

62

Ham, Zamboanga, and Bacon (2011)

377

None

70%

77%

Other

Yes

SIAS

Not rep.

AUDIT

Not rep.

n/a

CEOA

Ham et al. (2009)

817

Non-drinkers excluded

74%

74%

Other

Yes

SIAS

Not rep.

AUDIT

Not rep.

DMQ

n/a

Ham, Zamboanga, Olthuis, Casner, and Bui (2010) Heideman (2008)

715

Non-drinkers excluded

75%

68%

In person

Yes

SIAS

n/a

n/a

n/a

n/a

CEOA

High SA; high alcohol use/problems

44%

89%

In person

No

SIAS and BFNE

Month

RAPI

Month

n/a

n/a

None

70%

66%

Other

Yes

SA subscale of SCS

Month

n/a

n/a

n/a

n/a

AU Quant. = −.24 AU Freq = .39 AU FQ = .11 ARP = −.20 AU FQ = −.10

Non-drinkers excluded

0%

92%

Not rep.

Yes

n/a

n/a

n/a

n/a

AEQ

Pos. = .28

316

High alcohol use/problems

54%

99%

Other

Yes

FNE, SAD, and SA subscale of SCS IAS and LSAS

Month

RAPI and YAAPST

Year

DMQ

n/a

McKeon (2005)

697

None

50%

90%

Other

No

FNE and SAD

Month

RAPI

Year

n/a

CEOA and A-AESES

Merrill (2000)

264

Non-drinkers excluded

100%

Not rep.

In person

No

FNE

6 months

sMAST

Lifetime

n/a

n/a

Mignogna (2010)

140

High alcohol use/problems

44%

85%

In person

No

SIAS and FNE

Month

B-YAACQ and CAPS-r

Not rep.

n/a

n/a

Miller (1989)

365

None

66%

70%

In person

No

SAD

Not rep.

Drinking Conseq. Scale of Drinking Styles Quest.

Not rep.

n/a

n/a

AU Quant. = −.09 AU FQ = −.10 ARP = .14 Cope = .28 Conf. = .24 AU Quant. = −.08 AU Freq. = −.09 AU Binge = −.12 ARP = −.12 Pos. = .07 Neg. = .13 AU Quant. = .00 AU Freq. = −.06 ARP = .05 AU Quant. = −.01 AU FQ = .01 ARP = .31 AU FQ = −.21 ARP = −.18

LaBrie, Hummer, and Neighbors (2008) Leonard and Blane (1988) Lewis et al. (2008)

14

1168 86

A.R. Schry, S.W. White / Addictive Behaviors 38 (2013) 2690–2706

Rec./sel.

Report information Sample size

Rec./sel.

% Female

%

Caucasian

Data coll. method

Pub./ peer-review

SA meas.

AU time-frame report

ARP meas.

ARP time-frame

Motive meas.

AOEs meas.

Correlations

AU Quant. = −.01 AU Freq. = −.07 AU FQ = −.12 ARP = .10 Cope = .40 Conf. = .25 Enh. = .04 Soc. = .12 AU Quant. = −.04

118

High SA

61%

40%

In person

Yes

SIAS/SPS total and FNE

3 months

RAPI and modified TLFB

3 months

DMQ

n/a

O'Grady, Cullum, Armeli, and Tennen (2011) O'Hare (1988), (1990)

476

Non-drinkers excluded

52%

86%

In person

Yes

SA subscale of SCS

Month

n/a

n/a

n/a

n/a

606

None

56%

67%

Other

Yes

Social Anxiety Scale

Month

Rutgers Survey

Year

n/a

AEQ

Owen (1995)

312

None

50%

90%

In person

No

FNE and SAD

Week

Not rep.

n/a

n/a

Popali-Lehane (2006)

215

None

78%

43%

In person

No

SIAS/SPS total

Year

Problems from Drinking Scale of SAQ Core Alcohol and Drug Survey

Year

DMQ

CEOA

0%

Not rep.

In person

Yes

3 months

n/a

n/a

n/a

n/a

100%

88%

Other

No

Social and Test Anxiety Scale SIAS/SPS total and SPAI-23

Year

Norberg et al. (2009) list of ARPs

Year

DMQ

n/a

Rohsenow (1982)

AU Freq. = −.07 ARP = −.04 Cope = .25 Conf. = .34 Enh. = .01 Soc. = .13 Pos. = .09 Neg. = .19 AU FQ = −.41

Schry (2011)

588

High alcohol use/problems Non-drinkers excluded

Schry and White (2009)

412

Non-drinkers excluded

100%

88%

Other

No

SPAI-23

Month

n/a

n/a

n/a

DAMS

Schry and White (2010)

383

Non-drinkers excluded

100%

88%

Other

No

SIAS/SPS total and SPAI-23

Month

n/a

n/a

n/a

n/a

Schry and White (2012)

674

Non-drinkers excluded

69%

85%

Other

No

SIAS/SPS total

Month

Norberg et al. (2009) list of ARPs

Month

n/a

n/a

9024

None

73%

62%

Other

Yes

SIAS

Month

n/a

n/a

n/a

n/a

287

None

72%

72%

In person

Yes

SAS-A

n/a

PAI

Not rep.

n/a

n/a

AU Quant. = −.05 AU Freq. = −.13 AU Binge = −.06 ARP = .07 Cope = .25 Conf. = .27 Enh. = .04 Soc. = .08 AU Quant. = −.04 AU Freq. = −.15 AU Binge = −.08 Cope = .19 AU Quant. = −.02 AU Freq. = −.17 AU Binge = −.05 AU Quant. = −.08 AU Freq. = −.15 AU FQ = −.14 ARP = .03 AU Quant. = −.10 AU Freq. = −.11 ARP = .12

388

None

68%

70%

In person

Yes

SAS-A

n/a

PAI

Not rep.

n/a

n/a

ARP = .11

Schwartz et al. (2011) Storch, Bagner, Geffken, and Baumeister (2004) Storch, Storch, Killiany, and Roberti (2005)

36

AU Quant. = −.14 ARP = −.04 Pos. = .15 AU FQ = −.09 ARP = −.05

A.R. Schry, S.W. White / Addictive Behaviors 38 (2013) 2690–2706

Norberg et al. (2009), (2010), (2011)

(continued on next page)

2703

2704

Appendix (continued)A

(continued)

Report information

Sample size

% Female

% Caucasian

Data coll. method

Pub./ peer-review

SA meas.

AU time-frame report

ARP meas.

ARP time-frame

Motive meas.

AOEs meas.

Correlations

None

61%

Not rep.

Not rep.

Yes

SIAS

Not rep.

AUDIT

Not rep.

n/a

Alcohol Outcome Exp, Quest.

AU Quant. = −.07 AU Freq. = −.12 AU Binge = −.06 Pos. = .09 Neg. = .17 AU Quant. = .34 AU Freq. = .29 AU FQ = .34 ARP = .32 AU Quant. = .12 Pos. = .25

Strahan, Panayiotou, Clements, and Scott (2011)

824

Terlecki, Buckner, Larimer, and Copeland (2011), (2012) Tran, Anthenelli, Smith, Corcoran, and Rofey (2004) Tran, Haaga, and Chambless (1997)

70

High/low SA; high alcohol use/problems

31%

86%

In person

Yes

SPS

Month

RAPI

Month

n/a

n/a

152

High/low SA; high alcohol use/problems None

49%

94%

In person

Yes

SIAS

Year

n/a

n/a

n/a

AEQ and AESES

66%

82%

In person

Yes

SIAS

Month

n/a

n/a

n/a

AEQ and AESES

229

AU Quant. = −.05 AU Freq. = −.14 Pos. = .17

Note. Measures only included if results were available for that measure. AEQ = Alcohol Expectancy Questionnaire; AESES = Alcohol Expectancies for Social Evaluative Situations Scale; AU = Alcohol Use; AUDIT = Alcohol Use Disorders Identification Test; BFNE = Brief Fear of Negative Evaluation Scale; B-YAACQ = Brief Young Adult Alcohol Consequences Questionnaire; CAPS-r = College Alcohol Problems Scale — Revised; CEOA = Comprehensive Effects of Alcohol Scale; Conf. = Conformity Motives; Cope = Coping Motives; DAMS = Drinking for Anxiety Management Scale; Data Coll. Method = Data Collection Method; DCSAS = Drinking to Cope with Social Anxiety Scale; DEQ = Drinking Expectancy Questionnaire; DMQ = Drinking Motives Questionnaire or DMQ-Revised; EDA = Effects of Drinking Alcohol Scale; Enh. = Enhancement Motives; Exp. = Expectancies; FNE = Fear of Negative Evaluation Scale; FQ = Frequency by Quantity Index; Freq. = Frequency; IAS = Interaction Anxiousness Scale; LSAS = Liebowitz Social Anxiety Scale; Meas. = Measure; n/a = Not Applicable; Neg. = Negative AOEs; Not rep. = Not Reported; PAI = Personality Assessment Inventory; Pos. = Positive AOEs; Pub/Peer-Review = Published and Peer-Reviewed; Quant. = Quantity; Quest. = Questionnaire; RAPI = Rutgers Alcohol Problems Index; Rec./Sel. = Recruitment and Selection Criteria; SA = Social Anxiety; SAD = Social Avoidance and Distress Scale; SAQ = Student Alcohol Questionnaire; SAS-A = Social Anxiety Scale for Adolescents; SCS = Self-Consciousness Scale; SIAS = Social Interaction Anxiety Scale; SIDS = Social Impressions while Drinking Scale; sMAST = Short Michigan Alcohol Screening Test; Soc. = Social Motives; SPAI = Social Phobia and Anxiety Inventory; SPS = Social Phobia Scale; TLFB = Timeline Followback; WMH-CIDI = World Mental Health Initiative Version of the Composite International Diagnostic Interview; YAAPST = Young Adult Alcohol Problems Screening Test.

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* Indicates reports included in the meta-analysis.

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