An Interview with Psychologist Katherine Walukevich-Dienst
Katherine Walukevich-Dienst, Ph.D. is a post-doctoral fellow at the University of Washington School of Medicine. She’s an expert in the field of substance abuse and social anxiety, particularly among young adults.
Tori Steffen: Hi, everybody. Thanks for joining us today for this installment of the Seattle Psychiatrist Interview series. I'm Tori Steffen, a research intern at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.
I'd like to welcome with us today psychologist Katherine Walukevich-Dienst. Dr. Walukevich-Dienst is a post-doctoral fellow at University of Washington School of Medicine. Dr. Walukevich-Dienst specializes in alcohol and cannabis use and co-occurring mental health problems among young adults. She's written several publications on the topic, including using substances to cope with social anxiety, associations with use and consequences and daily life, and hours high as a proxy for marijuana use, quantity and intensive longitudinal designs.
So before we get started today, could you please let us know a little bit more about yourself and what made you interested in studying substance abuse and social anxiety?
Katherine Walukevich-Dienst: Absolutely. So thank you so much for having me. I could talk forever about this topic, so feel free to interrupt me if I go on and on. So I guess my journey kind of starts back when I worked at an anxiety lab at the University of Miami, and it was focused on anxiety across the lifespan. So we did a lot of work with kids and teenagers and young adults as well. And what I noticed, especially when studying people with social anxiety is that a lot of these individuals, teens and young adults in particular, mentioned using alcohol or cannabis to cope with their social anxiety. So that led to me to applying to grad school to work with my mentor, Dr. Buckner, who is kind of the queen of when it comes to research with social anxiety and substance use. Substance use doesn't occur in a vacuum, and it doesn't really ignore any type of person. So I was particularly interested what made these individuals, who are socially anxious, more vulnerable to using substances.
Tori Steffen: Okay. Yeah, that's definitely a really interesting topic to study, so it's very cool that you found a great mentor for that.
Katherine Walukevich-Dienst: Absolutely.
Tori Steffen: Yeah. So I guess getting down to basics about our topic, could you explain for the listeners why social anxiety typically develops and how it tends to present itself?
Katherine Walukevich-Dienst: For sure. So that's a really big question, especially with how it tends to develop, so we haven't narrowed down in research the one thing that tends to lead to social anxiety. And it's kind of a combination of a bunch of different things, including your genetics, your childhood history, experiences in adulthood, how you cope with things, among other susceptibility to other diagnoses among other things.
So people with social anxiety... Social anxiety is really common, and most people feel socially anxious in at least some situations. I know that I feel particularly socially anxious when I give a talk in front of a big group. And part of social anxiety is worried about fear or worry about what other people are thinking of you, and mainly that people might be judging you negatively, or that you might act in a way that's embarrassing, or that other people might see that you're anxious.
The important thing with that is that social anxiety, while we all experience that, people with social anxiety disorder experience that a lot of the time in a lot of different situations. So additionally, it is getting in the way of living the life that they want to lead. So while I am socially anxious in this one situation, people with social anxiety disorder might be anxious in a lot of different situations, and it's really getting in the way for them. They're really bothered by it, or it's causing problems in their life. For example, they really want to have a promotion at work, but find a really hard time speaking up in meetings, because they're so worried about being judged. So they end up getting passed over for a promotion over and over again, because they're not willing to speak up in those moments.
Tori Steffen: Right. Okay, awesome. Yeah, thank you. That's a really... Paints a good picture for how social anxiety presents itself as a disorder, and then just in common. So that's really interesting. Well, in what ways are substance abuse and social anxiety connected?
Katherine Walukevich-Dienst: So substance use and social anxiety have kind of a complicated and puzzling relationship, and this is part of the reason why these years later I'm still interested in this topic and I feel like we still have a lot to learn. So people with higher social anxiety don't actually tend to use substances more often than people with lower or no social anxiety. And in some cases, the research has shown, particularly with alcohol, like young adults with higher social anxiety drink less. However, what we do see pretty consistently in the literature is that people with elevated levels of social anxiety experience more problems or negative outcomes related to their use, even though they're not drinking more. So some of the research that I've done on this is trying to figure out, in particular context or situations, is it how people are drinking and when that are leading to these greater problems, even though they're not necessarily drinking more or more frequently than their non socially anxious peers?
Tori Steffen: Okay. Yeah, that definitely makes sense. How would you say that alcohol use typically influences the way that one experiences social anxiety?
Katherine Walukevich-Dienst: For both alcohol and cannabis, it tends to boil down to expectancies. And both alcohol and cannabis can reduce anxiety. So a lot of people expect that both what we call tension reduction expectancies. "If I drink, or if I use cannabis, I'll feel more relaxed, I'll be less stressed out, and that will make it easier for me to socialize with other people." There's also kind of that social facilitation expectancies. "I can only be in this situation when other people are drinking if I'm drinking too, and that will make it easier for me to have these conversations."
The thing with expectancies is that there's no kind of magical properties of alcohol or cannabis that makes you funnier or makes it easier to talk to people. It's really, a big part, the expectancies. There's been a lot of research done on that that is really interesting. So those are the two main reasons, or the two main expectations that people have is the social facilitation and the tension reduction as well.
Tori Steffen: Okay. Yeah, that's really interesting about the expectancies. And your article about substance abuse and social anxiety compared alcohol-only days, cannabis-only days, and then co-use days, and then how that impacted social anxiety, or coping with it. So could you explain a little bit about your findings around that for us?
Katherine Walukevich-Dienst: Absolutely. So I was lucky to work with this really large dataset from my post doc mentor, Dr. Christine Lee, where we measured 409 young adults, we measured them multiple times a day for two weeks at a time over a period of two years. So basically, we had a lot of data on these people.
Tori Steffen: Yeah.
Katherine Walukevich-Dienst: And while these people weren't selected particularly for social anxiety, there were high levels of social anxiety in the sample. Particularly, a pretty large number of individuals met the cutoff, clinical cutoff for social anxiety disorder. And what we looked at it was to see, on days people use substances to cope with social anxiety are those greater risk days for experiencing negative consequences, using more, and experiencing more positive consequences as well. So a lot of the literature has looked at negative outcomes or negative consequences, but we do know that people get positive things, or there's positive outcomes from drinking or using cannabis.
So what we found is that on days that people used substances to cope with social anxiety, they drank more, they experienced more negative consequences and positive consequences as well. So regardless of whether they were actually meeting criteria for social anxiety disorder or not, based on the measure that we had. So it was a high risk day for all people, regardless of social anxiety, which was kind of an interesting finding.
We also looked at the item level, which positive and which negative consequences people were more or less likely to experience. And what we found is that on the days that people used to cope with social anxiety, they experienced more likelihood of positive consequences, like feeling like they were more sociable, and not so much the negative consequences on those days. So it may be that they're saying, "Okay, this is great. I felt more sociable, I was able to express my feelings more easily." So they drink more, or used cannabis more often. And then it's using it kind of more often for those people in particular, or the way that they're doing that, that might be causing these problems.
Tori Steffen: Right. Okay. Yeah, that's definitely interesting for the comparison of alcohol and cannabis use. So that's good to know. When measuring substance use, does the amount of alcoholic drinks per day or hours high have a significant impact on one's experience of social anxiety?
Katherine Walukevich-Dienst: So I think that's a really good question as well. And I think it kind of boils down to how alcohol and cannabis work in the body. So for alcohol in particular, we know a lot more about alcohol and what the dosing looks like and what the response looks like for alcohol than we do cannabis. But we often think in young adults in particular that the more you drink, the better that is. So like, "If I have 10 shots, that's better than having just five over a longer period of time." But what we actually see is that there is this kind of we call it the biphasic effect, whereas people drink more, you get to this certain point where you're feeling the really good effects, but if you keep drinking, that actually gets worse and you start to experience some of those negative effects, like stumbling over your words, feeling dizzy or feeling nauseous, not remembering things. And that people tend to, in that moment, be like, "Oh, shoot, I need to drink more to feel good again." But once you hit that point, you can't.
And although we know less about cannabis, we do know that cannabis causes anxiety and can cause anxiety, especially in high THC or acute doses, which a lot of people use high THC products. So the more you use, even though it feels like the more you use, the less anxious you'll feel, sometimes the more you use, there's that sweet spot, and then you'll feel pretty anxious afterwards.
So I think the takeaway from that is more isn't always better, particularly with anxiety, and particularly with alcohol and cannabis.
Tori Steffen: Right. Yeah. That's so interesting how your study looked at the nuances of people's experiences and exactly breaking it down, "Here's the positive effects, and then here are the negative effects." So yeah, that's all super interesting information. Have you found that socially anxious young adults are at a higher risk for substance abuse?
Katherine Walukevich-Dienst: Again, that question is tricky, but it can be, yes. They're more likely to experience problems related to their use. And some people have done research finding that it's actually people with moderate levels of social anxiety, not necessarily clinical. Although, clinical levels are associated with worse outcomes. It's the people in that moderate range who might be going to the social situations, that might be putting themselves at risk, that are experiencing the most consequences and are the heaviest consumers of these substances. Because in some ways, social anxiety might be protective in that they might be avoiding situations where drinking or cannabis use is happening because of their social anxiety. Or we've also looked at finding that some people tend to use alone. So social anxiety is a big risk factor for using alone or by yourself.
Tori Steffen: Yeah. That definitely makes sense as far as maybe keeping you from wanting to socialize.
Katherine Walukevich-Dienst: One of the things about the study that we were talking about a little bit earlier that I found interesting is that the one negative consequence that came out significant for cannabis use days was on days people used to cope with social anxiety, they were more likely to feel antisocial or want to avoid other people. So even though they were using to cope with social anxiety and these other reasons, because of their cannabis use, they reported feeling more socially anxious and more avoidant-
Tori Steffen: Yeah.
Katherine Walukevich-Dienst: ... which is pretty unfortunate.
Tori Steffen: Man, yeah, that's good to know though, that it can have those kinds of effects, especially if you're wanting to use cannabis to treat social anxiety, but it can have those reverse effects.
Katherine Walukevich-Dienst: Absolutely.
Tori Steffen: Yeah. Well, another article notes that smoking to manage anxiety can be targeted as a false safety behavior. Can you kind of explain that for our audience?
Katherine Walukevich-Dienst: Yeah. So a false safety behavior is basically anything that we do that helps us feel, in the moment, less anxious or safe. So for example, non substance related false safety behaviors, particularly for people with social anxiety, can be only going places when you have a person with you or that you feel comfortable with. So this might look like only going to parties if you have that one friend who you know feel comfortable going with you, or only going places if you know that you'll have your medication with you. And if you have your medication, or if you have your safety emotional support water bottle or whatever thing, that makes it okay to go.
But when it comes to substance use as a false safety behavior, this can look like only going to social situations or being in situations where you are able to consume substances either before, during, or after to help manage social anxiety. And kind of targeting a false safety behavior means to first identify it and then try to fade it out. So try to go a longer period of time without using, or start to go maybe the first 20 minutes of the party you go and you don't use, and then you decide at that point, "Do I want to use and how much?" Or decreasing the amount that you use over time. So eventually, the idea is that you're not doing it anymore, this behavior anymore, to manage anxiety. So you may still use cannabis, you may still drink, but the goal is not to do so to manage anxiety.
Same with a safety behavior, like going somewhere with a friend. Right? Of course, you want to spend time with your friends, but if it's only to help you manage your anxiety, or in part to help you manage your anxiety, we want to reduce that part, so you're spending time with your friends because you want to and not to help you feel less anxious.
Tori Steffen: Right. Okay, awesome. Yeah, that definitely breaks it down really well. Thank you. Well, other than engaging in substance abuse, how can young adults cope with negative symptoms related to their social anxiety?
Katherine Walukevich-Dienst: So part of what alcohol and cannabis make tricky when it comes to social anxiety is that they do a really good job of making people feel less anxious in the moment, and pretty immediately too. But by... I keep using this example of being in a party setting, but by going into a party setting only while intoxicated, you're never really learning and your brain is never really learning like, "Oh, I'm actually okay here." Or, "Yeah, I said that something that was really embarrassing, or I couldn't figure out what to say, and that was okay." And that it's really not learning that these situations, while uncomfortable, you can survive them and you will be okay. And that the more that you do them, the more comfortable you feel. We call that habituation. So what substances do is they act as a way for us to avoid confronting that cycle and tolerating that discomfort that comes initially when you're in a new situation, or when you're in a social situation that makes you feel particularly anxious.
So with treatment, in part, what we argue for is, “Just do it,” which sounds really easy, but is really hard in practice. And instead of using substances to avoid, try to approach some of the things, little by little, that you feel produce anxiety or make you feel socially anxious. Start with something on your list that feels a little bit easier, and then maybe work your way up to some harder situations. But see what it's like to be in a situation without substances and try that a couple of times, get some more data on what that looks like, because for people who tend to do this, they haven't been in those situations very often without substances.
Tori Steffen: Right. Yeah. It sounds almost like ERP a little bit.
Katherine Walukevich-Dienst: Yeah.
Tori Steffen: Are there any specific types of therapy like that that can be beneficial for treating social anxiety and substance use?
Katherine Walukevich-Dienst: The good news is there is. So once you identify these things, one of the treatments is cognitive behavioral therapy for social anxiety, which includes exposure. So exposure is like what you're talking about with ERP. So coming up with a hierarchy of situations, that behavior piece is coming up with a hierarchy of situations that make you feel anxious, and working with a therapist to gain both cognitive skills and behavioral skills to experience and expose yourself to that anxiety.
So for example, if somebody says that they feel socially anxious about giving a presentation and the only way that they feel less anxious is by using cannabis before, the first exposure might be giving a presentation to your therapist, and the second without cannabis, and saying, "What's the worst thing that could happen here?" I'm telling myself I'm going to sound like an idiot, or I'm going to sound like I don't know what I'm talking about. What would be the worst thing about that? And coming up with a response like, "Even if these things happen, it will be okay," or, "I'll probably be embarrassed for a bit, but I'll get over it." Even having that more balanced way of thinking can be helpful. And it's not going into the situation saying, "I'm going to do amazing, and nothing's going to go wrong," because that's not necessarily helpful either if something does go wrong. It's finding a balance perspective, and then putting yourself in that situation.
So then what the therapist might assign for homework, an exposure homework, is then to do that in real life. So to set up a presentation, do it in real life without using substances. And if this sounds scary, it's because it is. And part of this is that you might feel really, really anxious at first. But I've done a lot of treatment with people with social anxiety and substance use, and it's pretty amazing how confidence grows in these different situations, and not necessarily their confidence in performing well in these situations, but their confidence in their ability to tolerate the anxiety and discomfort that might come from these things.
Tori Steffen: Right. Yeah, that's amazing. That sounds so important to know the difference between that and treatment, so very cool. Well, do you have any final words of advice or anything else that you'd like to share with the listeners today?
Katherine Walukevich-Dienst: I think final word of advice would be, if this is something that you're concerned about for yourself, start just paying attention to it and gathering some data, paying attention to, "What do I expect from using cannabis and alcohol in social situations? And am I actually obtaining those rewards?" So if I expect that using cannabis will make me funnier, or more enjoyable to be around in a social situation, does that actually happen? And does that happen every time, or just some of the time? And I think starting to gather that data can be really helpful in making different decisions potentially about using in those types of situations, or your need to.
Tori Steffen: Yeah. Awesome. Well, thanks so much for sharing that advice, and thanks so much for sharing your knowledge with us today, Dr. Walukevich-Dienst. It was really great to talk with you.
Katherine Walukevich-Dienst: All right. Thanks so much, Tori.
Tori Steffen: Thank you. And thanks, everybody, for tuning in.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.