Social Anxiety Disorder Treatment
You’ve been diagnosed with social anxiety disorder (SAD). You might experience intense anxiety about attending parties, eating in front of others, talking to people you just met, or making eye contact in general. And because of your profound fear, you usually avoid these situations. Or you’ve been diagnosed with performance-only SAD, because you experience extreme anxiety when speaking or performing in public (but not during other times; for instance, you’re totally fine at work meetings and dinner parties).
Either way, the core fear underlying your disorder is that you’ll be negatively evaluated by others—you’ll do something to embarrass yourself, or you’ll offend someone, or you’ll get rejected. Which feels incredibly painful.
Thankfully, highly effective treatment exists for both the generalized form of SAD and for performance-only SAD (treatments vary depending on your diagnosis; more on that in the medication section).
Overall, the first-line treatment for SAD is therapy (namely cognitive behavioral therapy, or CBT). But it really depends on the availability of treatment, severity of your SAD, the presence of co-occurring disorders, and your preference. For instance, you might not be able to find a therapist who specializes in CBT.
Medication is an effective alternative. The first-line medication is a selective serotonin reuptake inhibitor (SSRI), or venlafaxine (Effexor), a serotonin and norepinephrine reuptake inhibitor (SNRI).
Guidelines from the Royal Australian and New Zealand College of Psychiatrists suggest CBT for mild SAD; CBT, or an SSRI/SNRI, or a combination of therapy and medication for moderately severe SAD; and a combination of CBT and medication from the start for severe SAD.
Guidelines from the National Institute for Health and Care Excellence (NICE) recommend CBT as the first-line treatment. If CBT doesn’t work, or an individual doesn’t want to try it, NICE recommends the SSRIs escitalopram (Lexapro) or sertraline (Zoloft).
It’s very common for people with SAD to have additional conditions, including other anxiety disorders, depression, and substance abuse. Which, as mentioned earlier, can affect your treatment (e.g., you end up taking an SSRI for your depression).
When guidelines appear to differ slightly, the best approach is to talk to your doctor about your particular situation, and what might be most effective for you.
Psychotherapy for Social Anxiety
Cognitive-behavioral therapy (CBT) is the first-line treatment for social anxiety disorder (SAD). Some research has shown that effects of psychological interventions are long lasting, whereas a portion of individuals who stop taking medication experience a relapse and symptoms return within 6 months.
CBT is an active, collaborative therapy. In CBT, you’ll explore what maintains your symptoms. You’ll learn to notice your thoughts, question them, and reframe them. You’ll also slowly and systematically face your social fears, which show you, by objective example, that your feared outcome is unlikely, “not so bad,” or less probable than you anticipated.
For instance, you might go to the grocery store with your therapist, and intentionally ask an embarrassing question, such as “Why is blue cheese moldy?” In other words, you purposefully make yourself feel embarrassed to disprove your biased predictions about the consequences of various social actions.
After each experiment, you and your therapist will process what happened. You’ll discuss how much anxiety you felt at various points and what you learned—lessons that challenged your original predications (e.g., “Yeah, it was weird to do that, but the woman did not bite my head off for asking about the blue cheese…I bet people ask weird questions all the time”). Plus, you’ll work on reducing your safety behaviors (e.g., wearing makeup to hide blushing).
Another option that’s been less researched than CBT but appears to be effective is psychodynamic psychotherapy. Guidelines developed by the National Institute for Health and Care Excellence working group (NICE) on SAD recommend short-term psychodynamic psychotherapy (STPP, specifically designed for SAD) for individuals who decline CBT and medication. NICE notes that STPP should consist of 25 to 30 50-minute sessions for 6 to 8 months, which include: education about SAD; emphasis on a core conflictual relationship theme that connects to SAD symptoms; exposure to feared social situations; help with establishing a self-affirming inner dialogue, and with improving social skills.
According to one study on psychodynamic psychotherapy, a conflictual relationship theme has three parts: a wish (e.g., “I wish to be affirmed by others”); an anticipated response from others (e.g., “Others will humiliate me”); and a response from the self (e.g., “I am afraid of exposing myself”). Your therapist helps you work through this theme with both your present and past relationships.
Medications for Social Anxiety
If you’d like to treat your social anxiety disorder (SAD) with medication, the doctor will likely start with a selective serotonin reuptake inhibitor (SSRI). Again, SSRIs are the first-line treatment for SAD.
SSRIs specifically approved by the U.S. Food and Drug Administration (FDA) for SAD are paroxetine (Paxil), sertraline (Zoloft), and extended-release fluvoxamine (Luvox). However, your doctor might prescribe a different SSRI “off label.” There’s no research evidence that one SSRI is better than another for this disorder.
Or your doctor might prescribe the serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor).
If you don’t respond to the first SSRI (or SNRI) your doctor prescribes, they’ll likely prescribe a different medication from the same class.
It takes about 4 to 6 weeks after starting the medication to feel significantly better, and up to 16 weeks to feel the greatest benefit. But if you aren’t experiencing a reduction in your symptoms, talk to your doctor.
SSRIs are better tolerated than other antidepressants, but they still come with a variety of bothersome side effects, which might cause you to want to stop taking your medication. These include agitation, headache, diarrhea, nausea, insomnia, and sexual dysfunction (such as decreased sexual desire, and an inability to have an orgasm).
Venlafaxine can cause insomnia, sedation, nausea, dizziness, and constipation. In addition, it can increase blood pressure. In many people, this increase will be small, but in some people, it can be significant. Venlafaxine should not be given to people with hypertension. If you end up taking venlafaxine, your doctor should monitor your blood pressure.
Never abruptly stop taking your medication. SSRIs and SNRIs can cause discontinuation syndrome, which is akin to withdrawal-like symptoms, such as: anxiety, depression, dizziness, fatigue, flu-like symptoms, headaches, and loss of coordination. This is why it’s critical that getting off these medications is a slow and gradual process. And even then, discontinuation syndrome can still occur. Paroxetine and venlafaxine seem to be associated with the greatest risk for discontinuation syndrome.
When SSRIs or SNRIs don’t work, monoamine oxidase inhibitors (MAOIs), particularly phenelzine (Nardil), are another option. While not FDA-approved for SAD, MAOIs have a long track record for treating the disorder. Yet, even though they’re effective, MAOIs come with difficult side effects and stringent diet restrictions. That is, you must eat a low-tyramine diet, which means you can’t eat aged cheeses, pepperoni, salami, soy sauce, pickles, avocadoes, pizza, and lasagna, among other foods.
If you do take an MAOI after taking an SSRI or SNRI, it’s vital to wait about 1 to 2 weeks before starting your new medication (or 5 to 6 weeks if you were previously on fluoxetine). This is to prevent serotonin syndrome, a potentially life-threatening reaction that occurs when someone takes two medications that affect levels of serotonin. This causes the body to have too much serotonin.
Symptoms typically occur within a few hours of taking the new medication, and can be mild, moderate, or severe. For instance, symptoms can include: irritability, anxiety, confusion, headache, dilated pupils, excessive sweating, shivering, twitching muscles, increased heart rate, high blood pressure, and hallucinations. More severe and potentially fatal symptoms can include high fever, seizures, irregular heartbeat, and unconsciousness.
Some research has found that gabapentin (Neurontin) and pregabalin (Lyrica) are effective for the generalized form of SAD. Side effects of gabapentin can include dizziness, drowsiness, unsteadiness, involuntary eye movements, and swelling of the arms, hands, legs, and feet. Side effects of pregabalin can include dizziness, drowsiness, dry mouth, nausea or vomiting, and constipation.
According to UpToDate.com, for performance-only SAD, benzodiazepines can help on an “as needed” basis (if you have no current or past history with a substance use disorder). That is, you might take clonazepam (Klonopin) 30 minutes to an hour before giving a speech.
Another option is taking a beta blocker, particularly if you struggle with substance use or experience sedation from a benzodiazepine (a common side effect). Beta blockers work by blocking the flow of epinephrine (more commonly known as adrenaline) that occurs when you’re anxious. This means they can help to control and block the physical symptoms that often accompany social anxiety—at least for a short while.
Currently, there’s no evidence that beta blockers are effective for performance-only SAD, but according to clinical experience, about half of individuals (or fewer) find beta blockers to be helpful.
However, guidelines from the Royal Australian and New Zealand College of Psychiatrists advise against prescribing beta blockers for SAD (but they didn’t separate SAD into the generalized form and performance-only SAD).
This is when it’s important to talk to your doctor about your specific situation, and raise any concerns you have. Also, ask your doctor about side effects, and how you might minimize them. Ask them when you should expect to feel better, and what that’ll look like. Ask them about discontinuation syndrome, and the process of tapering off a medication.
Self-Help Techniques for Social Anxiety
Practice deep breathing exercises. We usually identify the physical symptoms of anxiety more readily than the psychological symptoms—so they’re often the easiest to change. One of those prominent physical symptoms is breathing. We feel a shortness of breath when anxious, like we can’t breathe normally or can’t catch our breath. A simple breathing exercise you can practice at home can help:
- In a comfortable chair, sit with your back straight but your shoulders relaxed. Put one hand on your stomach and the other hand on your chest, so that you can feel how you breathe while practicing the exercise.
- Close your mouth, and inhale slowly and deeply through your nose while counting slowly up to 10. You may not make it to 10 when you first try this exercise, so you can start with a smaller number like 5.
- As you count, notice the sensations of your body while inhaling. Your hand on your chest shouldn’t move, but you should notice your hand on your stomach rising.
- When you reach 10 (or 5), hold your breath for 1 second.
- Then, exhale slowly through your mouth while counting out 10 seconds (or 5 if you’re just starting). Feel the air pushing out of your mouth, and the hand on your stomach moving in.
- Continue the exercise, breathing in through your nose and out through your mouth. Focus on keeping a slow and steady breathing pattern. Practice at least 10 times in a row.
The more you do this, the more you learn to control your breathing—which you thought was uncontrollable—on your own.
Sharpen your skills. We aren’t born knowing how to effectively communicate with others. We learn these skills, and many of us weren’t really ever taught. Consider reading books and how-to articles on being assertive and using other communication techniques. Practice what you’re learning with your loved ones, colleagues, and strangers.
Change cognitive distortions. All of us engage in automatic thoughts that are distorted and irrational, which leads us to make (untrue) assumptions about our own and other people’s thoughts, feelings, and behaviors. Thankfully, just because we have a thought doesn’t mean we have to believe it. We can question it, and we can change it. You can review the 15 most common cognitive distortions and then learn how to fix them.
Take small steps to face your fears. For instance, if you experience a lot of anxiety at dinner parties, go out with a smaller, more trusted group of friends first. Pay attention to what you’re feeling throughout the night, and when you feel little spikes of anxiety. What happened just before these spikes? How did you keep them from turning into something bigger? Also, consider facing other social fears with the help of a close friend.
Try a self-help workbook. Nowadays, there are great reputable resources written by anxiety experts, which you can work through on your own. For instance, check out Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach or The Shyness and Social Anxiety Workbook: Proven, Step-by-Step Techniques for Overcoming Your Fear.
You can find more expert self-help suggestions in this article.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Andrews, G., Bell, C., Boyce, P., Gale, C., Lampe, L., Marwat, O., … Wilkins, G. (2018). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalized anxiety disorder. Australian & New Zealand Journal of Psychiatry, 52, 12, 1109-1172. https://doi.org/10.1177/0004867418799453.
Bögels, S.M., Wijts, P., Oort, F.J., Sallaerts, S.J.M. (2014). Psychodynamic psychotherapy versus cognitive behavior therapy for social anxiety disorder: An efficacy and partial effectiveness trial. Depression and Anxiety, 31, 5, 363-373. DOI: http://dx.doi.org/10.1002/da.22246.
Hofmann, S.G. (2018, January 26). Psychotherapy for social anxiety disorder in adults. UpToDate.com. Retrieved from https://www.uptodate.com/contents/pharmacotherapy-for-social-anxiety-disorder-in-adults.
Kawalec, P., Cierniak, A., Pilc, A., Nowak, G. (2015). Pregabalin for the treatment of social anxiety disorder. Expert Opinion on Investigational Drugs, 24, 4, 585-594. DOI: https://doi.org/10.1517/13543784.2014.979283.
Leichsenring, F., Salzer, S., Beutel, M.E., Herpertz, S., Hiller, W., Hoyer, J., …. Leibing, E. (2013). Psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: A multicenter randomized controlled trial. The American Journal of Psychiatry, 170, 759-767. DOI: 10.1176/appi.ajp.2013.12081125.
Leichsenring, F., Salzer, S., Beutel, M.E., Herpertz, S., Hiller, W., Hoyer, J., …. Leibing, E. (2014). Long-term outcome of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder. The American Journal of Psychiatry, 171, 1074-1082. DOI: 10.1176/appi.ajp.2014.13111514.
Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D.M., Ades, A.E., Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. Lancet Psychiatry, 1, 368-376. DOI: https://doi.org/10.1016/S2215-0366(14)70329-3.
Social anxiety disorder: recognition, assessment and treatment. (2013, May). National Institute for Health and Care Excellence (NICE). Retrieved from https://www.nice.org.uk/guidance/cg159.
Stein, M.B. (2018, January 26). Pharmacotherapy for social anxiety disorder in adults. UpToDate.com. Retrieved from https://www.uptodate.com/contents/pharmacotherapy-for-social-anxiety-disorder-in-adults.
Stein, M.B., Taylor, C.T. (2019, June 5). Approach to treating social anxiety disorder in adults. UpToDate.com. Retrieved from https://www.uptodate.com/contents/approach-to-treating-social-anxiety-disorder-in-adults.
Williams, T., Hattingh, C.J., Kariuki, C.M., Tromp, S.A., van Balkom, A.J., Ipse, J.C., Stein, D.J. (2017). Pharmacotherapy for social anxiety disorder (SAnD). Cochrane Database of Systematic Reviews, 1-377. DOI: 10.1002/14651858.CD001206.pub3.
Wiltink, J., Ruckes, C., Hoher, J., Leichsenring, F., Joraschky, P., Leweke, F., … Beutel, M. (2017). Transfer of manualized Short Term Psychodynamic Psychotherapy (STPP) for social anxiety disorder into clinical practice: results from a cluster-randomized controlled trial. BMC Psychiatry, 1-11. DOI: https://doi.org/10.1186/s12888-017-1257-7.
Tartakovsky, M. (2019). Social Anxiety Disorder Treatment. Psych Central. Retrieved on February 24, 2020, from https://psychcentral.com/anxiety/social-anxiety-disorder-treatment/