Social Anxiety Disorder — formerly known as social phobia — is commonly treated by either psychotherapy or certain types of psychiatric medications. Social phobia is characterized by a persistent fear of social situations or performance situations (such as public speaking) where embarrassment might occur. The core fear underlying social anxiety is the fear of negative evaluation by others.
While both psychotherapy and medications have been shown to be effective in the treatment of social anxiety disorder, a combination approach to treatment — utilizing both at the same time — may be the most timely and beneficial.
While some people may find relief from some social anxiety symptoms through trying simple self-help techniques, most people with a diagnosed social phobia condition will need professional treatment in order to overcome it.
Psychotherapy for Social Anxiety
Psychotherapy is a very effective method of treatment for social anxiety disorder. Specifically, cognitive behavioral treatments — which include techniques such as exposure therapy, cognitive restructuring without exposure, exposure therapy with cognitive restructuring, and social skills training — appear to be highly effective in treating social anxiety in a time-limited manner. Most cognitive-behavioral therapy (CBT) can be administered within 16 sessions (usually one session per week). At the end of treatment, a person’s anxiety symptoms are greatly reduced or even disappear in some cases. CBT for social anxiety appears to be equally effective whether delivered in an individual or group-format basis.
In addition to CBT, other psychological treatments have also been found effective in the treatment of social anxiety. These include cognitive therapy (a component of CBT), social skills training alone, relaxation exercises, exposure therapy alone/behavioral therapy, and some other types of less-practiced forms of psychotherapy. Group-based CBT has also shown to be effective, as the group component may directly target some of the core concerns of public speaking-related or generalized social anxiety.
Exposure therapy is often a primary component of psychotherapy treatment of social anxiety disorder. Exposure therapy, practiced either on an individual or group basis, involves a person learning to understand the irrational basis for their fears (cognitive restructuring), teaching simple relaxation skills to practice while in the moment, and gradually being “exposed” to the situation which causes the anxiety.
One format of exposure involves imagining an anxiety-provoking scenario and walking through it with the therapist in the safety of the psychotherapy office.
As the patient’s confidence grows, he or she will begin to apply the skills they’ve learned in the therapy session to outside world events and environments. Termed “in-vivo exposure,” this can be assigned as therapy homework. In another scenario, a therapist can accompany their patient out in the community. This can be highly effective for building therapeutic trust and self-confidence within the patient. In-vivo exercises are meant to deliberately and repeatedly expose a patient to feared situations gradually as an attempt to show the individual, by objective example, that their feared outcome is either unlikely, “not so bad”, or less probable than are anticipated to be in their mind.
As one example, a person with social anxiety phobia may feel certain that if he were to speak up in a group or to a person of romantic interest, he would be utterly humiliated and rejected because he would stutter and say something stupid; therefore, this person has avoided making friends, dating, or interviewing for new jobs altogether. In-session the therapist may enter a grocery store with this patient and have them ask an intentionally embarrassing question (e.g., asking why blue cheese is moldy). Alternatively, in group therapy format, the therapist may have the patient deliver a short speech weekly in front of other group members concerning a “hot topic” or one in which they know little about. In any of these cases, the individual would essentially make themselves feel embarrassed purposefully to disprove their biased prediction about the consequences of such an action.
Cognitive processing may follow where the therapist and patient discuss how much anxiety was experienced by the patient from beginning-to-end of the exposure routine, as well as asking the patient (if anything) what was learned as a takeaway to challenge their original threat predictions (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 things all the time”). Gradually, with repeated exposure, the patient would work up to achieving goals or tasks in life that have been avoided due to the social anxiety.
Psychotherapy treatments, especially those that are exposure based, have been shown to be highly effective in treating social anxiety disorder (Acarturk et al., 2009; Powers et al., 2008). Most people who try psychotherapy with a therapist who has experience in treating social anxiety disorder will find relief from their symptoms.
Medications for Social Anxiety
The primary class of drugs used to treat social anxiety are called selective serotonin reuptake inhibitors (SSRIs). This class of drugs was first developed to treat depression and so are often referred to as antidepressants. Since then, however, they have been found to be effective in the treatment of a wider range of disorders. Common SSRIs include Paxil (paroxetine), Zoloft (sertraline), Prozac (fluoxetine), and Luvox (fluvoxamine).
Another type of antidepressant called Effexor (venlafaxine) may also be prescribed to help with the symptoms of social phobia.
These kinds of medications generally take 6 to 8 weeks in order to start feeling the full therapeutic effects of them. While it may be frustrating to wait during that time and feel little relief, always take all medications as prescribed by your doctor. If you experience any distressing side effects, talk to your doctor immediately.
There is little specific reason to prescribe one antidepressant over another for the treatment of this disorder. Your doctor may choose your medication based upon their own experience in prescribing it, or based upon the typical side effects most people who take it experience. If you are not experiencing relief in 6 to 8 weeks from the first medication prescribed, talk to your doctor. He or she may decide to either up your dose or try a different medication altogether.
In addition to SSRIs, others kinds of medications are occasionally prescribed in the treatment of social anxiety disorder.
Anti-anxiety medications called benzodiazepines are rarely prescribed for social anxiety disorder, because they are extremely habit-forming and act as a sedative. However, because they act quickly in the short-term, they may be prescribed when a specific situation warrants their use — such as an unexpected public speaking engagement that can’t be avoided.
A class of drugs called beta blockers may also be used for relieving social anxiety. 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. They are primarily used for short-term situations, such as when you need to give a speech. However, like benzodiazepines, they are not generally recommended for the treatment of social anxiety and are rarely prescribed for it.
Self-Help Techniques for Social Anxiety
A number of self-help techniques may be tried to help control social anxiety symptoms. These are techniques adopted from cognitive behavioral therapy (CBT), but can also be used outside of formal psychotherapy.
1. Practice deep breathing exercises.
We often identify the physical symptoms of anxiety more readily than the psychological symptoms — so they are 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 alleviate this feeling of shortness of breath.
- 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 first.
- 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.
2. Take baby steps forward.
Baby steps are such an important of any treatment, but they can also be helpful for self-help exercises. After all, you didn’t get this way overnight. So changing it isn’t going to happen in one try either.
For social anxiety disorder, this can mean learning relaxation exercises (such as the deep breathing exercise above), and practicing them until they become second nature and easily done in any situation, at any time.
People fear the very idea of “exposure therapy,” so it’s important to understand what it does not mean. It doesn’t mean going into your most-feared social situation tomorrow without little help or techniques under your belt. It also doesn’t mean having to face your worst fears in order to overcome them.
Exposure therapy simply refers to being exposed, very gradually, to social situations that would normally be anxiety-provoking. But your exposure to them is in lock-step with your learning relaxation and coping techniques that help you deal with anxiety as it arises.
You can try this out in a smaller form on your own, with the help of a close friend or anxiety buddy. For instance, if you fear the social requirements of a dinner party, try going out with a smaller, more trusted group of friends first. Try and recognize what you’re feeling throughout the night, and when you feel little spikes of anxiety. What happened just before them? How did you keep them from turning into something bigger?
3. Listen to your self-talk or inner voice.
We often tell ourselves things in our heads that may or may not be true. Psychologists call this sort of thing “self-talk,” while others call it their inner voice. Some of this self-talk is positive and can help bolster our self-esteem. Other times, this self-talk can be negative and destructive to our happiness.
When this latter thing happens, psychologists call it a “cognitive distortion” — that is, our thoughts are distorted and irrational. We all engage in these automatic thoughts or cognitive distortions, many times throughout the day. They lead us to make assumptions about our own and other people’s thoughts, feelings and behaviors which are often untrue.
The key is to identify the automatic thoughts as they occur, and then answer them back so you don’t let them get the better of you.
Social anxiety disorder is a fairly common concern which can be treated with a combination of psychotherapy, medications and self-help techniques. But the first step to any treatment is acknowledging the problem, and then seeking out help from a trained mental health professional, such as a psychologist.
Acarturk, C.; Cuijpers, P.; van Straten, A.; de Graaf, R. (2009). Psychological treatment of social anxiety disorder: A meta-analysis. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 39, 241-254.
Powers, Mark B.; Sigmarsson, Snorri R.; Emmelkamp, Paul M. G. (2008). A meta-analytic review of psychological treatments for social anxiety disorder. International Journal of Cognitive Therapy, 1, 94-113.
Roy-Byrne, Peter P.; Cowley, Deborah S. (2007). Pharmacological treatments for panic disorder, generalized anxiety disorder, specific phobia, and social anxiety disorder. In: A guide to treatments that work (3rd ed.). Nathan, Peter E. (Ed.); Gorman, Jack M. (Ed.); New York, NY, US: Oxford University Press, 395-430.