How Social Anxiety Disorder Is Treated

People with social anxiety disorder (SAD), a type of anxiety disorder, experience intense discomfort in social situations because they are extremely afraid of being judged or of feeling humiliated or rejected by others. As a result, they often engage in avoidance behavior, which can negatively affect their work, school, and other day-to-day activities. Prescription medications and psychotherapy, alone or together, are recommended for the treatment of SAD.

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Prescription Medications

Mental health professionals often recommend that people with SAD start a prescription medication and participate in different types of psychotherapy. Studies have shown that these two approaches together can improve long-term outcomes in people with SAD.

Medication Safety

Medication should be placed in a secure area where only you can access it. It’s important to ensure that no other people at home, including children and pets, can get into the medication. Anyone who takes the medication, whether it has been prescribed to them or not, can experience side effects. If the side effects are severe, call 911 and go to the nearest hospital right away.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Serotonin is an important chemical messenger, or neurotransmitter, that regulates many body functions, including sleep, mood, and appetite. When serotonin levels are low, people may experience symptoms of anxiety and depression.

SSRIs are considered first-line treatment for SAD because of their efficacy and mild side effect profile, which have been demonstrated in clinical trials. This class of medication works by blocking the reuptake (absorption) of serotonin in the brain, leaving more serotonin to be available to help alleviate anxiety and mood symptoms.

SSRIs used to treat social anxiety include:

  • Paxil (paroxetine)
  • Luvox (fluvoxamine)
  • Zoloft (sertraline)
  • Lexapro (escitalopram)
  • Celexa (citalopram)
  • Prozac (fluoxetine)

More than 20 placebo-controlled trials have shown that SSRIs are highly effective in the treatment of SAD. However, they can cause side effects, including headaches, gastrointestinal issues, insomnia, fatigue, sexual side effects, and initial anxiety.  

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Another class of medications called SNRIs target not only serotonin but also the neurotransmitter norepinephrine. Norepinephrine is important for attention and other cognitive functions, energy, and mood.

This class of medications shares a similar safety and efficacy profile as SSRIs, and are also considered first-line treatment for social anxiety. A review identified five large placebo-controlled trials that support the efficacy of venlafaxine, an SNRI, for SAD.

SNRIs used to treat SAD include:

  • Effexor XR (venlafaxine extended-release)
  • Cymbalta (duloxetine)
  • Pristiq (desvenlafaxine)

Side effects from these medications may include initial increases in anxiety, insomnia, restlessness, possible sexual dysfunction, and headaches.

The SSRIs and SNRIs that are approved by the Food and Drug Administration (FDA) for the treatment of SAD are paroxetine, sertraline, fluvoxamine controlled-release, and venlafaxine extended-release.

Monoamine Oxidase Inhibitors (MAOIs)

An older class of antidepressants called MAOIs also affect neurotransmitters in the brain. They work by blocking the monoamine enzyme in the brain, which breaks down different types of neurotransmitters, including norepinephrine, dopamine, and serotonin. MAOIs stop the breakdown of these neurotransmitters and therefore increase their levels. Research has shown people with social anxiety respond well to these medications, and MAOIs can reduce the severity of SAD symptoms.

MAOIs used to treat SAD include:

  • Nardil (phenelzine)
  • Parnate (tranylcypromine)
  • Marplan (isocarboxazid)

However, these medications are not used often because they can cause serious side effects and have potentially dangerous interactions with other medications and certain foods. They are commonly prescribed in cases where other treatments have failed. Their use also requires following dietary guidelines.

MAOIs prevent the breakdown of tyramine and certain foods and drinks, such as aged cheese and beer on tap. People who take MAOIs and consume tyramine-containing foods or drinks will have a high serum tyramine level, which can cause a sudden increase in blood pressure.

The most common black box warning (the most serious warning from the FDA) for antianxiety and depression medications is an increased risk of suicidal thoughts and behaviors in children, adolescents, and young adults. If you or a loved one starts taking a prescribed medication and have thoughts of self-harm, contact your healthcare provider immediately or go to the nearest hospital. Your mental health provider will reevaluate your anxiety management plan.

Benzodiazepines

Benzodiazepines target the neurotransmitter GABA to increase its effects in the brain. GABA has an inhibitory function, and it suppresses signals that are traveling down a neural pathway. Benzodiazepines can therefore create calm in the body and mind, and can help with the anxiety symptoms associated with SAD.

These medications can be used on an as-needed basis by people with social anxiety. They are usually taken at least half an hour before encountering a situation that triggers anxiety. They can also be used by people who cannot tolerate or who have not responded to SSRIs or SNRIs.

While these medications are very effective, they can be very habit-forming and many people become dependent on them, especially for those who have been taking them continuously for extended periods. People with a substance abuse disorder generally should not take these medications.

Benzodiazepines used to treat social anxiety include:

  • Ativan (lorazepam)
  • Valium (diazepam)
  • Xanax (alprazolam)
  • Klonopin (clonazepam)

It can also be very difficult to discontinue benzodiazepines. Therefore, it’s important to discuss how to most safely come off one of these medications with your healthcare provider so they can lower the dose slowly over time. You should never stop an antianxiety medication on your own.

Beta-Blockers

SAD, as well as other types of anxiety, causes emotional and physiological symptoms. Since the body feels it's in a threatening situation, it will go into fight-or-flight mode. This means that all resources in your body are made ready to run away or fight for survival. Therefore, heart rate and breathing will increase. Beta-blockers are commonly prescribed for heart disease, and they work by slowing your heart rate and decreasing your body's reaction to the fight-or-flight hormones.

Beta-blockers used to help with SAD include:

  • Inderal (propranolol)
  • Tenormin (atenolol)

Similar to benzodiazepines, these medications are often taken in anticipation of a stressful situation to avoid the uncomfortable physiological effects, such as public speaking.

Most SSRIs, SNRIs, and MOAIs are taken orally once or twice daily. However, benzodiazepines and beta-blockers may be prescribed to be taken as needed. It is very important to ask your healthcare provider exactly how many pills you need to take a day and at what times. Your medication will be most effective if taken in the same manner as recommended.

Psychotherapy

Nonpharmacological approaches to SAD are also very important in helping people to better manage their symptoms. The type of psychotherapy commonly used to treat this anxiety disorder is cognitive-behavioral therapy (CBT). It's designed to help people better understand their thought processes. Different forms of CBT can be used to treat SAD.

Exposure Therapy

During exposure therapy, a person with social anxiety is gradually presented with the situation that causes them feelings of anxiety, with exposure to increasingly anxiety-provoking situations. Their therapist will then help them identify ways to manage their fear. This exposure may be virtual or in person.

Cognitive Restructuring

Through cognitive restructuring, someone with SAD will work with a mental healthcare provider to find the source of their negative thought patterns. By identifying these circuits, they can then explore other ways to redirect their thoughts so they can take another path. This may help reduce the impact and frequency of negative thoughts.

Social Skills Training

The goal of social skills training is to work on specific behaviors that people may struggle with in social situations that cause stress. This may help improve the way they act in a social situation, such as being able to have a conversation at a busy restaurant.

Interpersonal Therapy

Interpersonal therapy is a psychodynamic therapy that has been used for depression and is being adapted for patients with SAD. It uses role-playing and other techniques, including role playing to improve their ability to interact and socialize with other people.

Complementary and Alternative Medicine

Plant medicines, including herbal teas, have long been cited as natural ways to induce calm. Despite popular use, only certain types of plant medicines have been thoroughly evaluated in clinical trials for helping with SAD:

  • Passionflower, kava, and valerian have been evaluated in clinical studies and found to exert mild-to-moderate effects on anxiety symptoms.
  • More recently, people have been using cannabidiol, or CBD, from the hemp plant to ease anxiety. Some research has shown that it may be effective for social anxiety, but this compound has not been comprehensively studied.

There are many options available at health food stores and online, but since over-the-counter medications are not regulated, not all products are safe or contain what is advertised.

Tell your healthcare provider before starting other treatments or supplements. While using a tea, for example, may seem harmless, plant compounds can potentially interact with prescription medications and cause serious effects.

Lifestyle Changes

Managing SAD requires commitment to treatment. It's also important to follow a healthy lifestyle. Anxiety symptoms can be triggered or worsened by certain lifestyle choices.

SAD affects the body and brain, and it’s important to keep both as healthy as possible.

Consider changing up your habits to include:

  • Spending more time outside
  • Eating more fruits, vegetables, and protein-rich foods
  • Talking to loved ones (under nonstressful conditions)
  • Keeping a regular sleep schedule
  • Drinking more water

Talk with your healthcare provider about how to set up healthy habits that you can stick to and enhance your treatment plan.

A Word From Verywell

Starting a new treatment, whether a prescription medication or psychotherapy, can feel very overwhelming. Be sure to raise any questions you might have with your healthcare provider. Since there are many different types of medications and therapy approaches, it's OK if the first method you try doesn't work. Your provider will work to continue evolving your symptom management plan to find the right treatment for you.

Remember that medications and therapy take several weeks to start showing improvement, so it's important to be patient. However, if your symptoms worsen or you experience side effects, reach out to your healthcare provider right away.

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