Social anxiety disorder (SAD), also known as social phobia, is a common mental health condition characterized by intense anxiety and excessive self-consciousness in social situations.
People with SAD have a persistent, intense fear of being watched and judged by others and of doing something embarrassing. This leads them to avoid social situations or endure them with extreme distress.
If left untreated, social anxiety disorder can severely impact a person’s ability to form relationships, succeed at work or school, and live a fulfilling life.
Seeking treatment for social anxiety disorder is critical to overcome distressing symptoms, regain confidence, and improve quality of life.
This article outlines some of the most effective SAD treatment options available, including medications like SSRIs and SNRIs as well as psychotherapy approaches such as cognitive behavioral therapy and exposure techniques.
Different interventions may work better for certain individuals depending on factors like symptom severity, so it is important to discuss options with a qualified mental health provider to determine the best course of action.
This article intends to give a broad overview of treatments and should not substitute professional medical advice. If you struggle with intense anxiety in social situations, know that you don't have to continue suffering - help is available.
Medication
Several types of medications are commonly used to treat social anxiety disorder (SAD). These include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and certain antidepressants.
Selective serotonin reuptake inhibitors (SSRIs)
Selective serotonin reuptake inhibitors (SSRIs) such as escitalopram, paroxetine, and sertraline have demonstrated efficacy in both short-term and long-term treatment of social anxiety disorder.
SSRIs work by blocking the reabsorption (reuptake) of serotonin in the brain, leading to higher serotonin levels, which can improve mood and anxiety symptoms.
A systematic review and meta-analysis found that SSRIs are a valid option for people with SAD, with one meta-analysis suggesting that specifically paroxetine should be used as a first-line treatment.
Potential adverse effects:
SSRIs may elicit side effects like nausea, headache, sleep issues, sexual dysfunction, and activation symptoms in some people.
Serotonin and norepinephrine reuptake inhibitors (SNRIs)
Serotonin and norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine XR have also shown efficacy in treating social anxiety disorder in both the short term and long term.
SNRIs also inhibit the reuptake of serotonin and norepinephrine, which can help improve mood and anxiety symptoms.
Systematic reviews and meta-analyses suggest that SNRIs can be an effective treatment for social anxiety disorder in adults as well as in adolescents and children.
Potential adverse effects:
SNRIs can potentially lead to side effects such as nausea, increased blood pressure, sweating, constipation, and sexual problems
Anti-anxiety medications
Anti-anxiety medications such as benzodiazepines are sometimes used to treat social anxiety disorder (SAD) symptoms. Examples include medications like clonazepam (Klonopin), lorazepam (Ativan), and alprazolam (Xanax).
Benzodiazepines work quickly by enhancing the effects of the neurotransmitter GABA to reduce neuron activity. This can lead to rapid relief of anxiety symptoms. Accordingly, benzodiazepines may be used short-term or as-needed in SAD to manage severe anxiety.
Potential adverse effects:
Benzodiazepines may cause side effects such as sedation, memory and coordination issues, dependence, withdrawal symptoms upon discontinuation, and abuse potential.
Therefore, treatment guidelines typically only recommend short-term benzodiazepine use for severe anxiety in SAD. Long-term treatment relies more on medications like SSRIs and SNRIs with lower abuse potential.
Other medications
Other agents that have demonstrated some efficacy include moclobemide (a reversible inhibitor of monoamine oxidase A or RIMA), phenelzine (a monoamine oxidase inhibitor or MAOI), and pregabalin.
Potential adverse effects:
However, MAOIs and RIMAs may have more side effects and drug interactions compared to first-line SSRI/SNRI treatments. MAOIs require dietary restrictions and can confer side effects like dizziness, dry mouth, and headaches.
Because of this, MAOIs are rarely prescribed anymore and have been generally replaced by antidepressants.
Overall, SSRIs and SNRIs are recommended as first-line pharmacological treatments for social anxiety disorder, with optimal treatment duration of at least 6 months or longer in individual cases.
Before considering medication options, please discuss your options and the full side effects with a health professional. This article is meant only as a summary of medications and should not be taken as medical advice.
Psychotherapy
Cognitive-behavioral therapy
Cognitive-behavioral therapy (CBT) is considered the gold standard psychological treatment for SAD. CBT targets the distorted thoughts and maladaptive behaviors that maintain social anxiety.
While not universally effective for all (depending on demographics and coexisting conditions, for instance), CBT is considered the most empirically-supported first-line psychosocial treatment for social anxiety available today.
CBT works by using several evidence-based techniques:
Exposure therapy
This involves gradually and systematically exposing individuals to feared social situations so they can face anxiety-provoking cues and see that their feared outcome is unlikely to happen.
For example, someone with social anxiety may start by making small talk with a cashier and work up to giving a speech. Through repeated practice, anxiety lessens over time.
A randomized controlled trial suggests that even virtual reality exposure therapy can be equally effective as exposure therapy conducted in a group setting.
Cognitive restructuring
This targets distorted negative thoughts like “Everyone will think I’m stupid,” which trigger anxiety in social situations. The goal is to identify irrational fears, challenge them, and replace them with more balanced thoughts.
For instance, a person may examine evidence against their belief from past social situations where they did fine.
People with SAD may benefit from cognitive restructuring to target their unhelpful thoughts and imaginal self-representations.
Social skills training
Social skills training supplements CBT for social anxiety disorder by providing opportunities to practice social functioning in a safe environment. Techniques include roleplaying exposures, getting feedback, building emotional awareness, testing negative beliefs through experiments, and rehearsing specific interaction skills.
Combining social skills application with exposure therapy has been found to improve outcomes more than exposure alone.
Mindfulness
Staying grounded in the present moment with nonjudgmental awareness of anxiety-related sensations, urges, and thoughts may reduce avoidance of social cues. Mindfulness skills allow anxiety to naturally rise and fall without escalating.
Research suggests that mindfulness-based interventions can be effective during CBT sessions, especially when combined with exposure techniques.
Mindfulness-based cognitive therapy (MBCT) is a therapy that combines CBT with mindfulness, and research findings suggest that it can help reduce social anxiety symptoms in a sample of students.
Considerations
Below are some potential limitations for using CBT to treat SAD:
- CBT relies heavily on the individual’s ability and willingness to challenge their irrational thoughts and behaviors. Those with severe social anxiety may struggle to engage in exposures or behavioral experiments.
- Generalization of skills learned in therapy to real-world situations can be difficult. An individual may do well in roleplays with the therapist but continue to struggle in actual social situations. More real-world practice may be necessary.
- For some individuals, especially those with severe childhood trauma or neglect, the cognitive distortions related to social anxiety may be deeply ingrained. CBT alone may not be enough to fully treat the disorder without also addressing underlying issues.
Acceptance and commitment therapy (ACT)
Acceptance and commitment therapy (ACT) is a form of psychotherapy that focuses on accepting difficult thoughts and feelings rather than trying to change or avoid them while also committing to actions that align with one’s values.
For social anxiety, ACT aims to increase “psychological flexibility” – the ability to experience anxiety and still choose to engage in valued actions.
Specific techniques used in ACT for social anxiety include:
- mindfulness exercises to practice nonjudgmental awareness of anxious thoughts/feelings;
- metaphorical stories and experiential exercises to understand the futility of avoiding anxiety;
- values clarification to identify meaningful life directions.
Individuals then make commitments to concrete goals that align with those values, using anxiety exposure strategies if needed. The goal is to accept anxiety when it arises without letting it dictate behavior.
ACT has been shown to be effective in reducing external shame and difficulties in emotion regulation and in increasing psychological flexibility and self-compassion in those with SAD.
Although ACT is a promising treatment, it is thought to not be an effective alternative to rival CBT, but it can act as an alternative for those who are non-responders.
Psychodynamic therapy
Psychodynamic therapy can help people with social anxiety disorder by uncovering the unconscious roots of their anxiety.
The therapist helps the client explore how early childhood experiences, like insecure attachment with caregivers or lack of nurturance, may have fostered negative beliefs about oneself and difficulties with emotional regulation.
By gaining insight into these unconscious dynamics, clients can start to separate past issues from present-day triggers.
Specific techniques focus on identifying and challenging automatic negative thoughts that precede anxiety, learning to tolerate emotional discomfort rather than avoid it, and developing awareness of emotional states before they become overwhelming.
With increased understanding, self-compassion, and coping strategies, clients are better equipped to manage social situations. Progress is gradual but can ultimately lead to reduced anxiety and healthier relationships.
A meta-analysis suggested that psychodynamic therapy can be used as an alternative treatment to CBT in the treatment of SAD. Another study found that CBT and psychodynamic therapy were effective in treating short- and long-term outcomes of those with SAD.
However, psychodynamic therapy requires individuals to have a substantial capacity for self-reflection. Those lacking in insight may struggle with this therapy approach. Even with the insight, this alone may not directly translate to behavioral change for some clients.
Self-Help Techniques
There are several self-help techniques that can be useful for managing social anxiety disorder symptoms. While seeking professional treatment is recommended for more severe cases, these strategies may help reduce anxiety levels.
Overcoming Avoidance
It’s important to gradually expose yourself to anxiety-provoking social situations instead of avoiding them. Start small and work your way up over time to build confidence in your ability to cope. Reflect afterward on whether your fears were realized and rate your anxiety levels.
Dropping Safety Behaviors
Let go of subtle safety behaviors you use to cope in social situations, like excessive use of a phone or wearing headphones to avoid interacting. This prevents you from truly testing your fears.
Feel the initial discomfort and it should subside over time as you realize the situations are manageable.
Practicing Self-Care
Make time for relaxation, hobbies, and activities that support your overall well-being. Be kind to yourself and reframe negative self-talk when you get anxious.
Acknowledge your progress and strengths. Self-care can relieve anxiety levels.
Breathing Retraining
Learning breathing techniques like deep belly breathing can help revert your breathing to a calmer baseline pattern and provide coping skills to use when anxious.
Progressive Muscle Relaxation
This involves systematically tensing and relaxing muscle groups to release tension that builds up with anxiety. It can be useful before and after anxiety-provoking social situations.
Celebrate Small Victories
Recognize and appreciate even small progress you make in facing social anxiety. This reinforces positive change and boosts self-confidence over time.
Build a Support Network
Surround yourself with supportive people you can share struggles with openly and without judgment. This can reduce loneliness, provide coping strategies, and offer a safe space to practice social skills.
Considerations
When seeking treatment for social anxiety disorder, there are several factors to consider:
- Individual vs Group Therapy: Group therapy allows for social interaction and support from others facing similar issues. However, individual therapy provides personalized attention. Discuss options with a therapist.
- In Vivo vs Virtual Reality Exposure Therapy: In vivo exposes individuals to real-life situations to face fears. Virtual reality creates simulated environments. Both can be effective depending on the person.
- Homework Between Sessions: Homework reinforces skills learned in therapy. This may involve exposures, CBT thought records, or relaxation practices. Completing homework is important for progress.
- Number of Sessions: People respond to treatment differently. Some benefit from 6-12 sessions while others may need longer-term therapy. Treatment length depends on severity and response.
- Medication: SSRIs or other medications are sometimes prescribed alongside therapy. This is determined on an individual basis. Discuss options with both a therapist and doctor.
- Support Groups: Support groups provide community and allow people to share strategies. They complement ongoing treatment and are not enough on their own.
- Relapse Prevention Planning: Create a personalized plan for what to do if symptoms worsen again. Identify triggers and early warning signs. Outline coping strategies and social supports.
The most effective approach depends on the individual. Working closely with a qualified mental health professional can help determine the best treatment options.
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