A Copyright Harvard Health Publications
Cognitive behavioral therapy is effective for most patients, while medication strategies depend on whether the disorder is generalized or specific.
Social anxiety disorder (also known as social phobia) is one of the most common psychiatric disorders. Although sometimes dismissed as shyness, social anxiety disorder can cause crippling fear that interferes with school attendance, work performance, and relationships. It affects about 7% of Americans in any given year, and about 12% at some point in their lives.
About half of the people with this disorder experience anxiety only in specific situations, particularly those involving some type of public performance such as speaking in front of people. Others have the generalized form, experiencing fear in almost any social situation.
Although many people occasionally get nervous at parties or at other public events, what distinguishes social anxiety disorder is the severity of distress and impairment that result. For example, research suggests that youths with this disorder are more likely than peers to drop out of high school. Adults with social anxiety disorder are more likely than others to miss work. Even intimate relationships are affected, one reason that people with social anxiety disorder are less likely than others to marry.
Yet because the symptoms are often dismissed as trivial, only about half of people with social anxiety disorder ever receive treatment, typically after experiencing symptoms for at least 10 years before seeking help. That’s unfortunate, because both psychotherapy and medication can help reduce symptoms for most people.
Causes, symptoms, and diagnosis
The first symptoms of social anxiety disorder typically appear between ages 10 and 19, most often in the early teenage years. Both genetic and environmental factors probably contribute. For example, brain imaging studies have found that, compared with other people, those with social anxiety disorder display greater activity in the amygdala, an area of the brain involved in the processing of emotions, particularly fear, when speaking in public or when they view pictures of people who look angry, contemptuous, or disgusted.
Adults with social anxiety disorder are afraid that they will embarrass themselves in front of other people, even though they recognize, on some level, that this fear is excessive. Typical symptoms of such anxiety in adults include a racing heart, a dry mouth, a shaky voice, blushing, trembling, sweating, and nausea.
In young children, the symptoms typically manifest as behaviors such as crying and tantrums at social events. And while many adolescents suffer bouts of shyness, self-consciousness, or social awkwardness, youths with social anxiety disorder have more prolonged and severe symptoms. They may try to cope by avoiding potentially stressful situations, resulting in significant functional and developmental impairment. For example, adolescents with this disorder may skip school so often that they fail classes.
Before making a diagnosis of social anxiety disorder, clinicians need to determine that symptoms are not caused by the physiological effects of a medication or a substance abuse problem. They also need to exclude other general medical conditions (such as essential tremor or stuttering) that might cause similar symptoms, and related psychiatric disorders (such as panic disorder or generalized anxiety disorder).
Multiple studies have concluded that cognitive behavioral therapy (CBT) is often effective for treating social anxiety disorder. The research is less robust for other psychotherapy options.
CBT. The goal of therapy is to provide techniques and practice so that patients with social anxiety disorder can learn to change how they think about and behave in situations that terrify them. CBT may be offered individually or as part of group therapy.
In exposure therapy, the type of CBT most often used and studied for social anxiety disorder, therapists gradually expose patients to the dreaded situation and suggest ways to manage fear. If an upcoming office party seems overwhelming, for example, one way to cope with it is to establish an achievable goal, such as striking up a conversation with one or two people. In other variations of CBT, not as well studied as exposure therapy, patients learn and practice social skills and relaxation techniques.
CBT usually consists of 12 to 16 weekly sessions lasting 60 or 90 minutes each. In studies, patients with social anxiety disorder usually needed to undergo 6 to 12 weeks of CBT before showing any improvement. Studies that have used standard clinical tools to assess improvement in social anxiety and ability to function have found that one-half to two-thirds of patients who underwent CBT experienced clinically meaningful improvements in symptoms after 12 weeks of therapy.
Selective serotonin reuptake inhibitors (SSRIs) and one serotonin and norepinephrine reuptake inhibitor (SNRI) are considered the best medication options for the generalized form of social anxiety disorder. More than 20 randomized controlled trials support use of these medications. Beta blockers or benzodiazepines are recommended first for people with a specific social phobia, because they can be used in the limited number of situations (e.g., giving a speech) where anxiety is likely to arise..
SSRIs and venlafaxine. The neurotransmitter serotonin is integral to brain circuits involved in regulating mood, sleep, appetite, and pain sensation. Reduced serotonin transmission contributes to anxiety (as well as depression). SSRIs such as citalopram (Celexa), paroxetine (Paxil), and sertraline (Zoloft) increase the availability of serotonin. Experts presume that this changes the functioning of critical brain circuits and results in a reduction of symptoms. The SNRI venlafaxine (Effexor) targets not only serotonin, but also norepinephrine (also known as adrenaline), which is involved in the regulation of fear conditioning and the stress response, including physiological responses such as constricting blood vessels and raising blood pressure.
Studies have found that 50% to 80% of patients with the general form of social anxiety disorder respond after taking venlafaxine or an SSRI for eight to 12 weeks. Most of these drugs are about equally effective at treating social anxiety disorder. The exception is fluoxetine (Prozac). Only one in three controlled studies found that it provided more benefit than placebo.
When used to treat patients with social anxiety disorder, venlafaxine or an SSRI is usually prescribed at half the dose used to treat depression, and then increased only gradually. Most patients respond within weeks. But more than 25% of those who are not responding by the eighth week will improve after another month of drug treatment, which is why many clinicians recommend that patients try a drug for 12 weeks before switching to another one.
Beta blockers. This class of drugs (examples are propranolol and atenolol) blocks the physiological response to anxiety, for example, sweating, rapid heartbeat, or shortness of breath. Several studies suggest that taking this type of drug about an hour before encountering an anxiety-producing situation, such as public speaking, helps patients with specific social phobia.
Benzodiazepines. These medications boost the activity of gamma-aminobutyric acid, which is an inhibitory neurotransmitter. In other words, it suppresses signals that are traveling down a neural pathway. The result, in terms of a person’s experience, is a calming of anxiety symptoms.
Like beta blockers, benzodiazepines can be used on an as-needed basis for patients with specific social phobias. These drugs are usually taken at least half an hour before encountering a situation that triggers anxiety. They also are an option for patients with the generalized form of social anxiety disorder who cannot tolerate or who have not responded to SSRIs or venlafaxine.
But people who take benzodiazepines, and the clinicians who prescribe them, need to be aware of a few potential pitfalls. Patients who use these drugs continually for more than two weeks increase their risk of becoming physically dependent on them. Clinicians are therefore cautious about prescribing benzodiazepines for patients with substance abuse problems. If people taking daily benzodiazepines want to stop the drug, they must taper gradually rather than stopping abruptly, to avoid withdrawal symptoms and a rebound of anxiety.