Social Anxiety Disorders
(including Performance Anxiety, Fear of Public Speaking,         Stage Fright, and Generalized Social Anxiety)

Note: The following is presented for informational purposes only. Assessment and treatment should always be directed through one-on-one consultation with a trained professional.

Detailed information about Social Anxiety Disorder and it's treatment can be found at my social anxiety website:

Social Anxiety Disorder is defined as feeling self-conscious and having a fear of negative evaluation around other people.  Social anxiety is usually most intense around authority figures, groups of peers, and people you are attracted to or admire. When the anxiety is intense enough, the negative thoughts or feelings can take away so much of your attention that you are unable to listen to what other people are saying in conversation.  Social anxiety disorder makes it harder to acquire social skills due to this impaired concentration while in social situations and also due to avoidance of many social interactions in the first place. Although social anxiety disorder typically impairs social, work and academic functioning, it is very responsive to treatment.

There are two forms of effective treatment for Social Anxiety Disorders: Cognitive Behavioral Therapy (CBT) and Medications.

Cognitive Behavioral Therapy for Social Anxiety Disorders

The most effective and well-documented psychotherapy for Social Anxiety Disorders is Cognitive Behavioral Therapy. Approximately 80% of patients respond to CBT for Social Anxiety and the effects appear to be more robust and more long-lasting than medication treatment alone.

The main techniques used in CBT for Social Anxiety Disorders are Thought Restructuring, Gradual Exposures and Social Skills Training. Thought Restructuring teaches patients how to talk back to self-deprecating/distracting thoughts that tend to occur in social situations so that these thoughts decrease in intensity or frequency. Gradual Exposures involves doing things that are just slightly outside of your comfort zone and repeating them many times until you are your brain habituates and you no longer have anxiety.  Social Skills Training includes conversation skills, dating skills, empathy, and assertiveness training as will as information on how to choose relationships and how to find the optimal frequency of contact with each person in your life. Cognitive Behavioral Therapy typically takes 10-16 weeks to complete and the longest follow-up study so far has shown that the results lasted 5 years later.

Medications for Social Anxiety Disorders

Medications are also effective for Social Anxiety Disorders (i.e. ~60% of patients respond to the first medication they try).

The most frequently used medications are the antidepressants known as Selective Serotonin Re-uptake Inhibitors (i.e. SSRI's). There are currently 6 SSRI's: Prozac, Luvox, Paxil, Zoloft, Celexa, and Lexapro. Effexor is a related medication that also works well. Each of these medications appears to be equally effective, so the choice of medication is often based on other considerations (i.e. Is it sedating or energizing?, Does it interact with other medications?). For Social Anxiety Disorders, these medications typically take 2-6 weeks to kick-in.

A class of medications know as Beta-Blockers (i.e. Inderal/Propranolol) can also be helpful for Social Anxiety Disorders, especially Stage Fright and Fear of Public Speaking. These are blood pressure medications that help control racing heart, sweatiness, and shaking. These medications are typically taken on an as-needed basis about 30 minutes before a particular speech or performance.

Combining CBT and Medications for Social Anxiety Disorders

Unfortunately, there are not enough studies to make a definitive statement about whether or not the combination of CBT and Medications is better than using either treatment alone. As a result, I make an educated guess based on how things have panned out for the other anxiety disorders where this question has been studied.

I usually recommend that patients with mildly to moderately impairing Social Anxiety Disorders try CBT alone first since it works as well as medications and has longer lasting benefits. In contrast, I usually advise patient with severe impairment, or patients who have not responded to CBT alone, or patients who want to use every option right off the bat to start both medications and CBT, with the plan to taper off of medications once the CBT is completed.

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