Medication, in combination with therapy, is considered the frontline treatment for social anxiety disorder. Fortunately, prescriptions that are FDA approved for this disorder are a generally safe and effective option when addressing symptoms. However, it is recommended that you have a conversation with your prescribing practitioner about any risks, benefits, and side effects associated with any medication when considering options
What Is Social Anxiety Disorder (SAD)?
Social Anxiety Disorder (SAD), previously called social phobia, is characterized by persistent distress about social situations that are out of proportion to the actual risks. These anxieties greatly impair a person’s daily functioning and are not caused by a medical condition, medication, or substance abuse.1
Social anxiety differs from other types of anxiety in that it is specifically associated with social interactions and fears of being judged negatively, embarrassed, or humiliated. Although this may sound similar to shyness, the difference between shyness and SAD is that SAD greatly affects an individual’s quality of life.
Social anxiety disorder can lead to negative impacts in one’s life, such as:
- Low income levels due to difficulties at work
- Poor education due to difficulty in school
- Difficulty forming romantic relationships
- Difficulty forming close friendships
- Low self-esteem
How Does Medication Treat Social Anxiety?
Medications can be used to address negative symptoms associated with SAD. When used in combination with therapy, they can provide significant improvement in social, educational, and professional functioning. Generally, medications target anxiety symptoms while therapy provides a person with strategies on how to deal with difficult situations.
SAD can not be “cured,” but a person can achieve “remission,” which means that their symptoms are no longer present. Some people may need treatment for SAD for years before experiencing remission, but others may experience it after several months.
Antidepressants for Social Anxiety
Certain antidepressants are considered first line treatment for anxiety disorders.2 Research suggests that the neurochemicals serotonin, norepinephrine, and dopamine play a role in mood and anxiety, and antidepressants work on increasing the activity of these in one’s brain.3.
Many may have misconceptions about how antidepressants make them feel. If the antidepressant is a good fit, an individual should experience mild or no side effects and symptom relief. In general, it takes between four to six weeks for antidepressants to work. If you are wondering how to get antidepressants, reach out to your primary care doctor or mental health provider.
Selective-Serotonin Reuptake Inhibitors (SSRIs)
Selective serotonin reuptake inhibitors (SSRIs) may have effects on mood and anxiety by increasing the serotonin availability in the brain. They do this by binding to the serotonin transporter (SERT) protein and inhibiting the recycling of serotonin.4 Some SSRIs are FDA approved for the treatment of SAD and therefore commonly recommended by professionals. However, certain SSRIs that are not specifically FDA approved may be used off-label. Generally, SSRIs are taken daily. Doses may be increased depending on tolerability and effectiveness.
SSRIs that may be used to treat social anxiety include:
- Zoloft (sertraline)
- Paxil (paroxetine)
- Lexapro (escitalopram)
- Prozac (fluoxetine)
- Clexa (citalopram)
Common side effects of SSRIs include:
- Headache
- Nausea, vomiting, diarrhea
- Dizziness
- Drowsiness
- Dry mouth
- Sexual problems such as low libido
- Appetite changes
- Nervousness
- Anxiety symptoms
- Insomnia
Selective-Norepinephrine Reuptake Inhibitors (SNRIs)
Serotonin-norepinephrine reuptake inhibitors (SNRIs) focus on increasing the serotonin and norepinephrine availability in the brain by blocking reuptake of both neurotransmitters.5 Like SSRIs, some SNRIs are FDA approved for the treatment of SAD while others may be used off-label.
Typically, SNRIs are taken once a day and doses are adjusted depending on the individual. The main difference between SNRIs and SSRIs is that SNRIs work on two neurotransmitters, but SSRIs work on only serotonin. Some patients may prefer or better tolerate one over the other.
SNRIs that may be used to treat social anxiety include:
- Effexor (venlafaxine)
- Pristiq (desvenlafaxine)
- Cymbalta (duloxetine)
Common side effects of SNRIs include:
- Headache
- Nausea, Vomiting, Diarrhea
- Dizziness
- Excessive Sweating
- Dry Mouth
- Sexual Problems such as low libido
- Appetite changes
- Insomnia
Monoamine Oxidase Inhibitors (MAOIs)
Monoamine oxidase inhibitors (MAOIs) are antidepressants that increase levels of norepinephrine, serotonin, and dopamine in the brain by inhibiting monoamine oxidase, an enzyme responsible for removing these neurotransmitters.6
Prescriptions may be taken daily orally or via patches. Additionally, these medications may be used off-label for social anxiety if other treatments have failed. MAOIs are not frequently prescribed due to their poor tolerability (side effects) and potential dangerous interactions with other medications, including other antidepressants and foods that contain tyramine (aged cheeses, fermented foods, and wine). Ask your doctor for a full list of medication, dietary, and beverage restrictions if you are considering MAOIs.
MAOIs that may be used to treat social anxiety off-label include:
- Marplan (isocarboxazid)
- Nardil (phenelzine)
- Emsam (selegiline)
- Parnate (tranylcypromine)
Common side effects of MAOIs include:
- Headache
- Nausea, vomiting, diarrhea
- Dizziness
- Dry mouth
- Sexual Problems such as low libido
- Tingling skin
- Involuntary muscle jerks
- Skin reaction at the patch site
Beta-Blockers
Beta blockers are FDA approved for the treatment of heart conditions, but can be used off-label for social anxiety and anxiety disorders. Beta blockers work by blocking adrenaline, a hormone that plays a role in the “fight or flight” response which sometimes results in stress.7 In practice, beta blockers can be used daily or on an as needed basis. For example, one may choose to use a beta-blocker only in situations in which they experience heightened social anxiety, such as when giving a presentation or attending a large event.
Types of beta-blockers that may be used to treat social anxiety include:
- Inderal (propranolol)
- Tenormin (atenolol)
- Lopressor (metoprolol)
- Bystolic (nebivolol)
- Zebeta (bisoprolol)
- Coreg (carvedilol)
Common side effects of beta-blockers include:
- Dizziness
- Drowsiness
- Feeling lightheaded
- Low blood pressure
- Depression symptoms
- Trouble sleeping
- Cold hands or feet
Benzodiazepines
Benzodiazepines are anti-anxiety medications used for short term relief of anxiety symptoms. These work by enhancing the neurotransmitter GABA, which has a calming and sedating effect.8 Benzodiazepines are used off-label in the treatment of social anxiety disorder, but may also be chosen for short term relief of acute anxiety symptoms.
Unlike antidepressants which are taken daily, benzodiazepines are administered when one’s symptoms start and do not assist in preventing anxiety. Another concern is that they come with the risk of tolerance, withdrawal, and physical dependence.8 This risk from these medications rises when people take them for chronically elevated anxiety as opposed to using them for peaks of acute anxiety. Since benzodiazepines are taken “as needed,” it is important to consult with your healthcare provider if you want to change or stop these medications in order to prevent benzodiazepine withdrawal.
Types of benzodiazepines used to treat social anxiety include:
- Xanax (alprazolam)
- Valium (diazepam)
- Klonopin (clonazepam)
- Ativan (lorazepam)
Common side effects of benzodiazepines include:
- Mental fatigue
- Slurred speech
- Drowsiness
- Dizziness
- Memory problems
- Light-headedness
- Confusion
- Unsteadiness (especially in elderly)
Other Medications or Natural Remedies
Research suggests that there are several herbs and supplements that may offer relief of anxiety symptoms. For example, St. John’s Wort is believed to increase serotonin, dopamine, GABA, and norepinephrine levels in the brain. However, options like this are not regulated by the FDA and do not undergo the same type of approval and testing as traditional medications. It is advised to use these supplements with caution, as they can adversely interact with other medications. This is particularly true in the case of St. John’s Wort and antidepressants.
Potential side effects vary depending on the herb or supplement. If you are interested in targeted recommendations, seek advice from a mental health practitioner that specializes in integrative psychiatry. Discuss any options you are considering with them before starting a regiment.
Other vitamins, herbs, and supplements that have some evidence in support of anxiety:*
- Chamomile
- Lavender
- Valerian root
- Magnesium
- Omegas
- Ashwagandha
- Vitamin D
- Vitamin B complex
*Dietary supplements (including vitamins, supplements, herbs, and natural medicines) are not regulated the same way as medications by the FDA. Before being sold to the public, these products do not have the same clinical trials to determine their safety and efficacy. You should consult your doctor or pharmacist before starting any new dietary supplement.
Choosing the Best Social Anxiety Medication for You
Before the process of choosing a medication is started, it is vital to receive an accurate diagnosis by a healthcare professional. This can be achieved through a primary care doctor, physician’s assistant, psychiatric mental health nurse practitioner, or psychiatrist. A formal diagnosis is so important as many disorders have diagnostic overlap, meaning they share similar symptoms with another condition. It takes a specialist to determine when a person meets criteria for social anxiety disorder and their symptoms may be addressed with medication.
Once an individual is diagnosed, it takes time before they find a medication that works best for them. Sometimes, the first prescription a person tries may be the right one for them, while another may undergo several medication trials before experiencing relief. Others may find a certain medication effective, but need an adjustment in their dosage. Be sure to work closely with your healthcare provider and ask them about any possible side effects as your body adjusts to a medication. Maintaining this good communication will help you both determine the best treatment option for you.
Additional Treatment Alongside Medication for SAD
It is recommended that one’s treatment for social anxiety includes a combination of psychotherapy and medication. Whereas medication largely acts on addressing brain chemicals to result in symptom improvement, psychotherapy is focused on behavioral changes, teaching coping skills, and facilitating cognitive restructuring. These work best in conjunction as they target symptoms from different angles.
Therapy options for social anxiety include:
- Cognitive behavioral therapy (CBT): CBT for social anxiety focuses on teaching clients coping skills for handling symptoms in situations where they may increase.
- Group therapy: Group therapy can be beneficial as individuals can share their experience, relate with others with similar symptoms, and build social skills.
- Acceptance and commitment therapy (ACT): ACT works to help individuals accept the role anxiety plays in their life. When this is achieved, they commit to changing what they can with the assistance of a therapist.
- Support groups: Support groups include members with a commonality (like social anxiety) who support one another through challenges.
- Dialectical behavior therapy (DBT): DBT can be beneficial for social anxiety symptoms as it helps teach individuals acceptance, emotional regulation, and cognitive restructuring.
Questions to Ask Before Beginning a New Medication
When starting a new medication, it is important to review the risks, benefits, alternatives, and side effects associated with that medication with your healthcare professional. This helps you make an informed decision about whether or not you feel this is a option for you.
Before beginning a new medication for social anxiety, consider asking your mental health professional the following questions:
- What symptoms does this medication aim to improve?
- What are the possible side effects?
- Which side effects typically go away over time?
- Are there any potentially dangerous or long-term side effects?
- How can I contact you if I have any concerns?
- Are there any alternatives to this option?
Final Thoughts
There are many treatment options for social anxiety and finding the best one for you will take time and patience. However, medication can help provide you with symptom relief and an improved well-being. When working with your doctor or therapist to develop a treatment plan, have an open mind, ask questions, and make sure you feel safe and comfortable with your final decision.
