Social Anxiety Disorder is characterized by an overwhelming fear of specific social situations and the avoidance of these situations, which can affect a person’s ability to function. Although social anxiety disorder (SAD) can vary in severity from person to person, relief from symptoms may be felt relatively quickly with the right treatment.
The most robust treatments include cognitive behavior therapy (CBT), medication, and lifestyle changes. The most effective CBT intervention is Exposure Therapy, a technique in which clients are gradually exposed to the situations they fear the most.
As frightening as this may seem, the goal is to start minimally and work your way up to the feared situation and eventually the fear and panic will reduce.1 With a combination of medication, therapy, and lifestyle changes many people find relief after a standard treatment of 7-12 sessions.2
Most Common and Effective Therapies for Social Anxiety
Therapy can be most effective for SAD when in individual or group formats. According to the National Institute of Mental Health, 7.1% of the population suffered from SAD in the past year, and 13% will develop SAD in their lifetime.3
Therapy is most beneficial if you are:
- Experiencing anxiety about social situations where it is believed one will face possible scrutiny from others
- Fearing negative evaluations by others
- Experiencing anxiety when in feared social situations
- Avoiding social situations at all costs
- Feeling that this creates significant distress in life
Therapy for SAD is usually covered by insurance, and many therapists specialize in the treatment of social anxiety or other anxiety disorders. Therapy that is evidence-based, like exposure therapy, can be covered if the therapist you are seeing takes insurance, and no referral is needed. The two forms of therapy that you will most likely encounter are individual or group therapy, whether in a community clinic, school or university, hospital, or therapist private practice.
Exposure Therapy
With Exposure therapy, the client lists every social situation they are afraid of, for example returning clothes at Target, asking a person on a date, or asking their boss for a raise. Each of these situations cause some type of fear and panic. The goal is to rank the situations from least anxiety to most anxiety, and role play situations in therapy as well as practice them for “homework.”
The standard treatment is between 7-12 weekly sessions (Please note that sessions may differ by therapist, and this is a general guideline):
Session 1
- Introduction to the therapist
- Describe what exposure therapy is and how it will be employed
- Discuss clients goals and situations that cause a lot of fear, describing avoidance and possible reasons we may get anxious
- Answer any questions clients may have
Session 2
- Create a fear hierarchy, where the client lists every social situation that produces anxiety
- Discuss how to successfully navigate exposures for practice, starting role plays (for example if a client is afraid to ask a boss for a raise the therapist will act as the boss and client will imagine how the scenario would go asking the therapist for a raise)
- Discuss the importance of noticing when anxiety is severe and when it starts to go down
- When doing exposures, a rule of thumb is to keep track of your thoughts and body sensations before, during, and after the exposure, through a mood log or another way of tracking (on phone, notepad, journal).
Session 3 – Session 6
- Continue reviewing your hierarchy and how the exposures are going
- Introduce education on where clients may have developed social anxiety disorder (genetically, early childhood experiences of bullying or family difficulties, etc)
- Start introducing anxiety-calming techniques, including deep breathing, meditation, grounding (discussed in detail later)
- Discuss how negative cognitions can play a role in social anxiety and proper ways of challenging these
- Once a client completes a step, they are rewarded with praise and sometimes will be asked to produce their own rewards for completing a step (buy new shirt, get massage, buy an art book)
- The goals during these sessions are to move up the hierarchy by completing the smaller anxiety situations first, discussing any roadblocks to completion, and brainstorming alternate ways to tackle them
- Therapists continue to ask clients to imagine and role play the current situation they are working on, and practice it until clients feel they have completely mastered it.
Session 7 – Session 12
- Discuss changes client has noticed
- Discuss situations that are still difficult
- Discuss how anxiety coping techniques are working, and see if client has noticed a difference in thoughts and body sensations before, during, and after feared social situations
- Discuss any negative thoughts that are still lingering and continue to work on challenging them.2
As an evidence-based practice, exposure therapy can help clients reduce anxiety symptoms completely or to minimal levels that no longer warrant a social anxiety diagnosis.
Although individual therapy can be sufficient, group therapy can see greater improvements due to being in a community with others struggling with similar issues, being able to practice and role play social anxiety situations with other group members, and feeling connected to others through shared struggles. Unfortunately, group treatments are not as accessible as individual treatments, and are less available for most people.
Anxiety Coping Techniques
During exposure therapy, clients are taught anxiety coping techniques to help reduce fear and anxiety reactions while practicing or role playing. These include deep breathing, grounding, imagery, and progressive muscle relaxation.
Deep Breathing
This technique involves breathing in through your nose, holding your breath, and then breathing out through your mouth. For simplicity I call this the 5-5-5 technique. While breathing in, count 5 seconds, hold your breath for 5 seconds, and then breathe out for 5 seconds. Deep breathing helps us relax when anxious or tense and leads to slower heart rate, normal breathing, relaxed muscles, and a clearer mind.4
Grounding
This technique involves being aware of your surroundings, turning away your attention from your anxiety and focus on the world around you. This helps us relax more and be better able to focus on what we are doing.
One particular grounding technique is called “5-4-3-2-1,” in which you focus on:
- 5 things you can see
- 4 things you can feel
- 3 things you can hear
- 2 things you can smell
- 1 thing you can taste5
Imagery
This technique can vary by therapist but the gist is to have the client think about a peaceful situation in their past when they were not anxious (for example, a day at the beach or camping with family), and have the client recreate this scene in detail. By thinking of this peaceful image, clients can reduce anxious body reactions as they imagine what it felt like to be at peace in that moment.6
Progressive Muscle Relaxation
This technique involves tensing a part of your body and then relaxing (for example fists, shoulders, legs). A good rule of thumb is to tense as hard as you can for 15 seconds then relax your muscle(s). This technique is helpful in reducing tense feelings in the body during an anxious state or anxiety attack.7
Medication for Social Anxiety (Most Common & Effective)
For those whose social anxiety can be very debilitating, medication might be a good option. The main types of medications that help treat the physical symptoms of SAD (fast heart rate, sweating, shaking, mind racing) are anti-anxiety agents and anti-depressants. Some classes of medication include selective serotonin reuptake inhibitors, benzodiazepines, serotonin norepinephrine reuptake inhibitors, and monoamine oxidase inhibitors.
Each drug acts on the brain a little differently, but all have properties to help with the panic reactions that accompany SAD. These medications are prescribed by a psychiatrist or primary care physician (PCP)/family doctor. Most health insurances require a referral from your PCP to be able to meet with a psychiatrist.
It is recommended that you only take the dosage recommended by your provider, and never abruptly stop taking a medication, as severe side effects and withdrawal symptoms can result. These medications are usually covered by insurance, but it’s important to check with your health insurance about prescription costs.8
Monoamine Oxidase Inhibitors (MAOs)
MAOs are a class of drugs that were first developed to treat depression. MAOs prevent the neurotransmitters serotonin, norepinephrine, and dopamine from leaving the brain. Lack of these neurotransmitters in the brain are said to be involved in depression. By keeping them circulating, MAOs relieve the effects of depression and allow you to feel less depressed for longer. They also have been shown to reduce anxiety as well.
MAOs can cause dangerous interactions with certain foods and beverages. You’ll need to avoid foods containing high levels of tyramine (an amino acid that regulates blood pressure) such as aged cheeses, sauerkraut, cured meats, draft beer, and fermented soy products (for example, soy sauce, miso and tofu). The interaction of tyramine with MAOs can cause dangerously high blood pressure.9
Benzodiazepines
This class of drugs, also known as tranquilizers, is used to treat anxiety, insomnia, alcohol withdrawal, pain, and control seizures. Benzodiazepines act on the central nervous system, produce sedation and muscle relaxation, and lower anxiety levels.10
Within this class of medications there are Anticonvulsants, which are used to treat seizure disorders and pain. It is thought that these drugs minimize the effects of nerves that cause pain.11
Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs are a class of drugs known as antidepressants. They can also help treat other mood disorders like social anxiety. They specifically slow the reabsorption of the neurotransmitter serotonin, a chemical that is believed to help regulate mood and anxiety.12
Lifestyle Changes & Self Help Strategies for Social Anxiety
Although most treatments for SAD revolve around exposure therapy and medication, lifestyle changes and self help strategies may lessen symptoms as well. These changes include attending a Toastmasters meeting, saying hello to others, having a regular exercise schedule, maintaining good sleep hygiene, limiting caffeine, alcohol, and smoking, joining a club or volunteer organization, and practicing social skills with a friend or loved one.
Toastmasters International
Toastmasters International is a nonprofit organization that assists with public speaking and leadership skills. There are currently 358,000 members, more than 16,800 clubs, and in 143 countries. This is a community of people who want to improve public speaking, increase leadership skills, and feel calm in front of others.13
Saying Hello
Saying hello to others is a good start to reducing the anxiety that occurs when meeting or talking to new people. By sticking to a goal of just saying “hello” or “how are you?” to a colleague or even a stranger will help speaking to people become more routine. Once you have mastered “hello” then you could work on small talk or a short 3 minute conversation, and so on.
Exercise
A regular exercise routine of just 30 minutes a day has shown to not only boost your physical health but help maintain a sense of calmness and peace. Whether you join a gym, commit to a walk every day, or some other form of movement, this can greatly improve your overall anxiety levels.
Sleep
Maintaining good sleep hygiene is paramount to staying calm. When you are sleep deprived you are more likely to be vulnerable to the effects of anxiety. Get at least 7-9 hours of sleep a night and be more in control of your mood.
Limiting Stimulants
Limiting caffeine, alcohol, and smoking can help decrease mood irregularities. Caffeine, including coffee, tea, and energy drinks, is a stimulant and can actually increase anxiety symptoms. Alcohol is thought by many to calm your nerves in social situations, but is an unhealthy coping mechanism that can increase your risk of an anxiety attack. Lastly, nicotine is a powerful stimulant, like caffeine, that does not reduce anxiety as once imagined. By limiting or completely eliminating these habits you will feel more in control of your moods.
Joining a Club/Volunteering
Joining a club or volunteer organization may be a great way to work on meeting new people, and engaging in an activity you enjoy. The club or volunteer activity will take your mind off the social aspect and give you something else to focus on while meeting others is an added bonus.
Practice
Practicing with a friend or loved one is one way to calm the nerves when you do need to meet others. By practicing social skills with someone you trust you can greatly build your confidence and view these social situations as more routine and normal.14
Questions to Ask About Social Anxiety Treatments
Now that you are taking steps to overcome your social anxiety through treatment it is important that you ask the right questions to help you make an informed decision of what treatment is best for you. These questions should be tailored to a therapist, doctor, or psychiatrist depending on what avenue you decide to take (therapy, medications, or lifestyle and self-help strategies).
Questions to Ask About Therapy (Therapist)
Questions to ask before starting therapy include:
- What therapeutic orientation do you employ for SAD?
- Have you had any training or certifications in treating SAD?
- How many sessions do you feel it will take to reduce my SAD?
- Do you offer individual or group formats? If you offer both what do you think is best for my specific type of SAD?
- Do you recommend any books related to SAD?
- Do you assign homework or worksheets between sessions?
- Do you feel comfortable treating SAD?
- Do you have any suggestions of websites where I can get more information?
Questions to Ask About Medications (Psychiatrist or PCP)
Questions to ask your psychiatrist or primary care physician before starting any medications include:
- Which medications specifically work to reduce symptoms of SAD?
- Which medications have the least side effects?
- Do you suggest taking multiple medications at the same time?
- What dietary or lifestyle changes must I employ when taking these medications?
- What medications help with multiple disorders like depression and SAD?
- Do you have suggestions of nutritional supplements that can help with SAD?
Questions to Ask About Lifestyle and Self Help Strategies (PCP, Therapist, Psychiatrist)
Questions that you could ask any member of your care team before implementing lifestyle changes include:
- What strategies will reduce social anxiety that I can employ at home?
- Any suggestions for websites, books, or apps that help overcome SAD?
- What self help strategies have worked for your patients with SAD?
- What suggestions of exercise and movement do you have for reducing SAD?
