Social Anxiety and Medication
Dr Jonathan Haverkampf
Social anxiety should primarily be treated with psychotherapy. However, medication can be an effective supportive measure.
Anxiolytics, particularly the benzodiazepines, often reduce the level of anxiety quite effectively and are the most widely prescribed medication to reduce anxiety sporadically. Although they often work quickly, they can be habit-forming and sedating, so they’re typically prescribed for only short-term use. They should also be tried before encountering an anxiety provoking social situation to get a sense for their effect. Also, they should not be combined with alcohol as this could lead to a potentiation of the sedative effect.
Anxiolytics, such as Lorazepam and even Diazepam, can be effective in low doses, but they should only be used sporadically. If taken regularly they can lead to addiction in the long-run. It would also be considered an off-label use, unless the anxiety has reached clinical proportions. Still, there is an intense discussion on the addiction risk of benzodiazepines. If the alternative is alcohol and drugs, a directed and considerate use of benzodiazepines in the short-run may still be the better option.
A more future oriented and over the long-run more effective treatment consists of selective serotonin reuptake inhibitors (SSRIs), antidepressants, which also help against anxiety and panic attacks. Since social anxiety is often linked to clinical or slightly subclinical anxiety or depression, they may be worth considering. Several types of antidepressants other than the SSRIs can theoretically be used to treat social anxiety disorder, including the serotonin-norepinephrine reuptake inhibitor (SNRI) Venlafaxine (Effexor® an others) and, to a lesser extent, the noradrenergic and specific serotonergic antidepressant (NaSSA) Mirtazapine (Remeron® and others). However, selective serotonin reuptake inhibitors (SSRIs) are often the first type of medication tried for persistent symptoms of social anxiety. The reasons are mostly empirical and anecdotal as they seem to work in practice, while having a relatively benign profile of possible side-effects. Venlafaxine may increase anxiety and panic attacks in the early phase of treatment.
The SSRIs increase level of the neurotransmitter serotonin in the synaptic cleft between the endings of nerve fibers from (mostly different) nerve cells. This leads to a change in the receptor density of certain serotonin receptor subclasses in the cell membrane and thereby directly reflects the flow of information between and through nerve cells. The SSRIs are effective against anxiety of all kinds, including obsessive-compulsive disorder, and depression. Especially after they came out, they received bad press that they change one’s personality and lead to addiction. However, the current consensus is that they do not radically change one’s personality and they are generally thought as being non-addictive. There is some concern over an emotional flattening in the long-run, but this has not been convincingly demonstrated yet. In clinical experience, they still represent a relatively favorable tradeoff between the more common side-effects and the change in the quality of life they can bring about. Discontinuing them is quite simple, but still should be discussed and the pros and cons weighed off carefully, not just if suicidality is an issue. The old symptoms may resurface after discontinuation, especially if they have been taken for less than a year. Recommendations vary for anxiety and depression, but there seems to be a consensus that they should be taken for a longer period if the clinical diagnosis justifies it.
It may take several weeks to several months of treatment for the clinical symptoms to noticeably improve. The reason why antidepressant medication affecting the serotonin system may take longer is because the number of receptors (density) in the cell membrane, which translate chemical signals into other chemical signals, but more importantly into fast moving electric signals along the cell membrane, must be changed. This requires transcription and translation from the DNA code into some receptor proteins and the ‘recycling’ of others.
Among the other options are the following:
These substances block the stimulating effect of epinephrine (adrenaline). They may reduce heart rate, blood pressure, pounding of the heart, and shaking voice and limbs. Because of that, they may work best when used infrequently to control symptoms for a particular situation, such as giving a speech. They’re not recommended for general treatment of social anxiety disorder. They should be tried out before encountering an anxiety provoking situations to psychologically decrease the anxiety of experiencing anxiety during the event.
Beta blockers are the only medication that tends to be used more often with social anxiety than other anxiety disorders. These are drugs like Propranolol that prevent the body from experiencing any profound anxiety symptoms. How they work is not entirely known, but it is believed that they prevent the heart from getting excited, which keeps the body calm in anxiety situations.
Buspirone (Buspar®) is a mild anxiolytic with few side effects, which is generally well tolerated. The main problem with buspirone is that the effect is often too weak.
There are a few other social anxiety medications, but those mentioned above four are the most common. In the past, other drugs like MAO inhibitors were used, but they have since fallen out of favor because of their unfavorable side-effect profiles.
In any case, it is important to keep in mind that in the long-run the emphasis for social anxiety should be on psychotherapy rather than medication. There is probably a beneficial effect of medication if taken over the long-run as the brain learns to be less anxious and less worried about experiencing anxiety in social situations. However, this effect is likely to wear off if working on the underlying issues is avoided.
© 2012, 2016 Dr Christian Jonathan Haverkampf. All rights reserved.
Psychotherapy & Counselling, Communication, Medicine (Psychiatry); Dublin, Ireland
This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition.
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