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Social Anxiety Treatment – Medications Review

published Monday, December 14th, 2009 at 2:19 pm by docdave

Introduction

In recent years Social Anxiety (SA) has become more recognized as a separate form of Anxiety Disorder. Anti-anxiety medications have been prescribed and in addition some medications originally developed for treating depression have been shown to be useful for anxiety. Several have received specific approval as being effective in treating SA.

Of course there are many pros and cons as regarding taking any medication. All of these medications can have side effects, some of them serious and others just bothersome. However, they do have a place. If you are having very severe and crippling anxiety or panic attacks or you have become fearful about even leaving home (agoraphobia), then it is advisable to consult your doctor about treatment, including the use of medications. If your anxiety is milder and only related to specific situations, then using medications is less important. If you have any doubt, consult your doctor. All of these medications are only available on prescription. I do not discuss any herbal remedies as I do not have enough knowledge about them.

Short Acting Medications

Benzodiazepines

Benzodiazepines, of which Valium is the best known example, are a class of medications which quickly relieve anxiety. They differ from one another in terms of how long their effect lasts and also how sedative they are. Some of this group are used as sleeping medications—examples would Halcion, Dalmane and Restoril.

There are three benzodiazepines which are particularly of interest in treating social anxiety disorder. The first of these is Ativan (lorazepam). This is useful because it is short acting, lasting only three or four hours and quick in its onset of action. It is available in a sublingual form. When this is placed under the tongue it dissolves quickly and enters the blood stream immediately. It acts almost as fast as an injection. The usual dose is 0.5 or 1 milligram. This makes it very useful for short term use in anxiety provoking situations such as giving a speech. However, it is very advisable to try its effect ahead of time in case it proves too sedating for you.

The other two are Xanax (alprazolam) and Klonopin (clonazepam). These two benzodiazepines are somewhat different and seem to be more effective in treating panic attacks. They differ in that Klonopin is longer acting than Xanax.

As with any medication there is a downside to the benzodiazepines. Firstly extended use may lead to the development of tolerance, that is to say that it takes a larger and larger dose to have the same effect. Secondly, dependency may develop. Coming off the medication may be difficult and disabling withdrawal symptoms may develop. These often resemble the original anxiety which makes diagnosing them difficult at times. While dependency is more often seen when the person has been taking a large dose over a long period of time, it can occasionally occur with a normal dose after a relatively brief exposure.

The other major problem with benzodiazepines is that they are subject to being abused. There is often an increased tolerance in those people who have previously or currently have alcohol problems. In fact there is often a cross addiction between alcohol and benzodiazepines, when a benzodiazepine addiction can become a substitute for alcohol addiction and dependence.

Beta Blockers

Beta-blockers are a different class of drug. While they do not stop anxiety they do block its physiological effects. These include rapid heart rate, tremors, dry mouth and sweating. They’re commonly used by performers such as musicians to control the effects of anxiety which could interfere with their performance.

The commonest beta-blocker which is prescribed is Inderal (propranolol). It is taken about half an hour before a performance.

Longer Acting Medications
Specific Serotonin Reuptake Inhibitors (SSRI)

These are a class of medications originally used to treat depression. Prozac (fluoxetine) was the original SSRI that was developed. Since then several others have been developed. These include Paxil (paroxetine), Effexor (venlafaxine), Luvox (fluvoxamine), Zoloft (sertraline), Celexa (citalopram), and Lexapro (escitalopram). Two of these (Paxil and Effexor) have received specific approval for treatment of SA, but in practice all of them can be used to treat anxiety. These drugs work by increasing the amount of available serotonin. This is a neuro-transmitter. Neuro-transmitters are the chemical link between brain cells (neurones) and serve to either fire the next neurone or to inhibit it from firing. Serotonin is involved in the emotional centers in the brain and generally has a calming effect. It also serves to protect the brain from the effects of chronic stress.

SSRIs do not have an immediate effect. Any response may take 2 to 6 weeks to appear, but they are often effective with panic disorder and more severe forms of SA and agoraphobia. This lag makes using these drugs an art form as much as a science. A person may not show a response to one of these drugs, but yet have a good response to another in this category. So often some patience is required before a remedy can be found.

There are some individual differences in the side effect profile of these drugs, but they all have a number of side effects which are experienced by a significant percentage of patients. The side effects are commonly experienced when first taking the drug and many disappear with continued use.

The common side effects include nausea, sedation, dry mouth, weight gain, sweating, tremor, diarrhea, increased anxiety, headache and dizziness. There are also some rare and more serious complications.

In practice, however, the commonest reason for discontinuing these medications are the sexual side effects. These can occur in up to 30% of cases. They include delayed ejaculation, inhibition of sexual desire, erectile dysfunction and failure to achieve orgasm.

As with all decisions in medicine, a decision as to whether to use a medication or not is a matter of weighing up the expected benefits against the risks. Your doctor can help you with this decision.

Other Medications

There are other medications which can be used for social anxiety. However, these are not, need to prescribed at because of the side effect profile. However, in some cases they may be used where other medications cannot be tolerated or are not effective. These include a class of drugs known as Monoamine Oxidase Inhibitors (MAOI). Drugs in this class are Parnate (tranylcipramine) and Nardil (phenelzine). These drugs have serious drawbacks in that there are potentially serious complications from their use and dietary restrictions apply. In addition, there is a number of potentially dangerous drug interactions.

A newer type of MAOI is Manerix (Moclebemide). This has less problems with drug interaction and no special diet is needed.

Doctor Dave

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Social Anxiety Treatment – What Are Your Options?

published Tuesday, December 8th, 2009 at 9:59 am by docdave

Understanding your Options – Seeking Professional Help

Treatments Available

There are a variety of approaches to treating Social Anxiety (SA). However, they basically come down to a two step approach.

Step 1 – reduce the anxiety.

Step 2 – encourage the person to engage in real life activities and, through repeated exposure to the feared situation, become comfortable in it.

Often a third step will be necessary; this is some kind of skills training.

Both Medication and Cognitive Behavior Therapy have been shown to be effective, in controlled clinical trials, for alleviating shyness and social anxiety.

Types of professional help available

The three principal kinds of professionals that you might consult for social anxiety are your family doctor, a psychiatrist or a psychologist.

Your family doctor.

Many family doctors are not familiar with social anxiety. Your family doctor is however able to prescribe medication and make a referral to a psychiatrist or a psychologist. Some family doctors do therapy, but this would be an exception. Unfortunately some family doctors are inclined to dismiss your concerns. If that is the case, don’t be put off but seek help elsewhere.

A psychiatrist.

A psychiatrist is medically trained and can use all of the treatment modalities available. In particular he or she will be able to advise you on suitable medication if you decide to go that route and monitor your progress. Some psychiatrists also specialize in psychotherapy and may offer you cognitive behavior therapy or some other kind of psychotherapy.

A psychologist.

If you see a psychologist for help you will most likely be offered Cognitive Behavior Therapy together with assistance in graduated exposure. In most jurisdictions in a psychologist cannot prescribe medications.

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Social Anxiety Treatment – Cognitive Behavior Therapy (CBT)

published Tuesday, October 6th, 2009 at 1:23 pm by docdave

Cognitive Behavior Therapy – Theory

As noted in the introduction, people with SA are able to experience anxiety through their thoughts alone, without being in the actual situation. However, the thoughts themselves may often be distorted. Since there is avoidance of the feared situation, this thinking does not get corrected by reality.

With CBT the therapist helps the client to identify distorted thought patterns and learn to correct them. A thought journal is often used for this process.

There is cumulative evidence that individuals with SA process information differently from people who are not socially anxious. It is found that they place much more importance on making a favorable impression on others, yet, they believe that they will act incompetently in social situations.

As a result of these concerns, people with SA use various processes intended to protect themselves in feared situations, which, unfortunately, often fail to help.

These processes include intensified attention on oneself, including paying attention to one’s internal state; viewing oneself from an observer’s perspective; overuse of safety behaviors. When in social situations, people who are anxious about how they are seen, commonly pay more attention to themselves and ignore useful and necessary social cues from others. This paying attention to oneself is encouraged by the presence of the physiological sensations of anxiety.

Another consequence of this inward attention is that people with SA usually construct a negative image of themselves, based on how they think others see them and how they feel.

Practice

Duration

Usually cognitive therapy is time limited. Commonly 10 to 20 sessions are required. If there is a more specific limited problem it could be dealt with in fewer sessions. Sometimes if there are complex problems more sessions may be required.

Therapeutic Alliance.

The therapist will work with the client to set up a collaborative relationship. It is important that the client be an active participant in the whole process. He or she cannot expect to make any improvement unless they are prepared to follow through and do the homework assignments. However, the client’s opinion and agreement will be sought throughout the process.

Set Agenda for Sessions

The therapist in collaboration with the client will set an agenda for each session. The activities will include giving constructive feedback, and employ cognitive therapy techniques on a regular basis and assign homework to link the sessions together.

Use Cognitive Techniques
Identifying Automatic Thoughts

Many people with SA commonly have thoughts which come into their mind in response to either a situation or to an emotion. They may be aware of the feeling but not recognize the thought. With SA these thoughts are commonly predictive of some disastrous event happening. Examples of these are given in Table II.

The therapist will guide the client in identifying these thoughts and then proceeding to the next step:-

Modifying Automatic Thoughts

Examining the Evidence for These Thoughts

The therapist will collaborate with the client in examining the evidence for these beliefs. This challenge also helps the client to more easily identify automatic thoughts in the here and now. There are common patterns of cognitive distortions which the therapist can help the client to recognize.

De-catastrophizing

Clients typically predict that dire consequences will happen if they engage in the feared social behavior. The therapist helps by challenging these assumptions.

Assign Homework

Homework assignments are routinely given in the course of CBT. Commonly a thought journal is kept in which the client records a triggering event, his or her emotional response to that event and the thoughts that accompany it. He or she is then requested to write down the evidence for this thought or to identify in what way it is distorted.

The therapist will be coaching the client in identifying these distortions. The homework and journal will be used as a basis for a subsequent session.

In addition to the thought journal graded exercises with exposure to the feared situation may be assigned.

Cognitive Therapy coupled with graduated exposure to the feared situation has been demonstrated to be an effective treatment for SA.

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What is Social Anxiety?

published Sunday, September 13th, 2009 at 3:43 pm by docdave

Social anxiety is where a person is nervous or uncomfortable in social situations. The fear is often one of doing something embarrassing, making a bad impression, or being judged negatively by others. Social anxiety may be specific or generalized. In the case of specific anxiety it is only triggered by one or two situations. These may be, for example, speaking in public or being interviewed for a job.

In the case or generalized social anxiety, almost any social situation can provoke anxiety. However, in all cases the anxiety does not arise in a vacuum, but is triggered either by being confronted with the situation or by thinking about it and anticipating it. Usually thinking about an upcoming situation is enough to create anxiety.

The response to these situations can include:-

The physiological and bodily changes of anxiety (See Table 1)

e.g. increased heart rate, dry mouth, sweating, gastrointestinal upset etc.

Worrying Thoughts (See Table 2)– these commonly involve a fretful anticipation of some disastrous or embarrassing consequence of engaging in a particular social interaction.

Avoidant Behavior. (See Table 3) Often people who exhibit shyness or social anxiety often avoid situations in which they may become anxious. Sometimes the avoidance is obvious but at other times there may be more subtle forms of avoidance. These include using alcohol or drugs to mask anxiety, staying in the kitchen to help out at the party, wearing a turtleneck or a lot of makeup to hide possible blushing.

Table I – Physical Feelings Associated with Social Anxiety

  • Racing or pounding heart
  • Breathlessness or feelings of being smothered
  • Dizziness or lightheadedness
  • Difficulty swallowing, choking feelings, or a “lump” in the throat
  • Quivering or shakiness (e.g., in the hands, knees, lips, or whole body)
  • Blushing
  • Nausea, diarrhea, or “butterflies” in the stomach
  • Excessive sweating
  • Trembling or quavering voice
  • Tearfulness, crying
  • Nervous laughter, smiling
  • Poor concentration (e.g., forgetting what you are trying to say)
  • Blurred vision
  • Numbness and tingling sensations
  • Feelings of unreality or being detached
  • Tightness or weakness in the muscles (e.g., wobbly legs, sore neck)
  • Chest pain or tightness in chest muscles
  • Dry mouth
  • Hot flushes or chills

Table II – Examples of Distorted Thinking

  • It is important that everybody like me
  • If my boss doesn’t like me, I will be fired
  • If I give a presentation, I will make a fool of myself
  • If I make a mistake, people will become angry with me
  • People are untrustworthy and nasty
  • People should always be interested in what I say
  • People should not look at me the wrong way
  • If I am not liked by a particular person, I am unlikable
  • If someone rejects me, I deserve it
  • It is awful to blush, shake, or sweat in front of others
  • People can tell when I am anxious
  • People find me unattractive
  • If I speak to my boss, I will look incompetent
  • I should be able to hide my anxiety symptoms
  • If my hands shake at work, it will be a disaster
  • Anxiety is a sign of weakness
  • I should not appear anxious
  • If I am too anxious, I will not be able to speak

Table III – Examples of Avoidant Behaviors

Avoidant Behavior Examples
Refusing to Enter the Situation Turning down an invitation to a party
Never answering questions in class
Making an excuse not to have dinner with a friend
Escaping from the Situation Always arriving late for meetings and leaving early to avoid making “small talk”
Offering to help with the dishes at a party to avoid talking to the guests

Making an excuse to get off the telephone with a friend or coworker
Subtle Avoidance Behaviors Distracting yourself from your anxious thoughts
Keeping the room dark during your presentations to keep the audience focused on the slides rather than on you
Filling out a check before arriving at store to avoid writing in front of others
Avoiding eye contact and speaking very softly when conversing with others
Overprotective Behaviors Wearing makeup and a turtleneck sweater to hide your blushing
Always attending the holiday office party with a close friend, spouse, other safe person even though your coworkers tend to attend alone
Always arriving early for meetings to ensure that it will not be necessary to enter the room after everyone else is already seated
Drug or Alcohol Use Having a couple of glasses of wine before meeting another person for a date

Examples of Social Situations

Interpersonal Situations

  • Asking someone out on a date
  • Initiating or maintaining a conversation
  • Going to a party
  • Having friends over for dinner
  • Meeting new people
  • Talking on the telephone
  • Expressing a personal opinion
  • Having a job interview
  • Being assertive (e.g., asking someone else to change their behavior)
  • Returning an item to a store
  • Sending back food in a restaurant
  • Making eye contact

Performance Situations

  • Public speaking
  • Speaking in meetings
  • Playing sports or participating in aerobics
  • Getting married
  • Performing music or acting on a stage
  • Eating or drinking in front of others
  • Using public bathrooms with others in the room
  • Writing with others watching (e.g., filling out a form)
  • Making a mistake in public (e.g., falling down, dropping your keys, etc.)
  • Walking or jogging in a public place (e.g., on a busy street)
  • Introducing yourself (e.g., saying your name) in front of a group
  • Shopping in a busy store
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