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
