Social Phobia Treatment & Management
- Author: Bettina E Bernstein, DO; Chief Editor: Eduardo Dunayevich, MD more...
A combination of pharmacotherapy and psychotherapy is usually indicated for persons with social phobia.
Antidepressants including selective serotonin reuptake inhibitors (SSRIs; citalopram [Celexa], escitalopram [Lexapro], fluvoxamine [Luvox], paroxetine [Paxil], fluoxetine [Prozac], sertraline [Zoloft]) and venlafaxine (Effexor) are commonly prescribed to treat the symptoms of social phobia and generally result in remission of symptoms after 4 weeks of treatment. However, it is important to balance benefits and the potential for adverse effects when prescribing medications.[40, 41, 4, 42]
SSRIs: SSRIs are quickly becoming the standard first-line medication for social phobia. Paroxetine received US Food and Drug Administration (FDA) approval for this indication in 1999, the first SSRI to gain such approval. In 2003, sertraline received FDA approval for short- and long-term (20-wk) treatment of social phobia in adults. It is also FDA-approved for the treatment of obsessive-compulsive disorder (OCD) in children older 12 years.
Serotonin norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine, were approved for the treatment of social phobia in 2003 for use in adults but may not be as effective or safe in children. Studies suggest that other SSRIs may also be effective. However, the FDA recommends caution when using these agents to treat social phobia in children younger than 18 years because of concerns about the potential increased risk of newly onset suicidal ideation, especially with venlafaxine and paroxetine. Nonetheless, numerous open and controlled studies support the efficacy of SSRIs/SNRIs in this population as part of a multimodal approach, with close monitoring of mental status. [43, 44, 41, 4]
Benzodiazepines: Benzodiazepines may be effective for social phobia but are generally undesirable in the absence of contraindications to SSRI use. Alprazolam and clonazepam have been used successfully for this indication, but all agents in this class, although very helpful in comorbid panic, should not be used for longer than 6 weeks because of the risk of increased depression and physical dependence. [41, 4]
Buspirone: Some studies suggest efficacy in persons with social phobia and less of a risk of physical dependence than is commonly seen with benzodiazepines. However, it has not been FDA-approved for the treatment of anxiety disorders in children. [41, 4]
Gabapentin: Recent studies suggest the efficacy of gabapentin for this indication; however, it is not FDA-approved for use in social phobia in adults or children. [44, 4]
Propranolol: Beta-blockers have been used to block the autonomic response in persons with social phobia. Preventing symptoms such as tremor and increased heart rate may lead to successful performance in social situations despite anxiety. However, propranolol should not be used in persons with asthma or in combination with other antihypertensive agents. This medication is not yet FDA-approved for use in children. 
Clonidine (alpha-adrenergic blocker) may work to block the autonomic response in persons with social phobia, similarly to the effect conferred by propranolol, and can be particularly useful in persons with comorbid posttraumatic stress disorder or acute stress reactions. 
Monoamine oxidase inhibitors (MAOIs): These agents are not approved for use in children, but they are FDA-approved for use in adults for unipolar depression. Phenelzine has been demonstrated to be effective in controlled studies. The dietary restrictions required when taking MAOIs reduces their popularity. Moclobemide, a newer reversible MAOI, has shown some efficacy in persons with social phobia. Selegiline (EmSam, a patch) may be superior to other agents in this class because of a slightly decreased risk of serotonin syndrome if used in the lowest dosage range. 
D-cycloserine: This medication has not yet been proven effective for the treatment of social phobia, but studies are ongoing. [45, 4]
Cognitive restructuring can be combined with in vivo exposure, performance feedback, and attention retraining and/or combined with nonspecific stress management or computer-based cognitive behavior therapy (CBT).
Cognitive therapy has evidence-based efficacy.[47, 48]
A study of adults was a randomized controlled trial of 117 persons undergoing social anxiety disorder (SAD) treatment who received 16 individual sessions of either cognitive therapy (CT) or interpersonal therapy (IPT) and 1 booster session.
Twenty weeks after randomization, a posttreatment assessment was conducted using the Clinical Global Impression Improvement Scale, as assessed by independent, masked evaluators, and a secondary outcome measures was conducted independent of assessor ratings using the Liebowitz Social Anxiety Scale, the Hamilton Rating Scale for Depression, and patient self-ratings of SAD symptoms.
At the posttreatment assessment, response rates were 65.8% for CT, 42.1% for IPT, and 7.3% for WLC (Wait List Control). Regarding response rates and Liebowitz Social Anxiety Scale scores, CT performed significantly better than IPT, and both treatments were superior to WLC. At 1-year follow-up, the differences between CT and IPT were largely maintained, with significantly higher response rates in the CT versus the IPT group (68.4% vs 31.6%) and better outcomes on the Liebowitz Social Anxiety Scale.
CT and IPT led to considerable improvements that were maintained 1 year after treatment; CT was more efficacious than IPT in reducing social phobia symptoms.
Adolescents, particularly school-refusing adolescents, improve with the use of CT, especially when developmentally sensitive, and when this therapy is performed in an inpatient setting. This may be related to the improvement of automatic thoughts and cognitive errors with the use of CBT.[49, 50]
Behavioral psychotherapies, such as gradual desensitization, are effective in persons with social phobia. This technique involves gradually exposing the patient to simulated situations that normally cause anxiety in the patient. By mastering the situation without anxiety, the patient is eventually able to tolerate more situations that previously induced anxiety.
Specific CBTs that have been found to be effective include computerized CBT (several types including "Coping Cat") and clinician-assisted computerized CBT (CaCCBT). Studies have shown that cognitive restructuring needs to include a component of in vivo exposure with attention retraining and performance feedback. As CBT interventions for social phobia tend not to generalize, it is important to design interventions specific to social phobia. Computer-based interventions have the advantage of eliminating scheduling problems, as they are convenient, potentially more sensitive to cross-cultural issues, appealing to children and adults, and more easily affordable.[23, 24, 26]
Cognitive and insight-oriented therapies have proved useful in treating social phobia. Individuals with social phobia often have significant cognitive distortions related to what other people could be thinking about them that might respond to restructuring.
Stress management and relaxation techniques such as biofeedback, meditation, and deep breathing can lessen anxiety but are not sufficient alone in the treatment of social phobia.
Group psychodynamic psychotherapy and individual psychoanalytic psychotherapy (an approach used for many years in the treatment of phobias) are approaches that are especially effective if combined with pharmacotherapy such as anxiolytics.[42, 51, 52]
A 2013 randomized control trial found that predictors of a less favorable treatment response include anticipatory worry, rumination, and harm-avoidant personality traits.
A 2015 multisite study, The Genes for Treatment Study (GxT), sampled data from 1,519 children who received a course of CBT for anxiety at 1 of 11 sites: Sydney, Australia; Reading, UK; Aarhus, Denmar; Bergen, Norway; Bochum, Germany; Basel, Switzerland; Groningen, the Netherlands; Oxford, UK; Miami, Florda, USA; Cambridge, UK; and Amsterdam, the Netherlands. Data showed that social anxiety disorder, compared with other anxiety disorders, predicted poorer response and remission to CBT over and above comorbid mood disorders.
Attention Bias Modification Training
Attention bias modification training (ABMT) is a promising alternative approach that may be effective in reducing anxiety in children and adolescents who do not improve with CBT. ABMT consists of a computer-based attention training program in which the person is trained to induce an attentional bias away from threat.
ABMT has been shown to be more effective than placebo for reducing symptoms of anxiety in children and adolescents.
Positive Cognitive Bias Modification for Interpretation
Cognitive bias modification of interpretations (CBM-I) training is an alternative method to reduce anxiety in children and adolescents who do not respond to either CBT or ABMT. CMB-I refers to computerized training to interpret ambiguity in a benign way so as to reduce threat-related interpretations and increase benign interpretations of ambiguous situations in participants' everyday lives. The goal of treatment for individuals with a prior interpretation bias includes training away negative social interpretation bias to reduce social anxiety symptoms. CMB-I has been proven to be more effective than placebo in laboratory studies for school-aged children.
CMB-I has also been shown to be effective for adolescents.[58, 59]
Surgical consultation for children with infantile facial hemangiomas could potentially prevent development of social anxiety disorder.
Toddlers and young children with excessive shyness and an inhibited temperament in childhood may be at greater risk of social phobia in adolescence. This may be in part related to the caregiver/parent’s response to the child’s emotional reaction to social situations, hence the importance of modeling and encouraging the young child’s ability to ignore negative internal cues and a gradual approach to coping with fears.[31, 32]
Because very low weight (600-1250 g) premature babies may also be at an even higher risk for later development of social anxiety disorder, caregivers/parents should be aware that typical parenting behaviors such as overprotectiveness may further increase risk for the development of social anxiety disorder.
Surgical treatment of infantile facial hemangiomas (IH) may prevent the later development of social anxiety disorder. One study found that preteen children with involuted, untreated facial IHs had greater symptoms of social anxiety compared with children who received treatment for facial IH.
Social phobia often leads to extreme social isolation in children and can be accompanied by selective mutism and/or can be a precursor to depression. Intermittent explosive disorder (IED) can also co-occur with social phobia. Data from the National Comorbidity Survey Replication and Adolescent Supplement Study indicated lifetime presence of an anxiety disorder increased the rate of IED by almost 3-fold (7.8% in adolescents without anxiety compared with 22.9% in adolescents with anxiety). Thus, monitoring for severe anger outbursts may prevent significant morbidity.
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