The two most common treatments for social anxiety disorder are medication therapy (pharmacotherapy) and cognitive-behavioral therapy (CBT). Both medication therapy and CBT have proven successful in treating social anxiety disorder. The clinician psychologist or physician can help choose the most appropriate course of action. Many find that a combination of medication and CBT is most effective.

Other kinds of treatments include relaxation techniques, social skills training, and exposure (without cognitive therapy). We will not review these here, although they may be as efficient as commonly used approaches.

Cognitive-Behavioral Therapy
Cognitive-Behavioral Therapy (CBT) is possibly the most effective, most commonly known and most thoroughly studied therapy for social anxiety disorder. In CBT, a person's cognitions (thoughts) have to be changed in a rational direction, and a person's behavior needs to gradually move away from avoidance and toward engagement and participation in life. CBT can be done initially on a one-to-one basis, but an active, behavioral therapy group, consisting of other people with social anxiety, is essential to fulfill the goals. There are usually about 6-20 members in such "CBT group". The treatment can last from a few intense weeks to a few months or more.
The primary aim of CBT is to extinguish the association between the stimulus (e.g. social event) and the anxiety/panic response and to extinguish the association between ineffective avoidance behaviors and the temporary relief of anxiety.
CBT attempts to remediate the exaggerated threat/appraisal of the patient by increasing the accuracy of the patient's appraisal, increasing the patient's ability to cope with the demands of a stressful situation or conditions.
Specifically, CBT combines Cognitive Restructuring ("cognitive" part) with Exposure ("behavioral" part).

Cognitive Restructuring: patients with anxiety disorders consistently overestimate the threat (danger) of situations and/or underestimate their ability to cope with such threats, thereby generating anxiety.
The individual anticipates threats to self and family, and such threats may be either physical (e.g., life-threatening, as in danger associated with flying) or psychological (e.g., threat to self-esteem, as in fear of looking foolish during public speaking) in nature.
Cognitive restructuring is a strategy employed to reduce anxiety by correcting this faulty appraisal style, which presumably generates the anxiety.
Specifically, cognitive restructuring focuses on:

• reducing anxiety by identifying the erroneous beliefs and perceptions of threat which generate negative thoughts which in turn leads to anxiety, and
• challenging and modifying the fearful thoughts by guiding the patient to access information incompatible with the anxiety response (corrective information).

Therefore, the therapist first works with the patient to uncover fear-related cognitions (automatic thoughts) during periods of increased anxiety or panic using a thought monitoring form and other tools. An example of automatic thoughts' identification and correction form can be found here.

Exposure: exposure helps patients to gradually become more comfortable with situations that frighten them ("the phobic stimulus"). More specifically, the goals of exposure are:

• to break or disconnect the associations between sensations of fear or anxiety and the phobic stimulus, and to
• break or disconnect the associations between the reduction of anxiety and the escape or avoidance of the phobic stimulus.

The exposure method involves actual confrontation with the phobic stimulus both in and out of therapy sessions. To accomplish this, phobic stimuli which create anxiety are initially identified and arranged hierarchically according to the amount of anxiety they evoke.

Not all patients benefit equally well from CBT and large variations in effect also exist. The chances of success with CBT largely depend on the experience of the CBT therapist(s). Before you choose one, look for positive testimonials of friends or acquaintances.

Medication
Medications help reduce the frequency and intensity of anxiety in social situations, and also help decrease anticipatory anxiety and avoidance behaviors. Clinical trails indicate that about 40-80% of patients with social anxiety disorder achieve worthwhile gains from medication therapy, whereas less than 30% of social anxiety disorder patients receiving a placebo (sugar pill) improve. Obviously, some patients treated with medication do not benefit, and it is currently impossible to predict who will improve on a particular medication unless they have previously benefited from that medication or from a different member of its class.
There are several families (or classes) of medications used in the treatment of social anxiety disorder:

1. Antidepressants
   • Selective Serotonin Reuptake Inhibitors (SSRIs)
   • Serotonin/Norepinephrine Reuptake Inhibitors (SNRIs)
   • Monoamine Oxidase Inhibitors (MAOIs)
2. Tranquilizers/Antianxiety
   • Benzodiazepines
   • Buspirone (BuSpar)
3. beta-blockers

All of these have been studied systematically and found helpful in controlled research trials.
As of April 2003, the U.S. Food and Drug Administration (FDA) has approved two medications for the treatment of social anxiety disorder. These medications are selective serotonin reuptake inhibitors, or SSRIs, known as paroxetine (Paxil) and sertraline (Zoloft). FDA approvals are based on multicenter, double-blind studies. Other brand names of SSRIs are Prozac, Celexa, Lexapro and Luvox. Clinical evidence suggests that all the SSRIs may be helpful in treating social anxiety disorder.

Which medication to use first is a matter of patient and physician preference. The SSRIs are generally considered medication of first choice for social anxiety disorder mainly because they are safe. The SSRIs have side effect profiles that make them quite easy for most patients to tolerate. However, many patients reported they experienced severe withdrawal reactions after taking SSRIs.

A different group of drugs is benzodiazepines (BZDs). Benzodiazepines are used to control and reduce anxiety and treat a wide variety of other psychiatric problems. Xanax, Klonopin, Valium, Ativan are well known brand names of benzodiazepines.
Clonazepam (Klonopin) is the most extensively studied benzodiazepine for the treatment of social anxiety disorder and has been shown to have significant beneficial effects. Alprazolam (Xanax) is very common too, and quite similar in mechanism to clonazepam (Klonopin). Unlike SSRIs, benzodiazepines have a quick effect and can also be used PRN.
Some claim benzodiazepines are addictive, but this claim is controversial when the primary indication is for anxiety disorders and providing that the patient is not a drug addict.

Another class of drugs is Monamine Oxidase Inhibitors (MAOIs), such as phenelzine (Nardil), which were once the most studied and probably the most effective medications for treating social anxiety disorder and depression.
Nevertheless, because of the possibility of dangerous as well as annoying side effects, MAOIs are not widely prescribed for social anxiety disorder as first choice, and are usually used for individuals who have not responded to other medications.
The last group, beta-blockers, are used to treat non-generalized social anxiety disorder (performance anxiety). Inderal (propranolol), for example, is a beta-blocker.

Medication therapy is also often recommended for the purpose of using it as a "tool" or as an "encouragement" while undergoing cognitive-behavioral therapy, especially if it allows the individual to practice better and clearer at the clinic and at home on CBT material.