Not long ago, a young woman, "Susan," took skydiving lessons.
She and her fellow students boarded a plane to practice. When it came time to
bail out of the plane, Susan volunteered to be the first to jump. The reason
wasn't because she was courageous, but because she dreaded having to talk with
other people on the plane.
Susan, in short, suffered from social anxiety (social phobia) disorder, a
condition that can be profoundly distressing and disabling, triggering
blushing, sweating, stuttering, shaking, and nausea.
"Social anxiety really strikes at the heart of what it is to be
human—to interact with other people," Mark Pollack, M.D., an
associate professor of psychiatry at Harvard University and director of the
Massachusetts General Hospital anxiety treatment program, told Psychiatric
Fortunately, Susan is being treated for her disorder. "More and more
Americans are seeking help for social anxiety, thanks to awareness campaigns
and media coverage of the past decade or so," Pollack said.
The scientific evidence of the effectiveness of a growing number of
treatments is robust. Notably, there are the SSRIs, SNRIs, monoamine oxidase
inhibitors, benzodiazepines, and cognitive-behavioral therapy, which in turn
includes cognitive restructuring and exposure therapy. Moreover, the SSRIs and
cognitive-behavioral therapy appear to be equally effective at combating
social anxiety, a recent study suggests (Psychiatric News, November
Nonetheless, the treatments do have some downsides. For instance, the
benzodiazepines can lead to abuse and do not relieve any depression that may
exist along with social anxiety, Pratap Chokka, M.D., an associate clinical
professor of psychiatry at the University of Alberta, reported at the annual
meeting of the Canadian Psychiatric Association in
From left: Pratap Chokka, M.D., Kevin Kjernisted, M.D., and Pierre
Bleau, M.D., discuss social anxiety and other anxiety disorders at the annual
meeting of the Canadian Psychiatric Association in October.
Further, some questions about the deployment of these treatments for social
anxiety disorder beg for answers. For example, should clinicians combine
treatments or not? What is the optimal time for treatment? Can early
intervention change the course of the disorder? Unfortunately, the scientific
evidence needed to answer these questions is not yet available, John Walker,
Ph.D., a professor of clinical health psychology at the University of
Manitoba, pointed out at the meeting.
"If you rate available treatments on a 10-point scale, I would give
them about a 6," Jonathan Davidson, M.D., a professor of psychiatry at
Duke University and director of the anxiety treatment program there, said in
an interview. "That is to say, they can make a difference, but they
leave people with a huge amount of continuing morbidity. If you treat somebody
for three to six months, they have still relatively significant scores on
anxiety measures. So there is need for improvement."
A cure for the disorder does not appear to be imminent. Nonetheless, some
new treatments being explored for social anxiety may expand the treatment
For example, Davidson and colleagues recently completed a small,
placebo-controlled study to determine whether the anticonvulsant levetiractam
(Keppra) might counter social anxiety disorder. The results, which have been
submitted for publication to a scientific journal, look promising. Davidson
and coworkers have found that when the botulism toxin (Botox) is given with an
SSRI, it can help with the sweating associated with social anxiety disorder,
as well as with the social anxiety itself. They were scheduled to present the
results of this double-blind trial at a meeting of the American College of
Neuropsychopharmaoclogy in San Juan at press time.
Davidson and his group are now conducting a double-blind,
placebo-controlled study to determine whether St. John's wort can ease social
anxiety disorder. There is also a possibility that chromium, which affects the
neurotransmitter serotonin, might help counter the condition. Chromium appears
to mitigate atypical depression, Davidson and his team have found.
Drugs that thwart the actions of corticotropin-releasing factor or
substance P may also turn out to dampen social anxiety disorder, Pollack said.
Corticotropin-releasing factor is produced by the hypothalamus in response to
stress and deployed by the amygdala to communicate with other structures in
the brain. Substance P is a neuromodulator that may play an important role in
the regulation of emotions.
"Though cognitive-behavioral therapy is clearly effective for the
treatment of social phobia and other anxiety disorders, it has not been widely
disseminated and is often available only at specialized treatment centers to
help affected individuals," Pollack added. "Efforts are starting
here and elsewhere to develop a more easily administered and time-efficient
form of CBT in order to make this treatment modality more widely