For this post, I’ve invited Dr. Tracy Marks to share her top tips for dealing with social anxiety. She’ll teach you two medication options for treating social anxiety and one powerful therapy option to retrain your brain to manage social anxiety differently.
Hi, everyone. I’m Emma McAdam. I’m a licensed marriage and family therapist. And by the time you read this post, I’m gonna have a new baby, so Dr Tracey Marks agreed to help me out.
She is one of my favorite YouTubers. She’s a psychiatrist, and she uses such great evidence-based, research-backed treatment in such a helpful way. She always gives people a lot of good ideas. And today she’s going to be teaching you about a couple of treatment approaches for social anxiety.
She’s going to be talking about two medication options for social anxiety and one behavioral option for social anxiety, which is learning how to set up a very gradual and gentle approach to exposure therapy with social anxiety. And this looks like setting up a fear ladder, so breaking down tasks into very small steps.
So I’m really grateful to Dr. Marks for joining us today and sharing her wisdom with us. And please check out her new book and her YouTube channel if you haven’t seen it already. It’s great. I learn from her all the time.
So without further ado, here’s Dr. Marks.
Dr. Tracey Marks
Hi, I’m Dr. Tracey Marks, a psychiatrist, and I make mental-health education videos. I am excited to borrow the mic from Emma to give her some needed time away to spend time with her sweet baby.
Today I’m going to be talking about three approaches to social anxiety. Two of them involve medication and one is behavioral.
Social anxiety used to be called social phobia, but the name change actually reflects better on the various ways that this problem actually affects you.
It’s not just fear of being social; you’re preoccupied with what people think of you, being judged, humiliated, or embarrassed around people, or you can be obsessed over offending people by something that you say or do. And this problem really affects your self-esteem and your confidence around people.
Sometimes your fears are not related to social interactions but are triggered by needing to perform. And perform in this scenario can mean performing on a stage, like playing an instrument or making a speech, but it can also be on a smaller scale, like speaking up in a group, taking a test, or sexual activity.
When Should You Get Medication for Social Anxiety?
How do you know if you should see a doctor for medication? It depends on how much your anxiety is interfering with your functioning.
Are you skipping out on important events? Are you failing to meet certain responsibilities, like calling out sick from work or school every time you have to do something that involves a presentation? Are you unable to be physically intimate because you have stomach upset every time someone wants to touch you?
If you’ve engaged in some of these avoidance behaviors, you may be at the point where something needs to change quickly.
Like let’s say you’ve been asked to give a talk about a project that you’re working on, and you’ve managed to get out of it a couple of times but you know that it’s just a matter of time before you’re gonna be asked again. You can’t create excuses forever. You can only get sick so many times, and there’s only so many funerals that you can go to.
So in a case like this, you need to make a quick turnaround before you’re faced with the situation again or your job may be at risk.
Therapy is always good, and in many situations may be the better approach to handling social anxiety, but therapy is not quick. It takes time to unpack your fears and examine your cognitive distortions around feeling judged by people or fearing embarrassment or shame.
When you engage in avoidance behaviors the anxiety intensifies and gets locked in. Medication may be what you need to reduce your anxiety enough so that you can at least perform your duties. However, medication won’t change how you think, but it will lessen the anxiety that you have around those fears so that you can rationally process through the fears.
Another reason someone may start medication before therapy is some people are just too anxious to work through the therapy or do exercises, and they need medication to reduce their anxiety enough to facilitate better work in therapy.
What Are Your Options for Medication for Social Anxiety?
There are two medication approaches: using serotonin-enhancing antidepressants or a beta blocker to address your body’s response to the anxiety.
Antidepressants for Social Anxiety
First, let’s talk about the antidepressants. We use antidepressants to treat anxiety. Even if you are not or have never been depressed, they’re called antidepressants because that’s how they were first classified until studies showed that they also treat anxiety. Usually anxiety needs a higher dose of the medication than for depression.
The antidepressants that work for anxiety are the ones that enhance serotonin, which are most of them. Some examples are fluoxetine, brand name Prozac; citalopram, brand name Lexapro; and venlafaxine, brand name Effexor.
Wellbutrin is the only antidepressant we have that does not affect serotonin, and as such it’s not that great for anxiety. It may help a little, but because it’s a stimulating antidepressant it may actually make you feel more anxious at the higher doses, so that’s something for you to watch out for if you’re on it.
To see improvement from an antidepressant you need to take the medication every day and give it at least a couple of weeks to work. Now, you may be thinking, “I thought you said meds work fast.” Well, they don’t work immediately, but they do work faster than therapy and can be used to support your therapy.
Beta Blockers for Social Anxiety
The second faster option is propranolol. Propranolol is called a beta blocker because it blocks the beta adrenergic receptors in your body. Adrenergic refers to adrenaline, also known as epinephrine. So these medications reduce your epinephrine levels, which slows your heart rate and lowers your blood pressure. These medications also reduce shaky hands, sweating, and flushing.
You do get an immediate effect from this medication, similar to taking pain medication. You take it and maybe 30 minutes to an hour later your heart slows, your hands stop trembling, and so on.
How does this help your anxiety though? Beta blockers help the person who experiences a lot of physical symptoms with their anxiety.
Imagine you’re riding in a car and an animal runs into the street and the driver suddenly breaks and swerves to miss the animal. It’s completely normal to feel your heart pounding out of your chest or for you to hyperventilate and maybe even feel like you’re going to throw up, but then as you process what happened you calm down and your body goes back to normal.
If you don’t have an anxiety problem you can handle your anxious reaction because you know it’s because of what just happened. The reaction was appropriate, and you accept that. But the person with anxiety can have these same body sensations spontaneously, without a recognizable trigger.
Emma talked about panic attacks like this in her video called What’s the Difference Between Panic Attacks, Anxiety Attacks, and Panic Disorder.
Social anxiety can also generate anxiety like this that you feel physically, and here’s how it can play out: when you anticipate needing to perform or interact with people you can get your initial nervous response of maybe sweaty palms or a lump in your throat.
Then in some people, feeling these body sensations ramps up your anxiety even more. You don’t see it as a normal reaction to being afraid of the situation; instead, it becomes evidence that something is seriously wrong with you.
You may even worry that any and everyone will see just how anxious you are, and then that becomes another source of anticipated criticism. “What will they think of me if they see my hands shaking and see me blushing? Everyone will know that I don’t know what I’m talking about.”
Now your distress has devolved into a mixture of negative thoughts about your ability to perform or interact, fears about your body betraying you, and worries about what these physical signs mean.
If this is you, a beta blocker can help by blocking or dampening the physical response so that it doesn’t send you into an anxiety spiral. Because it has this immediate effect on your body’s response, it’s a medication that you don’t have to take every day to see an effect.
Some people take it daily because they have daily anxiety, like daily panic, but some people will take it only when they need to do something that aggravates their social anxiety. So let’s say your anxiety is manageable except when you need to lead a team meeting, give a talk to a small group, or attend a networking event that you loathe. Propranolol is something that you could take just before those events.
Now, there’s some trial and error with finding the right dose of medication, but the usual range is 10 to 40 milligrams an hour before you need it.
Those are the two medication options. You may have noticed that I didn’t discuss benzodiazepines, or benzos for short. Benzos have their place in anxiety treatment, but given their habit-forming nature they are not the best choice for daily anxiety and not part of the protocol for treating social anxiety.
What About Therapy for Social Anxiety?
I mentioned that therapy is the better treatment for social anxiety, whether you take medications or not. The medication can help bring down your distress level, but with social anxiety you still have to address your cognitive distortions that feed your fears and eliminate your safety and avoidance behaviors.
There are several ways to address this. You can make faster progress with a therapist trained in cognitive behavioral therapy.
Graded Exposure Exercises for Social Anxiety
One self-help approach is to face your fears with graded exposure exercises. Avoidance makes your fear and anxiety grow bigger, and exposure desensitizes you to the thing that you fear, therefore reducing your anxiety.
One way to do this is to create your own fear ladder where you identify situations that you avoid because of your fears. To do this you take an inventory of your fearful situations. You may have several. For each situation, break down the situation into several steps that go from somewhat scary to very scary.
Here’s an example: let’s say you fear going to small social gatherings where you have to do a lot of small talk, but it’s something that you have to do for your job, so you can’t avoid it.
Here’s how your ladder might look with eight steps:
- Step 1: look at pictures of people chatting at a party.
- Step 2: say hello to the cashier at the store that you frequent.
- Step 3: say hello to a stranger at the grocery store.
- Step 4: ask a stranger cashier something about themselves. Now you’re getting more personal. It’s the beginning of the small talk.
- Step 5: give a stranger a compliment while looking them in the eye.
- Step 6: ask a co-worker or classmate about their weekend. Here the stakes are getting higher because you’re talking to someone who you’ll see again.
- Step 7: let yourself be in a group of people talking, then make eye contact with each person while they’re talking.
- Step 8: join a conversation of people talking, and have something to say.
You want to practice each step until you become comfortable with each one. You will feel anxious while you’re doing this, but if you keep at it, the anxiety will level off. Then you move up the ladder until you get to the last step and feel less anxious.
You want to practice these steps often, but you don’t want to rush through them. Just keep doing each step until you feel comfortable moving to the next one.
Other Exercises for Social Anxiety
There are some other things that you can do to address your thinking, like affective labeling, affirmation journaling, and reframing negative thoughts.
I teach you how to do these things in chapter 8 of my new book called Why Am I So Anxious? Powerful Tools for Recognizing Your Anxiety and Restoring Your Peace. This book is jam-packed with information to help you understand where your anxiety comes from and what to do about it.
It publishes on August 16th, but if you order before then you can get this illustrated guide that has some extras in it like How to Get Started Journaling, some affirmation cards, and 11 sample fear ladders, two of which are related to social anxiety. This guide is only available as a free download if you pre-order, and you can do that by clicking this link.
In the meantime, watch Emma’s video on the exposure hierarchy and how to do exposure exercises. I hope I’ll see you around on my channel too. Thanks for reading.
Back to Emma
Okay. Thank you so much, Tracey, for sharing your wisdom and experience with us. And again, I would encourage all of you guys, please check out Tracey’s channel. It’s right here on YouTube. The link’s in the description. And also check out her new book.
Thank you for reading, and take care.