Causes and treatment of social phobia. A strategy for competent treatment of social phobia

Panic attacks, VSD, phobias, and OCD belong to the group of anxiety disorders (neuroses), and the official treatment regimen for such disorders is psychotherapy plus pharmacological support. If the problem is not severe, then you can do without pharmacology and solve it only through psychotherapy - working with a psychologist. In severe cases, pharmacology cannot be avoided.

The main drug of pharmacological support for panic attacks and VSD is an antidepressant. Many people think that an antidepressant is only needed for depression, but in fact this is not the case. Antidepressants have both antidepressant and anti-anxiety effects. Depending on the class of antidepressant, the anti-anxiety effect may be weaker or stronger. At the moment, the strongest anti-anxiety effect is found in antidepressants of the SSRI group, which is why they are most often prescribed for anxiety disorders and anxiety-depressive disorders.

Antidepressants SSRIs and SSRIs for panic attacks, VSD, OCD and social phobia

SSRIs are selective serotonin reuptake inhibitors. To put it simply, antidepressants increase the amount of serotonin in the brain, which gives anti-anxiety and antidepressant effects.

The most modern and popular second generation SSRIs are ESCTALOPRAM, SERTRALINE and PAROXETINE. It is these antidepressants that are most often prescribed for panic attacks, VSD, OCD and social phobia. These are the names of the active ingredients; they may differ from the trade names of the drugs themselves. Manufacturers come up with their own trade name to promote a product, so you need to rely not on the trade name, but on the active substance.

Taking antidepressants is often associated with unpleasant side effects in the first days of use. In order to smooth out side effects, a very gradual increase in dosage is recommended.. It is better to start with 1/4 of the tablet, monitor your condition and if everything is fine, then increase the dosage by another 1/4. An approximate dosage regimen may look like this: two days 1/4 tablet, five days 1/2 tablet and if everything is fine then switch to a whole tablet. As soon as the active substance accumulates in the body, the unpleasant side effects will disappear and your condition will improve. As a rule, this takes no more than two weeks.

Also, to combat side effects, a “cover” drug is prescribed in the first 2-3 weeks of taking antidepressants. This is usually a tranquilizer or antipsychotic. The purpose of this drug is to stabilize the condition and compensate for side effects until the antidepressant begins to act.

You can take antidepressants for quite a long time without serious health consequences. Usually the course is prescribed for six months. A long course is necessary to form the habit of living without anxiety. However, if the psychological causes of increased anxiety are not resolved, then after the course is discontinued, after some time the anxiety disorder will resume. According to some statistics, after stopping an antidepressant for panic attacks, in about half of the cases, panic attacks return within three months. To prevent this from happening, it is very important during the course to solve the psychological causes of the problem through.

After stopping a course of antidepressant, the so-called “withdrawal syndrome” appears, which is accompanied by unpleasant sensations. To reduce withdrawal symptoms, you need to very gradually reduce the dose of the antidepressant. It is recommended to gradually reduce the dosage by a quarter of a tablet and monitor your condition.

Probably the main disadvantage of SSRI antidepressants is a decrease in libido. About half of patients experience this side effect. This is expressed in a decrease in sexual desire and difficulty in achieving orgasm in both men and women. An erection in men most often remains. Sometimes this side effect goes away after some time, sometimes it doesn’t go away, and sometimes it doesn’t appear at all, everything is individual. Therefore, if the sexual sphere is very important to you, then it is better to choose an antidepressant from another group.

Also, for the treatment of panic attacks, VSD and other anxiety disorders, antidepressants of the SSRI group are used - selective serotonin and norepinephrine reuptake inhibitors. At low doses, these antidepressants behave like regular SSRIs, but at medium doses they increase the amount of norepinephrine, which gives a stronger antidepressant effect. Thus, this group is preferable for anxiety-depressive disorder. In addition, antidepressants in this group reduce libido less. The most popular representative of this group VENLAFAXINE.

Choosing an antidepressant for panic attacks, VSD and other anxiety disorders

Antidepressants are sold by prescription, and the prescription is written by a doctor. Accordingly, the antidepressant is selected by the doctor. But the choice of a doctor is often determined by the promotion of “their” brand or habit or some personal preference. Therefore, the choice of a doctor is not always good; old antidepressants with a large number of side effects are often prescribed. Therefore, it is better to prepare in advance, choose the option that suits you and discuss this option with your doctor at the appointment.

Escitalopram

Trade names: cipralex, selectra, elycea, esipy, esopram, esoprex, essobel, lenuxin, lexapro, miracitol, cytoles, escitam, depresan.

Today it is the most prescribed antidepressant in the West. With good effectiveness, it has the least side effects among the entire group of SSRIs and the most comfortable withdrawal syndrome.

The dosage is selected individually and varies from 5 mg to 20 mg per day. For panic attacks, they usually gradually switch to 10 mg of an antidepressant, and if after a couple of weeks on this dose the condition is not stable enough, then increase it to 15 mg. If after a couple of weeks and at this dose the condition is not stable enough, then increase to 20 mg.

Considering all of the above, escitalopram is perhaps the best antidepressant from the SSRI group for the treatment of panic attacks, VSD, social phobia and other anxiety disorders.

Sertraline

Trade names: Zoloft, Stimuloton, Asentra, Serenata, Sirlift, Torin, Deprefolt, Zalox, Sertraloft, Depraline, Aleval, Lustral.

The dosage is selected individually and varies from 25 mg to 200 mg per day. The dosage is increased gradually until the condition stabilizes.

Sertraline is slightly stronger than escitalopram, but the side effects are also slightly higher. These two antidepressants can be taken during pregnancy, provided that the benefits outweigh the possible risks to the fetus. It is difficult to assess possible risks to the fetus; large studies have not been conducted on this topic. Presumably the risk of complications for the fetus is not high and does not exceed 5%.

Paroxetine

Trade names: Paxil, Rexetine, Plisil, Adepress, Actaparoxetine, Paroxin, Luxotil, Xet, Sirestill, Seroxat.

The most powerful antidepressant from the SSRI group. Accordingly, it has the strongest side effects and the most severe withdrawal syndrome. It is recommended to opt for it if the strength of escitalopram or sertraline is not enough to stabilize the condition.

The dosage is selected individually and varies from 10 mg to 50 mg per day. The dosage is increased gradually until the condition stabilizes. You can increase the dosage by 10 mg every week.

Venlafaxine (SSRI)

Trade names: velaxin, velafax, efevelon, effexor, venlaxor, trevilor, newelong, deprexor.

The drug, unlike SSRIs, suppresses libido less, so if the sexual sphere is important to you, then this is worth paying attention to. The anti-anxiety effect is comparable to paroxetine, and the antidepressant effect exceeds it. The side effects and withdrawal symptoms are quite strong and comparable to paroxetine.

The dosage is selected individually and varies from 75 mg to 375 mg per day. Somewhere starting from 150 mg, the effect of increasing norepinephrine appears. Given the strong side effects, for venlafaxine and paroxetine it is important to very gradually increase the dosage and use a cover drug.

Summary table of the most common side effects

As mentioned above, in most cases, side effects disappear after the first two weeks of taking the drug. If the side effects are noticeable and last more than a month, then it is better to change the antidepressant. To relieve side effects in the first month of use, and to reduce anxiety for the first time, until the antidepressant begins to act, a tranquilizer or antipsychotic is prescribed.

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Drug treatment of social phobia

Medications can be very helpful for people suffering from social phobia as they reduce symptoms. However, it is important to understand that medications cannot “cure” social phobia. Some people refuse to take any medications, others prefer to combine medications with cognitive behavioral psychotherapy and other means, and some use medications alone. The data provided here is for informational purposes only. You should not try to take the medications described here on your own. They can only be used as directed and under the supervision of a physician.

Benefits of the drugs
- The drugs reduce unpleasant symptoms of anxiety: palpitations, sweating, trembling, and so on.
- Medication can reduce the negative thoughts that almost all people with social anxiety experience.
- People with social phobia also often experience depression, and antidepressants can help improve their mood as well as reduce anxiety.

Selective serotonin reuptake inhibitors (SSRIs)

These drugs are classified as antidepressants and are currently the most popular drugs for treating anxiety and depression. This group has far fewer side effects than other groups of antidepressants. The main disadvantage of these drugs is their high price. This group includes fluoxetine (Prozac), paroxetine (Paxil), fluvoxamine (Luvox) and sertraline (Zoloft). They must be taken daily, following the treatment regimen. It may take up to several weeks for improvement to occur. Restrictions SSRIs may not be compatible with other medications, and you should talk to your doctor about this beforehand. Side effects The most common side effects from taking them are nervousness, anxiety, insomnia, headaches, nausea, and diarrhea. One of the most serious side effects is decreased sex drive. As the body adapts to the drug, side effects go away on their own in most people. If this does not happen, the doctor will reduce the dose, change the drug, or prescribe medications to relieve side effects. Monoamine oxidase inhibitors (MAO inhibitors)

These drugs are also antidepressants that interfere with the breakdown of serotonin and norepinephrine. Increased levels of these substances in the brain help reduce anxiety. Restrictions
People taking a drug from this group must follow a strict diet. They should not eat foods containing tyramine (cheeses, alcoholic beverages, soy, some sausages). These foods interact with medications to increase blood pressure and may cause symptoms such as headache and vomiting. Also, many medications are incompatible with MAO inhibitors. A severe increase in blood pressure in response to the combined use of the drug and certain foods in the absence of medical attention can lead to stroke, and even death.

Side effects
The most common side effects of MAO inhibitors are insomnia, fatigue, sexual dysfunction and weight gain.

Benzodiazepines

Benzodiazepines include drugs such as Valium, Xanax, and others. Benzodiazepines are very quick to calm and relieve anxiety, but their effect does not last long.

Side effects
Single doses can cause fatigue and dizziness, and reduce thinking abilities. Long-term use may cause sexual dysfunction.

Restrictions
Benzodiazepines, although effective against anxiety, have significant disadvantages. First, people who take benzodiazepines every day for more than a few weeks can become dependent on them. Moreover, these drugs should not be stopped immediately, as this can lead to withdrawal symptoms and worsening anxiety. Remember: benzodiazepines should never be taken without consulting your doctor. These drugs can be abused, so benzodiazepines are not recommended for people with drug addiction problems. In addition, alcohol should not be taken with benzodiazepines, as it increases their effect, which can lead to an overdose. Finally, people taking benzodiazepines should exercise caution when driving and operating complex devices, as their ability to do so may be impaired by the drugs.

Beta blockers

Beta blockers such as Inderal can also be used to treat anxiety. Beta blockers reduce heart palpitations, shaking, and other physical symptoms of anxiety by relaxing the muscles of the heart and skeleton. They also help with sweating and redness. Typically, such drugs are taken before an event that a person is afraid of. Their effect lasts for a couple of hours.

Restrictions
Beta blockers are the best treatment for stage fright: fear of public speaking, exams, musical performances, and so on. Beta blockers may be less effective against the negative thoughts that characterize social anxiety disorder and lead to physical symptoms. One of the limitations of beta blockers is unexpected and unplanned social situations that cause severe anxiety.

Side effects
Beta blockers generally cannot be used by people with asthma, diabetes, and certain heart conditions.

Burns, D. D (1999). The Feeling Good Handbook. New York, New York. Plume.

I.I.Sergeev
Department of Psychiatry and Medical Psychology
Russian State Medical University,
Moscow

Before discussing the role of antidepressants in the treatment of phobias, it is advisable to dwell on the boundaries of phobic disorders and their clinical variants (Table).

From our point of view, along with such recognized variants of phobias as agoraphobia, social phobias, nosophobia, specific (isolated) phobias, panic disorder, classified in both ICD-10 and B5M-4 as anxiety disorders, should also be included in the phobic circle disorders disorders.

Firstly, both the psychopathological and meaningful features of the experiences of patients during a panic attack are more typical for phobias than for anxiety: paroxysmal thanatophobia, cardiophobia, lyssophobia arise, and not anxiety, tension, devoid of a certain content. True, fear in the structure of panic attacks is not obsessive in nature. It is, rather, fear taking over. But other phobias, traditionally classified as obsessions, in large part, if not for the most part, according to our team (L.G. Borodina, 1996; A. Shmilovich, 1999), are not obsessive fears, but overvalued ones.

Secondly, panic attacks become the source of agoraphobia, social phobia and other phobias much more often than the basis of generalized and other protracted anxiety disorders. In this case, panic attacks lose their independence and act as one of the components of the phobic syndrome.

The means and methods for treating phobias are varied. In table they are, if possible, arranged in descending order of their current importance.

Psychopharmacotherapy actually takes the leading place in the treatment of phobias. Among the classes of psychotropic drugs, antidepressants are in the first position (if we take into account the results of most studies and established therapeutic practice). Next come tranquilizers and antipsychotics.

Psychotherapy could claim a leading position if there were a sufficient number of qualified psychotherapists, as evidenced by comparative studies (for example, A.B. Smulevich et al., 1998).

The use of antidepressants and psychotherapy are first-order methods of treating phobias, which in some cases can be used independently, as monotherapy.

General vegetative stabilizing measures are practically significant, especially in the earlier stages of phobic disorders.

At the end of the table. Treatment methods with limited or controversial effectiveness are listed (laser therapy, acupuncture, the use of thymostabilizers), used as additional ones in complex therapy, as well as treatment methods with relatively high effectiveness, but rarely used at present (sub-shock methods).

Without delving too deeply into the history of the issue, it should be noted that with the advent of tranquilizers, their intensive use in the treatment of phobias began, including the parenteral administration of high doses of relanium. However, a certain disappointment set in relatively quickly (table).

The effectiveness of tranquilizers was not as high as expected. In addition, the use of tranquilizers has time limits due to the risk of addiction (the duration of a course of treatment with tranquilizers should not exceed 4 or even 2 weeks, according to foreign data). The withdrawal of tranquilizers in most cases is accompanied by an exacerbation or resumption of phobias. As a result, tranquilizers, while maintaining a prominent place in the treatment of phobias, lost their dominant position. Currently, alprazolam, clonazepam, Relanium, and phenazepam are mainly used in the treatment of phobias, especially panic disorder. The latter is very promising due to the lower risk of addiction, according to a number of narcologists, and the emergence of an injectable form.

The beginning of the use of antidepressants for anxiety-phobic disorders dates back to 1962, when D.E. Klein reported positive results in the treatment of panic attacks with imipramine.

In fact, all or almost all antidepressants, both known for a long time and those that appeared relatively recently, have been used or are currently used for phobias.

Tricyclic antidepressants (TCAs) and irreversible monoamine oxidase inhibitors (MAOIs) were the first to be introduced into the treatment of phobias. The latter, like four-cyclic antidepressants, are in Table. are not presented, since at present they are almost not used to correct phobias. The main TCAs (amitriptyline, imipramine and especially clomipramine) are still widely used.

With the advent of new groups of antidepressants - selective serotonin reuptake inhibitors (SSRIs), reversible monoamine oxidase inhibitors (MAOIs) - the intensive introduction of these drugs into the treatment of phobic disorders began. A kind of competition has emerged between TCAs and newer antidepressants. Each group of antidepressants has its own advantages and disadvantages in terms of treating phobias (table).

Tab. 4. Advantages and disadvantages of various groups of antidepressants in the treatment of phobias
Preparation		Advantages	Flaws
TCA	Amitriptyline Imipramine (melipramine)	1. Availability 2. Availability of injection forms 3. Possibility of use in children	2. Less efficient 3. Lack of certainty about the mechanisms of action 4. Significant frequency and severity of side effects, including those that can increase anxiety-phobic disorders
	Clomipramine (anafranil)	1. Availability 2. Relatively high efficiency 3. Pathogenetic validity of use 4. Availability of injection form 5. Possibility of use in children	1. The need for high doses 2. Frequency and severity of side effects, including those that can increase anxiety-phobic disorders
CVD	Tianeptine (Coaxil)	3. Well tolerated	1. Lack of injection form 2. Impossibility of use in children
SSRIs	Paroxetine (Paxil) Sertraline (Zoloft) Fluoxetine (Prozac) Citalopram (cipramil) Fluvoxamine (fevarin)	1. Relatively high efficiency 2. Pathogenetic validity of use 3. Possibility of using medium doses 4. Less frequency and severity of side effects	1. Less availability 2. Lack of injectable forms (except citalopram) 3. Impossibility of use in children (except for sertraline)
OIMAO-A	Moclobemide (Aurorix)	1. Relatively high efficiency 2. Less frequency and severity of side effects	1. Less availability 2. Lack of certainty about the mechanisms of action 3. Impossibility of use in children

The most significant advantages of amitriptyline and imipramine include availability, reasonable cost of outpatient therapy, availability of injectable forms, and the possibility of use in children. Disadvantages: the need to use high doses, lower effectiveness compared to SSRIs (although the comparison results are not entirely clear), insufficient clarity of ideas about the mechanisms of their action in phobias, frequency and severity of side effects, including anticholinergic ones (tachycardia, extrasystole, arterial hypertension, tremor), which correspond to somatovegetative manifestations of panic attacks and other phobias and, in some cases, contribute to the strengthening of phobic disorders. According to our data, anticholinergic effects occur in every fifth patient with phobias receiving amitriptyline or imipramine (L.G. Borodina, 1996).

Clomipramine compares favorably with amitriptyline and imipramine in its higher effectiveness, associated with its pronounced serotonergic activity.

The disadvantages associated with classic TCAs do not apply to tianeptine, a representative of the CVD group, which is used in a standard daily dose, is well tolerated and appears to be a very promising long-term treatment for phobic disorders. We have a number of observations in which tianeptine was used for a long time and successfully for agoraphobia.

The significant advantages of SSRIs in comparison with classical TCAs are higher efficiency, the presence of pathogenetic grounds for their prescription, lower frequency and severity of side effects and, accordingly, greater possibilities for long-term use. However, SSRIs are inferior to TCAs in some respects. First of all, this is a non-medical disadvantage - the current lower economic accessibility and the associated problems of long-term outpatient therapy, the lack of injection forms for most drugs and the impossibility of use in children and adolescents under 15 years of age (with the exception of sertraline).

The advantages and disadvantages of MAOIs (moclobemide) are generally consistent with those noted for SSRIs.

Tab. 5. Daily doses of antidepressants used in the treatment of phobias and depression
Preparation		Treatment of phobias	Treatment of depression
		most commonly used or optimal daily doses of antidepressants, mg	daily doses of antidepressants, mg
			average	maximum
TCA	Amitriptyline	100-250	150	300
	Imipramine	150-250	200	400
	Clomipramine	100-250	75	300
SSHR	Tianeptine	37,5	37,5	50
SSRIs	Paroxetine	40-60	20	60
	Sertraline	100-200	50	200
	Fluoxetine	20-40	20	80
	Citalopram	20-40	20	60
	Fluvoxamine	100-200	100	400
OIMAO-A	Moclobemide	600	300	600

In table presents the most used or optimal, in the opinion of those who compared the effectiveness of different dosages, daily doses of antidepressants used in the monotherapy of phobias, in comparison with the average and maximum doses used for depression (from the literature and partially our own data).

Daily doses of TCAs used for phobias are quite high and approach the doses used in the treatment of severe depressive episodes.

At the same time, analysis of the relevant data on SSRIs only partially confirms the well-known position about the advisability of using low doses of SSRIs for phobias, which are significantly lower than the doses used for severe depression. This is true for fluoxetine, citalopram, fluvoxamine and, to some extent, paroxetine. The daily doses of sertraline and OIMAO (moclobemide), especially often and most successfully used in phobic disorders, are close to or correspond to the maximum.

To date, the insufficiency of central serotonergic structures in phobias can be considered established, which is usually considered as their main pathogenetic mechanism. This explains the significant effectiveness found in many studies for phobias of clomipramine and SSRIs, which increase the concentration of serotonin in the intersynaptic spaces.

It is more difficult to explain the effectiveness of amitriptyline and imipramine in relation to phobic symptoms. There is a point of view that while many TCAs can be successfully used for panic disorders, for obsessions only clomipramine and SSRIs can be used. However, various TCAs began to be used for phobias long before the advent of SSRIs. The results of their use, according to most publications and our own data, are generally positive, which becomes, at least partly, understandable taking into account the data of M.Kh. Leider (1994) about the inhibitory ability of some antidepressants at the experimental level (table).

Tab. 6. Relative inhibitory ability of some antidepressants (according to M.H. Leider, 1994)
Preparation	Rat brain, in vivo conditions			Human platelets
	Norepinephrine	Serotonin	Dopamine	Serotonin
Amitriptyline	-	++	-	+
Clomipramine	++	++	-	+++
Fluoxetine	-	++	-	++
Imipramine	+++	+	-	++
Paroxetine	-	++	+	++
Note. "+++" - very high inhibitory activity; "++" - high inhibitory activity; "+" - weak inhibitory activity; "-" - insignificant effect or its complete absence.

From these data it follows that amitriptyline and imipramine have a fairly high inhibitory ability for serotonin reuptake, not inferior or slightly inferior in this regard to fluvoxamine and paroxetine.

In addition, the effectiveness of TCAs may be partly due to their positive effect on depressive symptoms associated with phobias. One should also take into account the concept of the essential unity of phobias and depression, which is actively developed in Russian psychiatry by O.P. Vertrogradova (1998), who considers phobias as “a special equivalent of depression.”

In our opinion, today it is premature to reduce the pathogenetic mechanisms of phobias to the insufficiency of the functions of serotonergic structures. Most likely, the pathogenesis of phobias is more complex, and not all of its links have been established.

In table Literature data and partially data from our team are presented in a generalized form on the results of short-term and long-term monotherapy for phobias with various groups of antidepressants. The lowest and highest performance indicators are excluded.

The effectiveness of monotherapy for phobias in all groups of antidepressants is relatively high. Compared with amitriptyline and imipramine, the effectiveness rates of clomipramine and SSRIs are slightly higher. The lower efficacy rates of moclobemide are noteworthy. However, when assessing them, it must be taken into account that moclobemide was tested mainly for social phobias, which are particularly resistant to treatment.

As a result, taking into account the better tolerability of SSRIs and the possibility of using relatively low doses, they show noticeable advantages compared to TCAs. It should be noted that when assessing the immediate effectiveness of antidepressants, most often, as follows from table. , the proportion of patients with improvement is determined. Significant improvement is rarely specifically identified. According to our own observations, long-term results of treatment of non-psychotic disorders, including phobias, are mostly successful in cases where the immediate results of therapy reach the level of significant improvement. Otherwise, there is a high risk of exacerbations and relapses. According to various sources, for phobias it is 30-70%.

The antiphobic activity of specific antidepressants from the SSRI group is usually considered the same, which raises some doubts. To clarify this issue, comparative clinical trials of drugs are needed.

The effectiveness of various methods of treating phobias has been repeatedly compared: monotherapy with antidepressants, tranquilizers, psychotherapy alone and their combinations, with mixed results. However, complex therapy for phobias has the largest number of supporters.

Monotherapy for phobias with antidepressants is becoming increasingly popular, but in practice in our country it is carried out not so often and mainly on an outpatient basis. Long-term monotherapy with tranquilizers should not be carried out at all due to the high risk of addiction. Psychotherapy is used relatively often as the only way to correct phobias.

Indications for the use of antidepressants as part of monotherapy and complex therapy of phobias (according to our own data) are presented in Table. .

Tab. 8. Indications for the use of antidepressants as part of monotherapy and complex therapy of phobias
Treatment Options	Indications for use
monotherapy
Antidepressants	Specific phobias (for current and frequent phobic situations) Monosymptomatic forms of agoraphobia, social phobia, nosophobia Generalized phobias during periods of remission (maintenance therapy)
complex therapy
I. Antidepressants + psychotherapy	Moderate degree of generalization of phobias, rare and abortive panic attacks, incomplete avoidance of phobic situations, lack of a pronounced tendency to progress
II. Tranquilizers at the beginning of treatment (with replacement with antipsychotics after a month) + long-term antidepressants + long-term psychotherapy + beta blockers	A high degree of generalization of phobias (up to panphobia), frequent and severe panic attacks, complete avoidance of frightening situations, a tendency to progress, social maladjustment

Indications for monotherapy with antidepressants are very limited. These are isolated phobias, monosymptomatic variants of agoraphobia, nosophobia, social phobia and those cases of agoraphobia, social phobia when the degree of generalization of pathological fears and the degree of avoidant behavior are low and phobias do not show a tendency to progress. In addition, monotherapy with antidepressants can be used as long-term maintenance treatment after a successful course of active complex therapy. For social phobias and isolated phobias that arise in one, relatively rare and predictable situation, one-time doses of beta blockers or alprazolam before the occurrence of such a situation are sufficient.

When there is a combination of different phobias, the presence of several confusing situations with incomplete avoidance, a combination of antidepressants and psychotherapeutic measures is indicated.

For generalized phobias with complete avoidance, maladaptive personality, frequent and severe panic attacks, chronic or recurrent course of phobic disorders, the presence of a tendency towards their progression, the endogenous nature of phobic symptoms, the most active complex therapy is indicated, which is advisable to begin with the prescription of tranquilizers, including parenterally . Further treatment includes antidepressants, psychotherapy, and vegetative-stabilizing measures. After a month, tranquilizers are replaced with neuroleptics-behavior correctors or small or moderate doses of neuroleptics-antipsychotics.

Panic attacks often have a specific biological basis, being essentially vegetative crises with a phobic component (caused by cerebral-organic, endocrine, infectious-allergic or other visceral pathology). In such cases, correction of the somatic basis of vegetative paroxysms is of particular importance.

Phobic disorders in most cases require long-term (at least 6-12 months) treatment with very slow drug withdrawal.

As a result, antidepressants today occupy a leading position in the treatment of phobias, either in the form of monotherapy or as the main component of complex treatment.

Social phobia is a mental illness associated with the fear of performing any actions in the presence of strangers, speaking publicly in front of an audience, or being in society. This disorder makes life difficult for people, so it needs to be treated. There are two treatment options: with various therapies and with medications.

Medicines are used in case of refusal of psychological treatment for social phobia

Drug treatment of social phobia is used if the patient refuses psychotherapy, and in other cases it is an additional treatment aimed at eliminating anxiety and stress. Medicines cannot rid a person of social phobia; they can only suppress some emotions. The development of medicine does not stand still, and today there are quite a few medicinal methods for treating this disease.

Treatment of social phobia with medications

Pills for social anxiety can have both positive and negative effects. Their advantage is that they can reduce the impact of symptoms on the patient. But you should understand that their effect is not long-lasting, and it is necessary to take pills frequently, sometimes several times a day, depending on the type of medication. This can lead to dependence on the drugs, and in the future the standard dose will not have the desired effect. The course of drug treatment usually lasts no more than one month.

When treating social phobia, doctors prefer to combine psychotherapy methods with medications and homeopathic remedies. Cognitive-behavioral, group, or relaxation therapies help the patient face fear, get used to those situations that frighten him and cause anxiety, and also help the patient develop a new way of thinking about his fears. The advantages of the drugs are as follows:

1. Almost all medications are aimed at reducing the unpleasant symptoms of social phobia: rapid heartbeat, excessive sweating, trembling limbs, difficulty speaking, etc.
2. The drugs help get rid of negative and obsessive thoughts, thereby stabilizing a person’s mental state.
3. Antidepressants are the best way to improve mood and reduce anxiety.

Very often, psychologists and psychiatrists prescribe several medications to their patients with symptoms of social phobia, and sometimes during the course they prescribe different pills for each stage of therapy. In short-term treatment, psychoactive substances with hypnotic, sedative, relaxant and anticonvulsant effects are used. At the second stage of treatment, patients are transferred to other drugs. This is necessary to prevent physical dependence.

Duration of treatment

It is necessary to understand that social phobia is a chronic disease, so treatment will be very long: from two months to a year. In approximately 50% of cases, relapses occur after 6 months of treatment. Doctors say that this happens due to abrupt cessation of medication. Medicines should be discontinued gradually, reducing the dose with each dose.

It is worth starting drug therapy with the safest drug. After 4–8 weeks, the doctor assesses the patient’s condition and determines the effectiveness of treatment.

If the symptoms remain unchanged and the patient’s condition does not improve, then it is necessary to increase the dose of the medicine or prescribe another one.

The body's response to drug treatment

Throughout the course of taking medication, the human body’s reaction may be different: excitement and anxiety may disappear, but side symptoms may appear (fatigue, drowsiness, aggressiveness, dejection, etc.). The effectiveness of treatment is manifested in the following changes:

• the patient’s anxiety, which he experiences when necessary for social communication or social activities, appears less and less often;
• a person is often in a relaxed state, due to which he does not perceive the people around him so keenly and can make contact;
• obsessive and frightening thoughts disappear;
• Thanks to the pills, the social phobia gets out of the depressive state faster.

In most cases, the effect of drug treatment begins to appear after 2-3 weeks. Each body reacts to therapy differently, so you should not jump to conclusions that the drugs do not help. Under no circumstances should you stop taking the pills, even if there are no changes at the initial stage. Only a specialist can diagnose and determine further treatment.

Thanks to the pills, the severity of the negative reaction to others is reduced

What medications are there for social phobia?

Today, pharmaceuticals are at a fairly high level. There are many different medications available to treat social phobia. All tablets are divided into several types:

• psychoactive substances acting on GABA receptors - benzodiazepines;
• biologically active substances that block the destruction of monoamines by monoamine oxidase - monoamine oxidase inhibitors (MAOIs);
• pharmacological drugs aimed at blocking beta-adrenergic receptors - beta blockers;
• third generation antidepressants intended for the treatment of anxiety disorders and depression - selective serotonin reuptake inhibitors (SSRIs);
• “dual-acting” antidepressants intended for the treatment of severe depression - selective serotonin and norepinephrine reuptake inhibitors (SSRIs).

Each type of tablet is used in certain cases and has both advantages and disadvantages. Side effects can be quite severe and require additional treatment. It all depends on the individual characteristics of the human body.

You cannot select medications on your own; this should be done by the attending physician after a full examination. The choice of any medicine must be approached individually.

This class of psychoactive substances has hypnotic, sedative, anxiolytic, muscle relaxant and anticonvulsant effects. In the treatment of social phobia, they are used to combat mental anxiety, insomnia or agitation. Also, these tablets help get rid of physical dependence syndrome, which occurs in patients with long-term use of certain medications, alcohol and drugs. Benzodiazepines are sometimes used to prevent panic attacks.

These substances affect the central nervous system, reducing the excitability of neurons. Depending on the half-life of drugs, benzodiazepines are divided into 3 groups:

1. Substances with a short duration of action. Drugs in this group act from 1 to 12 hours. It is not recommended to take them before bed, as insomnia may occur after discontinuation of the drugs. Also, with prolonged use, the patient may experience increased anxiety.
2. Medium acting benzodiazepines. The half-life ranges from 12 to 40 hours. They can be used as a sleeping pill; after stopping the medication, insomnia may return.
3. Long-acting drugs. Substances remain in the body for 40-250 hours. When you stop taking them, withdrawal syndrome rarely occurs. For older patients and people with damaged livers, there is a risk of chemicals building up in the body.

Medicines of this type are taken orally, but can be administered intravenously and intramuscularly. They quickly calm the nervous system and relieve anxiety. They are very effective and well tolerated.

Benzodiazepine-based drugs are used to treat phobias

Side effects

With a single use of tablets, fatigue, drowsiness, dizziness, decreased thinking abilities, as well as decreased attention and concentration are possible. With long-term use, sexual dysfunction, impaired coordination, and lethargy may appear. When administered intravenously, there is a risk of respiratory distress and decreased blood pressure.

Sometimes the use of benzodiazepines is accompanied by decreased performance, memory impairment, skin rashes, and weight gain.

In rare cases, patients experience nausea, appetite changes, vision deteriorates, nightmares appear, and consciousness becomes confused. There is also a possibility of worsening depression and the emergence of suicidal tendencies.

Benzodiazepines may impair vision

Monoamine oxidase inhibitors

These biologically active substances, depending on their pharmacological properties, are divided into types:

1. Reversible MAOIs. Drugs in this group are safe and well tolerated. Moclobemide is prescribed for depression, blocks the destruction of serotonin and norepinephrine, pyrazidol suppresses strong emotional arousal, befol is prescribed for depressive syndrome, anxiety and delusional disorders, hallucinations, incasan is used for mental disorders, sudden changes in mood and in the treatment of alcoholism.
2. Irreversible MAOIs. The drugs contain 3 main active ingredients: selegiline is involved in the metabolism of dopamine, increasing the neurotransmitter in different parts of the brain; Rasagiline is an antiparkinsonian drug; Pargyline is an antidepressant used for mental and nervous disorders.
3. Selective MAOIs. These substances are aimed at inhibiting one of the types of monoamine oxidase.
4. Non-selective MAOIs. These substances inhibit both types of MAO-A and MAO-B. Drugs in this group maintain mental balance, reduce anxiety and anxiety, help recover from depression, and are used in the treatment of mental illnesses.

Therapy with MAO inhibitors and the dosage of medications are determined individually. Patients are prescribed a special diet during the course of treatment and for 2 weeks after it. There are also restrictions on the concurrent use of certain medications.

Side effects

Reversible MAO inhibitors can cause insomnia, anxiety, headaches, and dry mouth. Irreversible MAOIs can cause constipation, decreased blood pressure, nausea, decreased appetite, confusion, psychosis, and arrhythmia. In rare cases, disturbances in vision and functions of the urinary system are observed.

Beta blockers

For social phobia, beta blockers are used to treat anxiety because these drugs affect the sympathetic nervous system. They are aimed at reducing symptoms: reducing heartbeat, trembling in the limbs, reducing sweating and redness.

Doctors advise taking medications from this group as a sedative before any alarming event. Their duration of action is several hours, so they are often taken not only by those suffering from social phobia, but also by completely healthy people before important and exciting events: an exam, public speaking, business meeting, etc.

Beta blockers have little effect against the negative thoughts that often lead to the physical symptoms of social anxiety disorder. They are not the mainstay of treatment for mental illness.

Side effects

Chronic fatigue may develop with frequent use of beta blockers. Patients with asthma may experience an exacerbation of the disease, while diabetics may experience a decrease in LDL cholesterol and a decrease in blood sugar. After discontinuation of the drug, blood pressure may increase.

Chronic fatigue is a side effect of beta blockers

Selective serotonin reuptake inhibitors

These drugs are currently the main ones in the treatment of social phobia. They are highly effective and have much fewer side effects. They belong to one of the groups of antidepressants and are prescribed for mild to moderate depression to reduce anxiety. For severe depression, these medications are not as effective as tricyclic antidepressants.

These medications must be taken daily, following the treatment regimen. The results may appear in a few weeks. You cannot start taking these medications on your own, as there are a number of restrictions on their use. SSRIs are incompatible with some medications, and their interaction may cause new symptoms (headache, vomiting, increased blood pressure).

Side effects

The most common side effects are insomnia, feeling tired, weight gain, headache, dizziness, decreased appetite, sweating, and sexual dysfunction. Some patients experience irritability, aggressiveness, and nervousness.

Selective serotonin and norepinephrine reuptake inhibitors

These drugs also belong to the group of antidepressants and are used to treat anxiety. They are well tolerated by patients and have minimal side effects. They have a powerful antidepressant effect and are superior to SSRIs in their action. Psychiatrists often use them to treat severe depression because they are similar in strength to tricyclic antidepressants.

This article will help you understand whether medications can help get rid of social phobia and in what cases they should be taken. You will learn about the benefits and harms of pharmacological drugs in the treatment of social phobia. In addition, I will describe an effective technique for working on social fears.

What is necessary for taking medications to be truly justified?

Social phobia manifests itself in some typical physiological and psychological reactions: body trembling, excessive sweating, facial flushing, anxiety, depression, apathy, etc. It is precisely to quickly eliminate such undesirable consequences of social phobia that medications are used.

However, there is one important clarification: in order for medication to be truly effective, it must be accompanied by non-drug treatment methods (cognitive behavioral therapy, NLP, Gestalt therapy...). This is true 100% of the time when it comes to treating social phobia.

Without successful psychological treatment of fears, taking medications is absolutely unjustified. In this case, a person taking, for example, antidepressants, will be like a person who is trying to drown his grief in alcohol: while the alcohol is working, the person “feels good” - he forgets about his problems and “has fun.”

When the effect of alcohol wears off, the person returns to reality, and often finds himself even more unhappy than initially.

Of course, alcohol cannot be equated with drugs, but, nevertheless, they have one thing in common: If a person taking antidepressants does not work on learning to stop running away from situations that frighten him along with taking them, after finishing the course of taking antidepressants, he, as in the case of alcohol intoxication, will return to where he started.

The biggest disadvantage of medications in the treatment of social phobia?

Imagine that you are a gardener, and your trees are sick with some kind of nasty thing, because of which all their leaves have turned yellow. You call a specialist and ask him to cure the trees. And he, instead of understanding the causes of the disease and eliminating them, simply takes and paints the yellowed leaves green... “Voila!”, he tells you... But time passes, the paint comes off from the leaves, and the outside the appearance of the trees again begins to correspond to their internal state...

This analogy well illustrates what happens in most cases known to me when psychotherapists prescribed drugs to patients... doctors, just like our would-be tree specialist, followed the path of least resistance.

Their logic is this: if there are no symptoms, there is no disease. They prescribe medications to a person that remove the physiological and psychological manifestations of social phobia, and do not really deal with the real problem. Naturally, we are not talking about 100% of psychotherapists now. I’m just sharing the experience of the guys I’ve worked with personally.

What is needed to really work through social phobia?

To really work through social phobia, it is necessary first of all to work through the “root” – a person’s negative beliefs. This study should be accompanied by exercises aimed at developing calm and confident behavior in situations that cause fear (panic). In conclusion, to build warm relationships with people, you need to learn the main principles of attraction between them and the rules of communication, which, unfortunately, most people do not realize (which is why there are so many scandals, quarrels and misunderstandings between people).

Unfortunately, for some reason, not every psychotherapist is willing (or able) to offer such in-depth work. Therefore, before you start working with any specialist, if he wants to prescribe you to take medications, you should ask what direction your future work will take.

If a specialist does not offer a comprehensive treatment of fears and recommends limiting yourself only to medications (or does not give a clear description of further work), it is better to think three times before dealing with him.

Don't forget that Drug therapy can only be an addition and not the basis of treatment for social phobia.

The basis of effective treatment has been and remains therapy aimed at working through fears, flawed beliefs, and acquiring the necessary social skills.

By the way, in most cases, drug therapy is not necessary at all (and may even be harmful, given the presence of side effects)...

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