Therapeutic strategies for social anxiety disorder: where are we now?

ABSTRACT

Introduction: Classical well-established treatments of social anxiety disorder (SAD) are now complemented by more recent therapeutic strategies. This review aims to summarize available therapies for SAD and discuss recent evidence-based findings on the management of this disorder.

Areas covered: Recent guidelines recommend psychotherapy, particularly cognitive-behavioral therapy (CBT), and pharmacotherapy, as first-line treatments of patients with SAD, without a clear superiority of one option over the other. CBT includes classical approaches such as in vivo exposure to social situations and cognitive therapy, but new modalities and techniques have been recently developed: third-wave approaches, internet-delivered therapy, virtual reality exposure, and cognitive bias modification. Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors have been also extensively studied and shown to be effective in SAD. Two alternative strategies have been developed to treat SAD with disappointing results: cognitive bias modification, and pharmacological augmentation of psychotherapy using D-cycloserine during exposure sessions.

Expert opinion: Personalized treatments for SAD patients are now available. Innovative strategies such as online psychotherapy and virtual reality exposure are useful alternatives to CBT and SSRIs. Future developments and optimization of attention bias modification and of pharmacological augmentation of psychotherapy can be promising.

KEYWORDS:

• Cognitive behavioral therapy
• cognition bias modification
• pharmacotherapy
• psychotherapy
• randomized controlled trial
• selective serotonin reuptake inhibitor
• serotonin noradrenaline reuptake inhibitor
• social anxiety disorder
• social phobia
• virtual reality exposure

Article Highlights

• Psychotherapy and pharmacotherapy are first-line and equivalent strategies for the management of patients with SAD.

• Cognitive behavioral therapy (CBT), in individual or in group settings, is the most validated psychosocial approach, and includes various techniques such as psycho-education, behavioral exposure and cognitive therapy.

• Recent developments of CBT, with interesting applications in SAD management, include third wave approaches (mindfulness-based therapy, or acceptance and commitment therapy), internet-based therapy, virtual reality exposure, and attention bias modification.

• Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the most effective medications used for SAD, with response rates ranging between 43% and 71% at 12 weeks.

• Treatment with SSRIs and SNRIs should last at least 6 to 12 months, but clear recommendations on the exact duration are lacking.

• Potent pharmacological alternatives to SSRIs and SNRIs can be phenelzine, a monoamine oxidase inhibitor, or the anti-epileptic medications gabapentin and pregabalin although the efficacy of these two drugs in real world settings is questionable.

• Treatment of children and adolescents with SAD relies above all on psychotherapy, with adapted CBT methods, but SSRIs and SSRIs have been shown to be effective for young patients with severe and disabling SAD that is resistant to CBT.

• Several drugs are currently studied as potential future treatments for SAD, including cannabidiol, oxytocin or the pherine PH94B.

• Current research and potent innovations for the future include personalized therapy based on cognitive or clinical characteristics, and pharmacologically augmented psychotherapy using new drugs and interactive devices.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.