Can social anxiety be treated without medication?

If you’re considering whether to add medication to your mental health treatment plan for social anxiety disorder, the decision can feel like a heavy one. Personally, I spent years feeling terrified of medication. There were many points where the symptoms of my mental health conditions felt unbearable, but not knowing how medication would affect me made me worry that it would make things even more unbearable. It also, in some ways, felt like an admission of defeat—as if I was weaker for not being able to cope on my own, or with therapy alone.

The choice about medication is a personal one that depends on a variety of factors, says April Kilduff, LPCC, LCPC, LMHC, a therapist and clinical trainer at NOCD. “Some people can significantly reduce their symptoms of social anxiety with psychotherapy alone. But a lot of people take medication for social anxiety, and it’s not a bad thing at all.”  

Part of the reason many people are hesitant to take mental health medication is because, sadly, it still carries a stigma with it—much more than medication for a physical condition. But the reality is that it can be a lifesaver. If you need medication to get the greatest reduction in symptoms, well, that’s neither good nor bad—it just is. Would you think twice about taking medication for, say, high blood pressure or diabetes?

It’s totally valid to prefer treatment that doesn’t include medication. However, it’s worth asking yourself if your hesitation is because of a lingering stigma or preconceived notions you have about it. Keep reading for more information on social anxiety and how it can be treated.

What is social anxiety?

Everyone feels nervous, anxious, or self-conscious in the face of social situations from time to time—like going on a first date, or giving an important presentation at work. Sometimes, though, these feelings become so routine and overwhelming that they interfere with everyday life and cross the threshold into social anxiety disorder.

“The main hallmarks of social anxiety disorder, also called social phobia, are a chronic, intense and debilitating fear of being negatively judged or embarrassed in front of others,” Kilduff says. It can make everyday life difficult when you have to interact with people at school, work, checking out at a grocery store, ordering at a restaurant, and other ordinary tasks. This fear and anxiety can lead to avoidance that disrupts your life. 

If you live with social anxiety disorder, you might even feel anxious about your anxiety. You may worry that people will notice you’re uncomfortable, and think that your behavior is strange or embarrassing. Similarly, you may worry that others will see the physical symptoms that you experience, like blushing or shaking. Like all anxiety disorders, physical symptoms like these are common. Others include feeling your heart race, having sweaty palms, tense muscles, headaches, and gastrointestinal issues. 

As a result, you may avoid social situations—especially ones you haven’t been in before, like meeting new people, or interactions that have the potential for discomfort. This is known as a “safety behavior.” You might even worry about a social obligation for weeks before it happens. 

Some people with social anxiety disorder don’t experience uncomfortable feelings in interpersonal interactions, but when they have to perform in public—like giving a speech or presentation, competing in a sport, or karaoke. In this case, the symptoms are the same but are just triggered by a different situation.

“People can mistake social anxiety disorder for introversion or shyness,” Kilduff says. “But the motivation is different.” With introversion, for example, you may not be social simply because it drains your energy. Shyness also doesn’t typically involve feelings of anxiety, and isn’t debilitating.

Can social anxiety be treated without medication?

“It definitely can be,” says Kilduff. “The role or need for medication differs from person to person, and many people feel their symptoms get better through psychotherapy alone.” She adds that whether medication is appropriate depends on the severity of symptoms, whether or not therapy has proven to be ineffective on its own, and personal preference.

“My recommendation is if you really don’t want to be on medication, put in the work to do exposure and response prevention therapy (ERP). But if you’re still not seeing the changes you want, like a drop in distress and impairment, then you might want to consider medication,” says Kilduff.

She also notes that treating social anxiety with medication alone is not likely to be as effective as if you pair it with ERP therapy, which helps you change your behaviors in order to change your thoughts and feelings regarding socializing. Using both tools has a high success rate for many. So talk to a licensed mental health professional to find the best course of treatment for you.

If you do decide to pursue medication, it will most likely be an SSRI, or selective serotonin reuptake inhibitor. This category of drug is classified as an antidepressant, but is very commonly used to treat anxiety and other mental health conditions, such as obsessive-compulsive disorder (OCD).

How is social anxiety treated without medication?

As mentioned, the frontline treatment for social anxiety disorder is exposure and response-prevention (ERP) therapy. “ERP helps you face your fears and give up the behaviors that reinforce your anxiety,” says Kilduff. You’ll work with an ERP-trained therapist to better understand the nuances of your experience with social anxiety—like your specific fears, if there are certain situations that trigger your anxiety more than others, and whether you engage in safety behaviors, like avoidance.

From there, you’ll develop a hierarchy of exposures—meaning that your therapist will help you start with small anxieties and slowly work your way up. You won’t be forced to do anything that you don’t feel ready for. Of course, your therapist will encourage you to leave your comfort zone in order to expand it, but you’ll do it in baby steps, says Kilduff.

 There are three different categories of exposures:

• In vivo. These are real-life exposures of something you fear. For example, you might go to a restaurant to put in a to-go order, attend a party, or initiate a conversation with a stranger.
• Imaginal experiences are what they sound like—you use your imagination to expose yourself to fears, such as thinking about it, or looking at a picture of an anxiety-provoking situation, but not actually doing it in real life.
• Interoceptive. These are exercises designed to bring up the physiological experiences you have with anxiety and panic—your heart racing, having a hard time breathing—and allowing your body to get used to those sensations without panicking about them. Kilduff says these work best for pretty specific situations, and aren’t used as often as the two above. You might try this strategy if physical symptoms are at the forefront of your experience with social anxiety.

“People with social anxiety often assume that things are much worse than they are, like everyone is paying attention to them and thinking bad things about them,” Kilduff says. “With ERP, we can sort of test that. Are people really paying attention? And if they are, how much does that really matter in your life? Does it affect anything or is it just uncomfortable in the moment? The goal of ERP is about getting people to be more comfortable with discomfort.”

As you engage in exposures, you will practice sitting with the feelings that come up, resisting the urge to do anything about them, and not engaging in safety behaviors. This trains your brain to understand that feelings of anxiety, fear, and other forms of discomfort don’t need to sound your code-red alarm bells. By not behaving in a way that reinforces your anxiety, you can eventually break your cycle of anxiety. 

“Once you face that fear in real life and realize your world isn’t going to fall apart if someone doesn’t like you, or if you embarrass yourself, it’s easier to retain that information and move forward with less social anxiety,” Kilduff explains. 

As scary as ERP might sound, just imagine what lies on the other side of treatment: more freedom, more mental space to engage in your relationships, an easier time being present and enjoying the world around you. 

Whether you choose to use medication or not, you deserve a full life that’s free of anxiety—and it’s not out of reach.