286 CHAPTER 7
Targeting Neurological Factors: Medication
For people whose social fears are limited to periodic performances—whether a busi-
ness presentation, a class presentation, or an onstage performance—a beta-blocker,
such as propranolol(Inderal), is the medication of choice (Rosenbaum et al., 2005).
Beta-blockers bind to some of the brain’s receptors for epinephrine and norepineph-
rine, and hence make these receptors less sensitive. Both of these neurotransmit-
ters are released during the fi ght-or-fl ight response. Thus, if the person perceives a
“threat” and more epinephrine or norepinephrine is released as part of the fi ght-or-
fl ight response, he or she will not experience its physical effects, such as increased
heart rate, after taking a beta-blocker (see Figure 7.1 for a detailed list of the physi-
cal effects of the fi ght-or-fl ight response). Beta-blockers are not sedating.
For those whose social anxiety arises in a wider and more frequent set of cir-
cumstances, the medication of choice is the SSRI paroxetine (Paxil) or sertraline
(Zoloft). Other SSRIs and SNRIs, such as venlafaxine (Effexor) and nefazodone
(Serzone), and NaSSAs, such as mirtazapine(Remeron), can also help treat social
phobia (Rivas-Vazques, 2001; Van der Linden, Stein, & van Balkom, 2000). How-
ever, higher doses of these medications are necessary to treat social phobia than to
treat depression, and the medications may need to be taken for at least 6 months
before the patient’s fears and avoidance decrease (Rosenbaum et al., 2005). These
medications affect the amygdala and the locus coeruleus, decreasing their activa-
tion. As with panic disorder, medication may be effective in treating social phobia
in the short run (Federoff & Taylor, 2001), but symptoms generally return when
medication is discontinued; thus, CBT is often also appropriate.
Hughes did take medication, but not specifi cally for his social phobia. Follow-
ing a plane crash when he was about 40, he was so badly injured he wasn’t expected
to live through the night. He was given morphine for the pain. He did recover,
although he remained in the hospital for 2 months, during which time he received
increasing doses of morphine. His doctors later switched his pain medication to
codeine, a drug he continued to take in ever-increasing quantities over the rest of
this life. In his 50s, he also began taking the benzodiazepine Valium. Although the
codeine and Valium may have taken the edge off his social phobia, they are very ad-
dictive and certainly interfered with his cognitive functioning.Targeting Psychological Factors:
Exposure and Cognitive Restructuring
CBT is used to treat social phobia, and there is evidence that such therapy has ef-
fects on the brain that are comparable to those of some medications; both sorts of
treatments actually reduce the activity in certain key brain areas. For example, one
study investigated two kinds of treatments with participants who had untreated
social phobia (Furmark et al., 2002). The study began by scanning the participants’
brains as they performed a public speaking task—which made them all anxious.
Each participant was then randomly assigned to one of three groups: After the fi rst
scan, members of one group received the SSRI citalopram, members of
another received CBT, and members of the third group were placed on a
waiting list.
Nine weeks after the fi rst scan, patients in the two treatment groups
had improved by the same amount; however, patients in the waiting list
group did not improve. At this point, all participants received a second
brain scan, again while they performed the public speaking task. Compari-
son of the before and after brain scans revealed that a host of brain areas
had less activity after treatment, particularly those involved in fear (and
related emotions) and memory. Specifi cally, as shown in Figure 7.9, the
amygdala, the hippocampus, and related areas were activated less strongly
during the second scan, and the activation decreased comparably for the
participants in the two treatment groups. The patients who responded best
to treatment showed the greatest decrease in activation, which fi ts nicelySome people with social phobia dread speak-
ing in any group situation—such as a class or a
meeting—to the extent that they are willing to
be evaluated negatively for remaining quiet.
Exposure and cognitive methods can help
diminish the anxiety and avoidance.image100/Alamy