Social Anxiety Medication Options: Labeled and Off-Label

What social anxiety disorder is

The National Institute of Mental Health (NIMH) says a person with social anxiety disorder feels anxiety or fear in situations where they may be scrutinized, evaluated or judged. That can include speaking in public, meeting new people, dating, going to a job interview, or even talking to a cashier in a store.

NIMH also notes that for some people, anxiety appears only in performance situations, such as giving a speech, competing in a sports game or playing an instrument on stage. Avoiding those situations can feel helpful at first, but NIMH says the anxiety is likely to remain without treatment. The good news is that with the right treatment and support, people can manage their anxiety and improve their quality of life.

Medicines with an FDA social anxiety indication

The current FDA labels for these medicines include social anxiety disorder. This is a list of labeled uses, not a ranking.

• Sertraline (Zoloft), an SSRI.
• Paroxetine (Paxil), an SSRI, labeled in adults.
• Venlafaxine extended-release (Effexor XR), an SNRI, labeled in adults.

How these antidepressants are used

NIMH says providers typically begin with SSRIs or other antidepressants for social anxiety disorder because they have fewer side effects than other medications. It says they may take several weeks to work and may cause headaches, nausea or difficulty sleeping, which are usually not severe.

Boxed warning: antidepressants, including these three, increased the risk of suicidal thoughts and behavior in young people in short-term studies, and everyone taking one should be watched closely for worsening or suicidal thoughts. If you are in crisis, call or text 988, or call 911. Locascio Wellness does not provide emergency services.

These labels say the medicines must not be taken with MAOIs, because of serotonin syndrome, and warn of higher bleeding risk with aspirin, NSAIDs and blood thinners. They also advise reducing the dose gradually and not stopping suddenly. The venlafaxine label adds a warning about elevated blood pressure. Pregnancy and breastfeeding are important to mention, so please tell your prescriber.

Beta-blockers for performance anxiety: off-label

Propranolol is a beta-blocker. The current Inderal LA (propranolol) label covers conditions such as high blood pressure and angina. Anxiety is not on it. So using a beta-blocker for performance anxiety is off-label.

NIMH says beta-blockers can help control physical symptoms such as rapid heart rate, sweating and tremors, and says they are commonly chosen for the performance anxiety type of social anxiety disorder. It says they are useful as needed for severe short-term anxiety, and generally not recommended for people with asthma or diabetes.

The propranolol label says it must not be used by people with bronchial asthma, certain slow heart rhythms or cardiogenic shock. It also warns that stopping suddenly can worsen angina and, in some cases, has been followed by a heart attack, so the dose should be reduced gradually under a doctor's direction. Read more on our propranolol page.

Benzodiazepines and social anxiety

NIMH says benzodiazepines can reduce anxious feelings quickly, but some people build up tolerance and some become dependent, so a provider may prescribe them only for brief periods. Our guide to benzodiazepines for anxiety explains the boxed warning they carry and why they are never stopped suddenly.

Therapy alongside medicine

NIMH says treatment typically involves psychotherapy, medication or both. Cognitive behavioral therapy (CBT) is commonly used for social anxiety disorder. It teaches different ways of thinking and reacting, and can help a person learn and practice social skills, which NIMH calls very important for this condition.

Exposure therapy, a CBT method, involves gradually facing feared situations, and group CBT can offer its own benefits. NIMH also lists acceptance and commitment therapy as another option. These are general options. Not every therapist uses every approach, so ask.

How we can help

If social anxiety is getting in the way of work, school or friendships, our psychiatrist can talk it through with you by secure video while you are physically in Pennsylvania or New York. Whether any of these medicines is an option for you is a decision for you and your prescriber. Ask us whether our psychiatrist can help through our medication care contact form, or see how online anxiety treatment works with us.

Our anxiety therapy is online for clients in Pennsylvania, West Virginia, Arizona, Colorado and Florida. It is not offered in New York. Reaching out when social situations feel hard takes courage, and it can be a real turning point.