Behavior therapy provides patients with a successful method for controlling anxiety in social situations, for decreasing anticipatory anxiety, and for reducing the use of avoidance as a maladaptive coping tactic. It's not known why behavior therapy is an effective treatment for social anxiety disorder; it may well be that it modifies disturbed neurotransmitter systems in the brain.

Advantages to behavior therapy are that it is almost always safe and free of side effects, and the results are long-lasting. But, behavior therapy requires a significant amount of time and effort, and patients must be willing to face the situations they have been avoiding and to endure a temporary increase in anxiety and other symptoms in order to attain a long-term reduction of anxiety. Experienced behavior therapists are not always available and, even with good treatment, behavior therapy doesn't work for everyone. About 25% of patients with social anxiety disorder decline behavior therapy entirely when it is offered.

How does behavior therapy work?
How to start behavior therapy?
How long does it take?
Does behavior therapy have side effects?
What interferes with behavior therapy?
What is the success rate?
Dr. Isaac Marks on behavior therapy
What is cognitive therapy?
Correcting misconceptions

How does behavior therapy work?

Behavior therapy teaches patients to quell the anxiety that arises from social situations, and to face these situations rather than avoiding them. Behavior therapy is not something done to a patient; it is a structured set of techniques that a patient learns to employ whenever anxiety, panic, discomfort, dysfunction or avoidance arises. Rather than attempting to uncover the causes of excessive anxiety and avoidance, which has not been shown to be an effective approach, behavior therapy focuses on specific steps a patient can take to reduce anxiety and keep it from returning.

Basically, patients are asked to face the thing they fear, which is called exposure. They also must learn to stop using avoidance as a way of coping with any anxiety that occurs. Exposure may be done gradually or rapidly, much as one might enter a swimming pool filled with cold water by wading in from the shallow end or by jumping into the deep end. The total amount of discomfort is probably comparable, and the end result (immersion) is the same.

Surprisingly, many patients find that even after years of worrying about severe social anxiety and/or avoiding things they fear, very little discomfort or anxiety occurs when they undergo intensive and extensive behavior therapy. Instead, their anxiety abates, their urge to avoid diminishes and they are soon able to do things they have avoided.

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How to implement behavior therapy

The goals of this treatment are to help you overcome your avoidance and face the things you fear. It is necessary to accept and face some anxiety in order to learn to cope with stressful situations. The sooner you tackle your fears, the sooner you will get better. Your ability to do behavior therapy will improve with practice.

General rules:

• Three-hour homework sessions every day. (This can be broken into two 1.5-hour sessions.)
• Try to stop all social anxiety avoidance behaviors immediately, or at least reduce them steadily day by day.
• Tackle your most disturbing problem within the first two weeks of therapy.

Remember, only you know what triggers your anxiety and avoidance. Choose your exposure homework tasks as carefully and clearly as you can. The things you avoid are the guide to the things you must expose yourself to. Arrange exposure tasks in order of difficulty. Decide which goals you are going to achieve in each session every day for a full week. Be specific about your goals: for example, talk to your supervisor twice or more every work day this week, practice reading aloud in front of a video camera for at least 10 minutes each day, and watch the video tape to see whether you look as anxious as you think you do and to see what you can change for the better.

Coping with fear:
A certain amount of anxiety is normal. If you do get very anxious or panicky:

• Remember that what you are experiencing will pass in time; it won't damage you, and you won't lose control.
• Don't avoid!
• Practice another one of your exposure homework tasks to keep busy.
• Wait for your anxiety to decrease a little.
• Repeat any exposure task that causes anxiety as soon as you can; you have already faced it once and it will be easier the second time.
• Talk to a friend or a relative if doing so helps you face the situation and stop avoiding.

Three-hour homework session:

• Carry out the exposure homework tasks in the way you planned.
• Make sure that you know and can't avoid the fact that you are in contact with the things you fear (sometimes you can do exposure in real life [in vivo]; at other times you'll have to do it in your mind [fantasy]).
• Resist any urges to stop or avoid exposure or to run away.
• Wait in the feared situation until any increased anxiety abates.
• Repeat the exposure again and again—your discomfort will decrease over time.
• If necessary, get a friend to help you (for example, by playing the part of someone who's hard for you to talk with).
• Do not stop the exposure session until your anxiety has come down at least a little.

After the session:

• Give yourself a treat—you deserve it!
• If you have not achieved your treatment goal, don't worry. What is most important is that you have made an effort. We all have bad days.
• Note any problems you had so that you can devise tactics to deal with them.

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How long does behavior therapy take?

While improvement may occur during and after the first session of behavior therapy, it is more likely to appear after several sessions. Once improvement begins, it is likely to increase for many months. If partial improvement is not apparent within five or six sessions of properly conducted exposure therapy, it is unlikely to occur.

Often there is a lag between actual improvement in behavior and the belief that the gains are real. This lag between thought and mood may last up to four months and probably reflects the many years over which your anxiety coping tactics have become ingrained. Persistent exposure leads to a growing appreciation of progress as real reductions occur in anticipatory anxiety and avoidance, and as comfort increases.

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Does behavior therapy have side effects?

Behavior therapy has few, if any, side effects. Occasionally patients become somewhat more anxious early in the course of behavior therapy, and sometimes patients report that they dream more actively and at times have nightmares at the start of therapy. Patients with heart disease such as angina pectoris, as well as those with stomach ulcers, asthma and ulcerative colitis, may be wise to proceed gradually with behavior therapy, but these problems seldom justify foregoing this treatment altogether.

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What can interfere with behavior therapy?

Severe depression can interfere with the effectiveness of behavior therapy. Certain medications can impede behavior therapy progress because of state-dependent learning-what the person learns while taking the medication is lost when the medication is stopped. Medications that may cause state-dependent learning include alcohol, barbiturates (such as phenobarbital, amobarbital and secobarbital), meprobamate (such as Miltown or Equanil), sedating antihistamines such as diphenhydramine (Benadryl and others) and hydroxyzine (Atarax, Vistaril and others). Ironically, benzodiazepines, which are often used effectively to treat social anxiety disorder, can cause state-dependent learning in some people, particularly when taken in large doses. SSRIs, SNRIs, MAOIs, gabapentin, and pregabalin do not seem to cause state-dependent learning.

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How successful is behavior therapy?

Successful treatment of social anxiety disorder with behavior therapy depends on the frequency and duration of exposure to situations that bring on anxiety and avoidance. That can be problematic because some situations are difficult to arrange frequently and long enough for exposure to work. It would probably be difficult for an individual whose social anxiety is evoked by authority figures to arrange frequent and extended discussions with a boss. Some of these exposure sessions must be done in imagination or in fantasy rather than in real life. The effectiveness of imaginal and fantasied exposure may be less than that of real life exposure.

Behavior therapy requires active patient participation in following treatment agreements and instructions. Just as penicillin must be taken properly in order to combat bacterial infections, behavior therapy must be done as homework in order to alleviate social anxiety disorder.

Various studies show that at least half of social anxiety disorder patients benefit from behavior therapy. The amount of improvement can be quite substantial. A few patients become completely free of symptoms for the rest of their lives, but most patients will have some symptoms recur from time to time. The most realistic expectation is that symptoms will be substantially reduced in both frequency and severity. Because behavior therapy is a treatment patients can apply whenever necessary, the gains realized are usually maintained for many years, and often indefinitely.

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Dr. Isaac M. Marks speaks out about behavior therapy.

What is cognitive therapy for social anxiety disorder?

Although there is little controlled research evidence that cognitive therapy alone benefits patients with social anxiety disorder, this form of treatment may be used in conjunction with behavior (referred to then as cognitive-behavior therapy) and medication therapies. Most patients with social anxiety disorder strongly desire to correct the faulty cognitions (beliefs or thoughts) that are part of this illness. Aware that their anxiety is excessive and their avoidance dysfunctional, sufferers who correct their misconceptions feel more in control, better able to cope, and thus more receptive to the benefits of the better established therapies.

In social anxiety disorder, anxiety and its accompanying physical symptoms produce misperceptions and fears that further increase anxiety, playing a crucial role in an ongoing vicious cycle, with anticipatory anxiety leading to avoidance. Cognitive therapy teaches patients to monitor their tendencies to dwell on such thoughts, to refute them as misconceptions, and to better tolerate their anxiety.

Correcting cognitive misconceptions

Misconception: Common physical symptoms will progress to panic.

Coping Technique: These symptoms are common, at least for me, and if I don't avoid the situation, they will diminish as time passes and my anxiety will also diminish.

Misconception: Everyone is watching me.

Coping Technique: Make an actual survey of people around you. Is everyone truly watching you? How many people actually even look your way? Collect data, be objective, don't catastrophize.

Misconception: Everyone will think me stupid if I (fill in your socially anxious behavior, e.g., shake, blush, forget my words, etc.).

Coping Technique: Ask what others think about the time(s) you have shaken, blushed, forgotten your words, etc. Did they feel empathy for the distress you were having? Did they hope you'd feel better soon? What were their reactions?

Misconception: The only option is to avoid situations that trigger my social anxiety.

Coping Technique: Avoidance is an option but the costs of that all-or-nothing approach are very high. Alternatives I will try are:

• Standing my ground for at least 15 minutes to see if my anxiety symptoms diminish. If they decrease even slightly, I'll wait an additional 15 minutes to see how much further they decline. (This is exposure in vivo and it usually leads to habituation or lessening of discomfort.)
• Let's see if I can heighten my anxiety even more to the point that I don't even feel like myself or know where I am (dissociation). (Usually this approach has a paradoxical effect of decreasing anxiety.)
• Let's see if I can exaggerate my blushing, heart rate, sweating, etc., even more. (Again, attempts to increase physical symptoms of anxiety often lead to their reduction.)

Misconception: There is no way to control the anxiety that triggers my social anxiety.

Coping Technique: Write supportive, true statements on index cards and keep them with you to read when anxiety occurs in social situations. Such statements might be:

• I'm anxious but I'm here and that's a victory.
• This is tough, but it will soon be over if I don't blow it out of proportion.
• I've handled this before and can handle it now.
• Breathe slow and shallow.
• I've exaggerated how much others are aware of my anxiety. I'll stay here and do my survey to see how much they're really noticing.
• I'll be fine in a bit if I don't avoid this situation. If I can stay in this room 15 minutes, I'll be proud of myself and it will be easier the next time.

Patients report that such techniques are helpful, and these successes have inspired further research that may uncover even more effective strategies.