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Social anxiety disorder (social phobia) - Diagnosis and treatment

Diagnosis

Your health care provider will want to determine whether other conditions may be causing your anxiety or if you have social anxiety disorder along with another physical or mental health disorder.

Your health care provider may determine a diagnosis based on:

  • Physical exam to help assess whether any medical condition or medication may trigger symptoms of anxiety
  • Discussion of your symptoms, how often they occur and in what situations
  • Review of a list of situations to see if they make you anxious
  • Self-report questionnaires about symptoms of social anxiety
  • Criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association

DSM-5 criteria for social anxiety disorder include:

  • Persistent, intense fear or anxiety about specific social situations because you believe you may be judged negatively, embarrassed or humiliated
  • Avoidance of anxiety-producing social situations or enduring them with intense fear or anxiety
  • Excessive anxiety that's out of proportion to the situation
  • Anxiety or distress that interferes with your daily living
  • Fear or anxiety that is not better explained by a medical condition, medication or substance abuse

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Treatment

Treatment depends on how much social anxiety disorder affects your ability to function in daily life. The most common treatment for social anxiety disorder includes psychotherapy (also called psychological counseling or talk therapy) or medications or both.

Psychotherapy

Psychotherapy improves symptoms in most people with social anxiety disorder. In therapy, you learn how to recognize and change negative thoughts about yourself and develop skills to help you gain confidence in social situations.

Cognitive behavioral therapy (CBT) is the most effective type of psychotherapy for anxiety, and it can be equally effective when conducted individually or in groups.

In exposure-based CBT, you gradually work up to facing the situations you fear most. This can improve your coping skills and help you develop the confidence to deal with anxiety-inducing situations. You may also participate in skills training or role-playing to practice your social skills and gain comfort and confidence relating to others. Practicing exposures to social situations is particularly helpful to challenge your worries.

First choices in medications

Though several types of medications are available, selective serotonin reuptake inhibitors (SSRIs) are often the first type of drug tried for persistent symptoms of social anxiety. Your health care provider may prescribe paroxetine (Paxil) or sertraline (Zoloft).

The serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor XR) also may be an option for social anxiety disorder.

To reduce the risk of side effects, your health care provider may start you at a low dose of medication and gradually increase your prescription to a full dose. It may take several weeks to several months of treatment for your symptoms to noticeably improve.

Other medications

Your health care provider may also prescribe other medications for symptoms of social anxiety, such as:

  • Other antidepressants. You may have to try several different antidepressants to find the one that's most effective for you with the fewest side effects.
  • Anti-anxiety medications. Benzodiazepines (ben-zoe-die-AZ-uh-peens) may reduce your level of anxiety. Although they often work quickly, they can be habit-forming and sedating, so they're typically prescribed for only short-term use.
  • Beta blockers. These medications work by blocking the stimulating effect of epinephrine (adrenaline). They may reduce heart rate, blood pressure, pounding of the heart, and shaking voice and limbs. Because of that, they may work best when used infrequently to control symptoms for a particular situation, such as giving a speech. They're not recommended for general treatment of social anxiety disorder.

Stick with it

Don't give up if treatment doesn't work quickly. You can continue to make strides in psychotherapy over several weeks or months. Learning new skills to help manage your anxiety takes time. And finding the right medication for your situation can take some trial and error.

For some people, the symptoms of social anxiety disorder may fade over time, and medication can be discontinued. Others may need to take medication for years to prevent a relapse.

To make the most of treatment, keep your medical or therapy appointments, challenge yourself by setting goals to approach social situations that cause you anxiety, take medications as directed, and talk to your health care provider about any changes in your condition.

Alternative medicine

Several herbal remedies have been studied as treatments for anxiety, but results are mixed. Before taking any herbal remedies or supplements, talk with your health care team to make sure they're safe and won't interact with any medications you take.

More Information

  • Social anxiety disorder (social phobia) care at Mayo Clinic
  • Cognitive behavioral therapy
  • Psychotherapy

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Lifestyle and home remedies

Although social anxiety disorder generally requires help from a medical expert or qualified psychotherapist, you can try some of these techniques to handle situations that are likely to trigger symptoms:

  • Learn stress-reduction skills.
  • Get physical exercise or be physically active on a regular basis.
  • Get enough sleep.
  • Eat a healthy, well-balanced diet.
  • Avoid alcohol.
  • Limit or avoid caffeine.
  • Participate in social situations by reaching out to people with whom you feel comfortable.
Practice in small steps

First, consider your fears to identify what situations cause the most anxiety. Then gradually practice these activities until they cause you less anxiety. Begin with small steps by setting daily or weekly goals in situations that aren't overwhelming. The more you practice, the less anxious you'll feel.

Consider practicing these situations:

  • Eat with a close relative, friend or acquaintance in a public setting.
  • Purposefully make eye contact and return greetings from others, or be the first to say hello.
  • Give someone a compliment.
  • Ask a retail clerk to help you find an item.
  • Get directions from a stranger.
  • Show an interest in others — ask about their homes, children, grandchildren, hobbies or travels, for instance.
  • Call a friend to make plans.
Prepare for social situations

At first, being social when you're feeling anxious is challenging. As difficult or painful as it may seem initially, don't avoid situations that trigger your symptoms. By regularly facing these kinds of situations, you'll continue to build and reinforce your coping skills.

These strategies can help you begin to face situations that make you nervous:

  • Prepare for conversation, for example, by reading about current events to identify interesting stories you can talk about.
  • Focus on personal qualities you like about yourself.
  • Practice relaxation exercises.
  • Learn stress management techniques.
  • Set realistic social goals.
  • Pay attention to how often the embarrassing situations you're afraid of actually take place. You may notice that the scenarios you fear usually don't come to pass.
  • When embarrassing situations do happen, remind yourself that your feelings will pass and you can handle them until they do. Most people around you either don't notice or don't care as much as you think, or they're more forgiving than you assume.

Avoid using alcohol to calm your nerves. It may seem like it helps temporarily, but in the long term it can make you feel even more anxious.

Coping and support

These coping methods may help ease your anxiety:

  • Routinely reach out to friends and family members.
  • Join a local or reputable internet-based support group.
  • Join a group that offers opportunities to improve communication and public speaking skills, such as Toastmasters International.
  • Do pleasurable or relaxing activities, such as hobbies, when you feel anxious.

Over time, these coping methods can help control your symptoms and prevent a relapse. Remind yourself that you can get through anxious moments, that your anxiety is short-lived and that the negative consequences you worry about so much rarely come to pass.

Preparing for your appointment

You may see your primary care provider, or your provider may refer you to a mental health professional. Here's some information to help you get ready for your appointment.

What you can do

Before your appointment, make a list of:

  • Situations you've been avoiding, especially those that are important to your functioning
  • Any symptoms you've been experiencing, and for how long, including any symptoms that may seem unrelated to the reason for your appointment
  • Key personal information, especially any significant events or changes in your life shortly before your symptoms appeared
  • Medical information, including other physical or mental health conditions with which you've been diagnosed
  • Any medications, vitamins, herbs or other supplements you're taking, including dosages
  • Questions to ask your health care provider or a mental health professional

You may want to ask a trusted family member or friend to go with you to your appointment, if possible, to help you remember key information.

Some questions to ask your health care provider may include:

  • What do you believe is causing my symptoms?
  • Are there any other possible causes?
  • How will you determine my diagnosis?
  • Should I see a mental health specialist?
  • Is my condition likely temporary or chronic?
  • Are effective treatments available for this condition?
  • With treatment, could I eventually be comfortable in the situations that make me so anxious now?
  • Am I at increased risk of other mental health problems?
  • Are there any brochures or other printed material that I can have? What websites do you recommend?

Don't hesitate to ask other questions during your appointment.

What to expect from your health care provider

Your health care provider or a mental health professional will likely ask you a number of questions. Be ready to answer them to reserve time to go over any points you want to focus on. Your health care provider may ask:

  • Does fear of embarrassment cause you to avoid doing certain activities or speaking to people?
  • Do you avoid activities in which you're the center of attention?
  • Would you say that being embarrassed or looking stupid is among your worst fears?
  • When did you first notice these symptoms?
  • When are your symptoms most likely to occur?
  • Does anything seem to make your symptoms better or worse?
  • How are your symptoms affecting your life, including work and personal relationships?
  • Do you ever have symptoms when you're not being observed by others?
  • Have any of your close relatives had similar symptoms?
  • Have you been diagnosed with any medical conditions?
  • Have you been treated for mental health symptoms or mental illness in the past? If yes, what type of therapy was most beneficial?
  • Have you ever thought about harming yourself or others?
  • Do you drink alcohol or use recreational drugs? If so, how often?

By Mayo Clinic Staff

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Social anxiety disorder (social phobia) - Symptoms and causes

Overview

It's normal to feel nervous in some social situations. For example, going on a date or giving a presentation may cause that feeling of butterflies in your stomach. But in social anxiety disorder, also called social phobia, everyday interactions cause significant anxiety, self-consciousness and embarrassment because you fear being scrutinized or judged negatively by others.

In social anxiety disorder, fear and anxiety lead to avoidance that can disrupt your life. Severe stress can affect your relationships, daily routines, work, school or other activities.

Social anxiety disorder can be a chronic mental health condition, but learning coping skills in psychotherapy and taking medications can help you gain confidence and improve your ability to interact with others.

Social anxiety disorder care at Mayo Clinic

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Symptoms

Feelings of shyness or discomfort in certain situations aren't necessarily signs of social anxiety disorder, particularly in children. Comfort levels in social situations vary, depending on personality traits and life experiences. Some people are naturally reserved and others are more outgoing.

In contrast to everyday nervousness, social anxiety disorder includes fear, anxiety and avoidance that interfere with relationships, daily routines, work, school or other activities. Social anxiety disorder typically begins in the early to mid-teens, though it can sometimes start in younger children or in adults.

Emotional and behavioral symptoms

Signs and symptoms of social anxiety disorder can include constant:

  • Fear of situations in which you may be judged negatively
  • Worry about embarrassing or humiliating yourself
  • Intense fear of interacting or talking with strangers
  • Fear that others will notice that you look anxious
  • Fear of physical symptoms that may cause you embarrassment, such as blushing, sweating, trembling or having a shaky voice
  • Avoidance of doing things or speaking to people out of fear of embarrassment
  • Avoidance of situations where you might be the center of attention
  • Anxiety in anticipation of a feared activity or event
  • Intense fear or anxiety during social situations
  • Analysis of your performance and identification of flaws in your interactions after a social situation
  • Expectation of the worst possible consequences from a negative experience during a social situation

For children, anxiety about interacting with adults or peers may be shown by crying, having temper tantrums, clinging to parents or refusing to speak in social situations.

Performance type of social anxiety disorder is when you experience intense fear and anxiety during speaking or performing in public but not in other types of more general social situations.

Physical symptoms

Physical signs and symptoms can sometimes accompany social anxiety disorder and may include:

  • Blushing
  • Fast heartbeat
  • Trembling
  • Sweating
  • Upset stomach or nausea
  • Trouble catching your breath
  • Dizziness or lightheadedness
  • Feeling that your mind has gone blank
  • Muscle tension
Avoiding common social situations

Common, everyday experiences may be hard to endure when you have social anxiety disorder, including:

  • Interacting with unfamiliar people or strangers
  • Attending parties or social gatherings
  • Going to work or school
  • Starting conversations
  • Making eye contact
  • Dating
  • Entering a room in which people are already seated
  • Returning items to a store
  • Eating in front of others
  • Using a public restroom

Social anxiety disorder symptoms can change over time. They may flare up if you're facing a lot of changes, stress or demands in your life. Although avoiding situations that produce anxiety may make you feel better in the short term, your anxiety is likely to continue over the long term if you don't get treatment.

When to see a doctor

See your doctor or a mental health professional if you fear and avoid normal social situations because they cause embarrassment, worry or panic.

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Causes

Like many other mental health conditions, social anxiety disorder likely arises from a complex interaction of biological and environmental factors. Possible causes include:

  • Inherited traits. Anxiety disorders tend to run in families. However, it isn't entirely clear how much of this may be due to genetics and how much is due to learned behavior.
  • Brain structure. A structure in the brain called the amygdala (uh-MIG-duh-luh) may play a role in controlling the fear response. People who have an overactive amygdala may have a heightened fear response, causing increased anxiety in social situations.
  • Environment. Social anxiety disorder may be a learned behavior — some people may develop significant anxiety after an unpleasant or embarrassing social situation. Also, there may be an association between social anxiety disorder and parents who either model anxious behavior in social situations or are more controlling or overprotective of their children.

Risk factors

Several factors can increase the risk of developing social anxiety disorder, including:

  • Family history. You're more likely to develop social anxiety disorder if your biological parents or siblings have the condition.
  • Negative experiences. Children who experience teasing, bullying, rejection, ridicule or humiliation may be more prone to social anxiety disorder. In addition, other negative events in life, such as family conflict, trauma or abuse, may be associated with this disorder.
  • Temperament. Children who are shy, timid, withdrawn or restrained when facing new situations or people may be at greater risk.
  • New social or work demands. Social anxiety disorder symptoms typically start in the teenage years, but meeting new people, giving a speech in public or making an important work presentation may trigger symptoms for the first time.
  • Having an appearance or condition that draws attention. For example, facial disfigurement, stuttering or tremors due to Parkinson's disease can increase feelings of self-consciousness and may trigger social anxiety disorder in some people.

Complications

Left untreated, social anxiety disorder can control your life. Anxieties can interfere with work, school, relationships or enjoyment of life. This disorder can cause:

  • Low self-esteem
  • Trouble being assertive
  • Negative self-talk
  • Hypersensitivity to criticism
  • Poor social skills
  • Isolation and difficult social relationships
  • Low academic and employment achievement
  • Substance abuse, such as drinking too much alcohol
  • Suicide or suicide attempts

Other anxiety disorders and certain other mental health disorders, particularly major depressive disorder and substance abuse problems, often occur with social anxiety disorder.

Prevention

There's no way to predict what will cause someone to develop an anxiety disorder, but you can take steps to reduce the impact of symptoms if you're anxious:

  • Get help early. Anxiety, like many other mental health conditions, can be harder to treat if you wait.
  • Keep a journal. Keeping track of your personal life can help you and your mental health professional identify what's causing you stress and what seems to help you feel better.
  • Set priorities in your life. You can reduce anxiety by carefully managing your time and energy. Make sure that you spend time doing things you enjoy.
  • Avoid unhealthy substance use. Alcohol and drug use and even caffeine or nicotine use can cause or worsen anxiety. If you're addicted to any of these substances, quitting can make you anxious. If you can't quit on your own, see your health care provider or find a treatment program or support group to help you.

By Mayo Clinic Staff

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Therapy of anxiety disorders: a modern view of the problem

Summary. The International Classification of Diseases-10 group of anxiety disorders includes generalized anxiety disorder, panic disorder, specific phobias, and social anxiety disorder (F40 and F41). Anxiety disorders are very common in the general population and occur in every 5th inhabitant of developed countries throughout life. One of the most difficult to treat in this group is Generalized Anxiety Disorder, characterized by excessive worrying about various events or activities, resulting in significant distress and disruption of social, work, and daily functioning. The use of antidepressants is ineffective in about ⅓ of these patients. In modern clinical guidelines, other groups of drugs are indicated in first and second line therapy - anticonvulsants, atypical antipsychotics. Among them, an important place is occupied by pregabalin, a drug of the anticonvulsant group, which is also used for chronic pain syndrome. The article considers the current state of the problem of treating anxiety disorders and (using pregabalin as an example) the feasibility of using alternative drugs to antidepressants.

Urgency

Anxiety disorders are among the most common mental health problems in the world. In addition, among all medical problems, anxiety also occupies a leading position in terms of prevalence. Within the framework of epidemiological studies, it is customary to talk about two variants of the prevalence of any condition - annual, that is, an assessment of this indicator in a small time slice (12-month prevalence), and lifelong - the proportion of people who have experienced this condition at least once. For the entire group of anxiety disorders, research has shown a 12-month prevalence of >15% and a lifetime prevalence of >20%.

As a clear demonstration of the relevance of the problem, we present the results of a large-scale study on the assessment of the mental and somatic health of US residents "National Comorbidity Survey". Along with Framingham, this is one of the largest observational studies, the results of which are often used to evaluate epidemiological data and the relationship between various factors that affect health. According to him, the 12-month prevalence of anxiety disorders is 17.2%, which means that every 6th person in the United States develops an anxiety disorder within one year. The lifetime prevalence is 24.9%; this means that every 4th person during his life at least once encounters an anxiety disorder (Kessler R.C. et al., 1994). These data are approximately the same for both Caucasians and African Americans. Thus, with a sufficiently high degree of accuracy, they can be extrapolated to the Ukrainian population.

An analysis of World Health Organization data suggests that this group of mental health problems is the 6th most common cause of disability in both high-income, middle- and low-income countries, including Ukraine. For every 100 thousand inhabitants of the Earth, anxiety disorders account for 390 years of disability. Among women, anxiety disorders are responsible for 65% of all years of life lost (disabled) from all causes (Baxter A.J. et al., 2014).

Among anxiety disorders, a special place is occupied by generalized anxiety disorder, which is characterized by excessive anxiety and feelings in relation to a large number of events or activities (for example, work), accompanied by severe anxiety, fatigue, irritability, difficulty concentrating, muscle tension and impaired sleep. This state of affairs leads to significant distress and difficulties in social, work or even normal daily functioning. For example, anxiety significantly complicates the performance of work duties, which can lead to job loss or provoke conflict in the family.

The sleep disturbance that often accompanies anxiety can be a serious problem in itself, as anxiety-induced insomnia is usually long-term and thus poorly controlled with benzodiazepines or their derivatives, as they are not recommended for long-term use. Another serious problem that deserves attention is a significant decrease in the quality of life of patients with anxiety. Given the gradual transition to patient-centered care, it is also recommended to use this indicator as a marker of the severity of the condition, in addition to standard diagnostic measures (clinical scales for assessing anxiety).

Studies have shown that anxiety is associated with a significant reduction in quality of life, especially when taking into account the widely used SF-36 quality of life scale. To a greater extent, the deterioration relates to the psychological and some characteristics of the somatic component of the quality of life. Thus, anxiety is associated with a deterioration in indicators on such a somatic scale as pain intensity. This may be due to the fact that patients with anxiety are often diagnosed with conditions associated with pain, such as chronic tension headache, nonspecific back pain, and a number of others. As an example, let's cite the results of a large-scale multinational survey, which also included Ukraine. According to the data obtained in our country, chronic pain has been noted in 19 patients over the past 12 months..7% of patients with anxiety or depression (Tsang A. et al., 2008). Thus, every 5th patient with an anxiety disorder also needs therapy aimed at eliminating pain.

Evidence-based therapy

A rational approach to patient care includes both an individualized approach, taking into account the characteristics of each individual case, and reliance on the existing evidence base, including clinical guidelines, meta-analyses and the results of recent randomized controlled clinical trials.

The National Institute for Health and Care Excellence (NICE), UK, is one of the well-known and leading providers of evidence-based clinical guidelines. In the latest guidelines on the quality standard of care for anxiety, a team of leading experts note that benzodiazepines and antipsychotics should be avoided in routine practice in patients with anxiety disorders (NICE, 2014). These recommendations are explained by the fact that taking the former is associated with the development of tolerance and dependence, and the latter with a relatively high risk of side effects. The authors recommend taking this into account, and if prescribed, then a short course in cases of exacerbation of symptoms, when other methods of treatment do not demonstrate sufficient effectiveness. Thus, antidepressants and/or cognitive-behavioral therapy are recommended as first-line therapy. For the pharmacological treatment of anxiety, in particular generalized anxiety disorder, NICE recommends selective serotonin reuptake inhibitors (SSRIs), selective serotonin and norepinephrine reuptake inhibitors (SNRIs), and pregabalin. The authors of the guidelines note that one should also be aware of the possible withdrawal syndrome when using SSRIs and SNRIs, especially paroxetine and venlafaxine.

The American Academy of Family Physicians (AAFP) and the American Psychiatric Association (APA) are other well-known organizations that compile guidelines for the treatment of mental disorders, offering the same psychological and pharmacological treatments. We are talking, in particular, about the guidelines for the diagnosis and management of generalized anxiety and panic disorder (AAFP, 2015) and the APA clinical guidelines (2009) only for panic disorder, which practically duplicate the above, however, the regimens for prescribing drugs and psychological methods of treatment are prescribed in more detail. The list of recommended drugs is presented in the table.

Table AAFP recommended drugs for first and second line therapy
for generalized and panic disorder

Drug Recommendations
SSRI
Escitalopram Generalized anxiety disorder, panic disorder
Fluvoxamine Panic disorder
Fluoxetine Generalized anxiety disorder, panic disorder
Paroxetine Generalized anxiety disorder, panic disorder
Sertraline Generalized anxiety disorder, panic disorder
SNRI
Duloxetine Generalized anxiety disorder
Venlafaxine Generalized anxiety disorder, panic disorder
Azaperone
Buspirone Generalized anxiety disorder
Tricyclic antidepressants
Amitriptyline Generalized anxiety disorder, panic disorder
Imipramine Generalized anxiety disorder, panic disorder
Nortriptyline Generalized anxiety disorder, panic disorder
Antiepileptic drugs
Pregabalin Generalized anxiety disorder
Antipsychotics
Quetiapine Generalized Anxiety Disorder

In addition to the medical communities of Great Britain and the USA, we also note the World Federation of Biological Psychiatry, which brings together specialists from different countries. In 2012, based on a review of the evidence base, this organization also published clinical guidelines for the treatment of anxiety disorders. The authors separately identified for panic, generalized disorder and social anxiety drugs included in first-line therapy:

  • for social anxiety: escitalopram, fluvoxamine, paroxetine, sertraline, venlafaxine;
  • for panic disorder: same drugs + citalopram and fluoxetine;
  • for generalized disorder: escitalopram, paroxetine, sertraline, venlafaxine, quetiapine, and pregabalin.

Particular attention in this list should be given to pregabalin, which belongs to the group of antiepileptic drugs. It should be noted that for a long time in the medical and pharmacological communities there has been a discussion of changing the existing approach to the classification of psychotropic drugs. Often the name of a group of drugs, such as antidepressants, antipsychotics (neuroleptics), or anticonvulsants (antiepileptic drugs), does not correspond to the diagnosis for which they are prescribed. So, antidepressants can be prescribed for anxiety, bulimia; antipsychotics - for anxiety, depression; anticonvulsants - for the same anxiety or bipolar affective disorder. Assigning a prescribed drug to any of these groups often confuses patients, which can be a cause for additional concern or reduced compliance. Discussion of the transition from the old classification model based on symptoms to the new one was one of the main topics of one of the largest annual world conferences on psychiatry and psychopharmacology "ECNP Congress" in 2014, 2015 and 2016, and it is possible that in the near future this new model will be implemented.

Pregabalin differs in its chemical structure and mechanism of action from SSRIs and SNRIs, while remaining highly effective in generalized anxiety disorder, as evidenced by its inclusion as first-line therapy in various management guidelines for these patients. Pregabalin is a γ-aminobutyric acid derivative and was originally used and approved by the US Food and Drug Administration and the European Medicines Agency for the treatment of epilepsy and various types of chronic pain syndrome, including diabetic peripheral neuropathy, postherpetic neuralgia, and fibromyalgia. Later evidence began to emerge for its effectiveness in anxiety disorders, especially generalized anxiety disorder and, to a lesser extent, social phobia.

Recently, this drug has increasingly become the subject of study specifically in the context of anxiety treatment as an alternative to SSRIs. The problem of the widespread use of the latter is mainly due to the relatively slow onset of action, the risk of withdrawal syndrome and the lack of a significant effect in relation to such often comorbid conditions as chronic pain syndrome of various origins. In addition, in about ⅓ of patients, the use of SSRIs and SNRIs does not lead to the desired effect and there is a need to look for another therapy with a different mechanism of action.

This was reflected in a systematic review of scientific studies conducted by the staff of the Villa San Benedetto Menni clinics in Rome, Maastricht University and the University of Miami. Summarizing the available evidence base for all drugs used in anxiety disorders, the researchers concluded that pregabalin is highly effective in generalized anxiety disorder. At the same time, as the authors note, the drug showed a low risk of adverse effects with long-term use and did not have a negative effect on cognitive or psychomotor functioning (Perna G. et al., 2016).

Also published this year are the results of an analysis of several randomized clinical trials that evaluated the effectiveness of pregabalin in the context of pain reduction and improvement in various areas of functioning. The authors note that taking pregabalin led to a significant reduction in pain, improved sleep quality and physical functioning. The analysis also assessed symptoms of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS). On the one hand, no significant differences were found with the control group (placebo), on the other hand, the study sample consisted of individuals with a low initial level of anxiety and depression, which did not reach the level of clinical significance (6 points each on the HADS anxiety and depression subscales at the threshold level ≥8 points and clinically significant ≥11 points) (Sadosky A. et al., 2016).

The problem of anxiety is also relevant for patients undergoing surgical treatment. This disorder often accompanies these patients both in the pre- and postoperative period. In addition, anxiety about the upcoming operation and pain has a negative effect on surgery and anesthesia. A new clinical trial conducted in 2016 demonstrated the effectiveness of pregabalin adjunctive therapy for bone surgery. In this study, patients of the experimental group were premedicated with pregabalin in different dosages before blockade of peripheral nerves. The control group did not receive any additional therapy. According to the results, the use of pregabalin significantly contributed to the maintenance of hemodynamic parameters during the intervention at a normal level and greater patient satisfaction with the quality of anesthesia. When using pregabalin at a dose of 150 and 300 mg, a significantly shorter duration of surgical intervention was also noted compared with the control (76. 5; 68.0 and 83.3 minutes, respectively).

Conclusions

Anxiety disorders are a common problem of our time, one of the main characteristics of which is a high comorbidity with both somatic and other mental disorders. The gradual discovery of new drugs and the study of additional properties of already long-term use has replaced benzodiazepines from the first-line therapy recommended in current guidelines for patients with anxiety disorders. Highly effective drugs are not limited to the SSRI and SNRI group; Today, there are other effective medicines classified as anticonvulsants and atypical antipsychotics. In particular, the study of the additional properties of pregabalin has demonstrated its high efficacy in generalized anxiety disorder, which is reflected in the most significant clinical guidelines and recommendations of the European Medical Agency. Experts conclude that pregabalin can be used as a first-line therapy for this disorder, and it may also be the best pharmacological alternative to SSRIs when they are ineffective or poorly tolerated. This drug occupies a special place in anxiety in patients with a neurological profile and those undergoing surgical interventions, since, in addition to the effect on anxiety, it reduces the intensity of pain and improves postoperative outcomes.

List of references

Correspondence address:
Vitaly Grigoryevich Bezsheiko
01030, Kyiv,
st. Mykhailo Kotsiubynskogo, 8A
Ukrainian Research Institute of Social and Forensic Psychiatry and Narcology

7 ineffective anti-anxiety remedies

Daniil Davydov

medical journalist

Author profile

Anxiety is now experienced by many, and can be difficult to cope with on your own . About what ways can really help, we wrote in the article "5 tips on how to cope with anxiety in difficult times."

However, some popular medications and supplements that are marketed as anti-anxiety medications have no evidence of effectiveness.

Some of them are relatively harmless, but others have side effects and contraindications, so under certain conditions they can do more harm than good. If you are planning to purchase a medication for anxiety, we recommend that you consult with your doctor. And this list will help you make an informed decision.

Novo-Passit

What is it. Phytotherapeutic tablets or solution based on herbal extracts of valerian officinalis, lemon balm, hypericum perforatum, hawthorn, passionflower incarnate, common hop, black elderberry and guaifenesin

Novo-Passit - GRLS

According to the manufacturer, the drug helps with a state of constant mental stress and mild forms of insomnia.

Proof of effectiveness. Novo-Passit is not mentioned in international databases of medicines, nor is it in clinical recommendations for the treatment of any diseases.

/list/medical-evidence/

14 authoritative medical sources

Some drugs are made from chemicals derived from plants. For example, cardiac glycosides are made from digitalis purpurea. But for the manufacture of the drug, not the whole plant and not the extract from it are used, but separate, carefully purified chemicals, the concentration of which is very strictly controlled.

Products containing extracts or whole parts of one or more plants are classified as herbal medicine and are considered dietary supplements in most countries. Therefore, they are neither in international drug databases nor in clinical guidelines for the treatment of diseases.

What is Phytotherapy - MedlinePlus Medical Handbook

There is no need to look for evidence of the effectiveness of dietary supplements, since by law it is just food.

All that is required of them is to be safe, that is, not to harm the health of the people who take them. Since it is not necessary to prove the effectiveness of herbal remedies, they are very poorly understood. When it comes to complex herbal remedies, research is further complicated by the fact that they do not work the way they would work separately.

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They say expensive dietary supplements are more effective than cheap ones. Truth?

For example, although the European Medicines Agency, or EMA, considers preparations based on essential oils and valerian rhizomes may have a calming effect, we do not know how this plant extract will work in combination with other plant extracts.

Valerian essential oils - EMA

Valerian rhizomes - EMA

Finding out how effective a multi-herb formulation works is also difficult because different researchers study different sets of herbal extracts at different concentrations. As a result, most scientists admit that we do not yet have reliable information on how effective herbal preparations based on herbs are for anxiety.

For example, psychotherapists in Switzerland who were trying to understand whether a combination of extracts of valerian, lemon balm, passionflower and butterbur helps with anxiety disorders. They gave part of the patients these supplements and compared the effect with patients who did not receive supplements, and came to the conclusion that the supplements can reduce the dosage of the main drugs - benzodiazepines.

Effect of a combination of valerian, lemon balm, passionflower and butterbur extracts on benzodiazepine prescribing in hospitalized patients with psychiatric disorders - Journal of Phytotherapy

This type of study is referred to as a case-control study. Even if they show that patients got better, this cannot be considered conclusive evidence of the effectiveness of the drug, since doctors knew who was receiving which drug and could unwittingly embellish the result. Patients who received supplements could also believe in their power and feel better - this is called the placebo effect.

To understand how well supplements really work, you need to study them the way you study drugs, that is, subject them to a randomized clinical trial. With this procedure, patients are randomly divided into two groups, one of which receives the drug, and the other receives exactly the same type of dummy pills, and neither doctors nor patients know which group they fell into until the end of the experiment. But there are still no such works devoted to supplements with herbal extracts for anxiety. Until they appear, nothing definite can be said about whether they work.

Another component of Novo-Passit, guaifenesin, is known mainly as a cough suppressant and expectorant. There is still no convincing evidence that guaifenesin helps with coughing - but it has quite a few side effects.

Guaifenesin - a cough remedy - drugs.com

I have not been able to find studies of guaifenesin as an anti-anxiety agent.

Contraindications and side effects. In the instructions, the manufacturer writes that Novo-Passit is contraindicated in children under 12 years of age and people with intolerance to the components of the drug - especially guaifenesin. As a rule, it is well tolerated, but some people complain of allergies, dizziness, weakness, drowsiness and gastrointestinal disorders - from vomiting and heartburn to diarrhea.

The cost of the drug depends on the number of tablets in the package and the volume of the vial A package of 10 tablets and a bottle of 100 ml solution cost about the same - 460-470 R
The cost of the drug depends on the number of tablets in the package and the volume of the vial A package of 10 tablets and a 100 ml solution bottle cost approximately the same - 460-470 R

Persen

What is it. Phytotherapeutic tablets and capsules based on the extract of rhizomes of valerian, lemon balm and mint.

Persen — GRLS

According to the manufacturer, the drug has a sedative effect.

Proof of effectiveness. Persen is not mentioned in the international databases of medicines, it is not in the clinical recommendations for the treatment of any diseases either. This is a phytotherapeutic drug similar to Novo-Passit, but with a slightly different composition. He has exactly the same problems with evidence of effectiveness.

Contraindications and side effects. According to the manufacturer, the drug should not be taken by people with hypersensitivity to its components, people with low blood pressure, diseases of the biliary tract, children under 12 years of age, pregnant and lactating women. The drug can cause allergic reactions - from rashes to edema, and with prolonged use, provoke constipation.

The cost of the drug depends on the number of tablets in the package. The price of a pack of 20 tablets is 351 R

Corvalol

What is it. Corvalol is sold in two versions:

  1. phytotherapeutic agent based on extracts of lemon balm leaves, peppermint and motherwort herb in tablets and water-based drops;
  2. phytotherapeutic agent based on extracts of lemon balm leaves, peppermint, motherwort herb, which contains phenobarbital. These are drops based on 95% alcohol.

Corvalol tablets - GRLS

Corvalol drops with phenobarbital - GRLS

According to the manufacturers, Corvalol in both versions "has a calming effect."

Proof of effectiveness. As an anxiety remedy, both versions of Corvalol, with and without phenobarbital, are not mentioned in any international drug database. In clinical recommendations for the treatment of any diseases, they are also absent.

There is no convincing evidence that any of the components of Corvalol without phenobarbital can work as a sedative. According to some studies, lemon balm tea or tincture relieves insomnia, and the smell of peppermint can reduce stress a little. But there is no evidence that in tablets or drops these components will act in the same way as in the form of tea or essential oil.

Perhaps lemon balm tea or tincture helps with insomnia - RxList

Perhaps the smell of mint can relieve stress - RxList

Why phenobarbital is dangerous - drugs.com

Corvalol with phenobarbital may indeed have a sedative effect account, in fact, phenobarbital. This is a very old tranquilizer, in most countries its is prescribed only as an anticonvulsant and its use is strictly controlled, since phenobarbital is addictive and has many side effects.

Contraindications and side effects. Manufacturers of Corvalol without phenobarbital warn that it has quite a few contraindications: from allergies to its components to peptic ulcer, liver or kidney diseases, pregnancy and breastfeeding. Children under 18 years of age should not take the drug.

Manufacturers of Corvalol with phenobarbital add alcoholism and traumatic brain injury to the list of contraindications. Experts from other countries warn that phenobarbital is also contraindicated in severe asthma and chronic obstructive pulmonary disease, i.e. COPD, porphyria, and for people with a history of drug dependence in the past. The list of side effects of phenobarbital drops includes dizziness, weakness, nausea, decreased alertness, and rash.

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tablets

Preparations and supplements with motherwort

What is it. Phytotherapeutic agents based on motherwort extract. According to the manufacturers, such drugs have a pronounced sedative effect - that is, they work as a strong sedative.

Preparation based on motherwort extract — GRLS

Motherwort-based supplements registered in Russia

Motherwort as a source of bioactive compounds — European Medicines Agency report medical reference book RxList

In Russia, there are both medicines and biologically active supplements based on motherwort - both in the form of liquid extracts and in capsules.

Proof of effectiveness. Motherwort preparations are not listed as an anxiety remedy in any international drug database. In clinical recommendations for the treatment of any diseases, it is also absent.

Theoretically, motherwort may have a potential neurological effect. Some substances in this plant can bind to receptors for gamma-aminobutyric acid, or GABA. This neurotransmitter is responsible for the inhibition of the nervous system, so the researchers suggested that the biologically active substances in motherwort would work in a similar way.

But when the substances in motherwort extract that could work as sedatives were tested separately, their biological effect was very weak. Most likely, patients with anxiety would simply not feel its effects.

The effectiveness of motherwort remedies in healthy people experiencing severe anxiety has not been tested. According to some studies, the combination of motherwort, valerian, hops, and lemon balm improves sleep in people with alcoholism who are trying to quit drinking. However, there is no conclusive evidence for this yet.

Contraindications and side effects. Motherwort preparation companies warn that some people may have allergies or digestive disorders - indigestion, that is, pain or discomfort in the stomach, and diarrhea.

Motherwort preparations and supplements are contraindicated in people taking calcium hydroxybutyrate, magnesium hydroxybutyrate, potassium hydroxybutyrate, or sodium hydroxybutyrate neurological drugs. Motherwort can enhance the effect of such drugs - up to severe poisoning and coma.

Motherwort is not compatible with hydroxybutyrates - Medscape Medical Guide

Some pharmaceutical companies offer motherwort extract based on 70% alcohol. According to the instructions, the drug should be used in 30-50 drops diluted in water - the maximum content of ethyl alcohol in such a dose is 0.55 g, and in the maximum daily dose - 2.2 g.

International organizations believe that women can take no more than one standard serving of alcoholic beverages per day, and for men - no more than two servings. This is 14 g of pure ethanol.

The amount of ethyl alcohol that can be obtained with the maximum dose of the drug is much less than the standard serving of alcohol. Nevertheless, people who take drugs that are incompatible with alcoholic beverages, such as antidepressants, should, just in case, abandon the alcohol tincture of motherwort.

The cost of the drug depends on the pricing policy of the manufacturer. The cheapest package of 10 tablets can be bought for 18 R

Validol

What is it. Sublingual tablets based on levomenthol - a substance that is obtained from peppermint essential oil.

Validol - GRLS

Manufacturers claim that this drug "has a sedative effect" - that is, it works as a sedative.

Proof of effectiveness. As an anti-anxiety drug, levomenthol-based drugs are not listed in any international drug database.

In some countries, levomenthol is approved only as an external agent for veterinary use. It is mainly used as a cough suppressant, anti-inflammatory and antipruritic drug in humans and animals.

Levomenthol — drugs.com

How levomenthol is used in medicine — PubChem chemical guide

No one has studied the effectiveness of peppermint essential oils and levomenthol preparations for anxiety in people.

Contraindications and side effects. There are few contraindications for drugs with levomenthol: mostly it is an allergy or intolerance to the components of the drug, the medicine is not suitable for children under 18 years of age. But there are side effects: nausea, watery eyes and dizziness. According to the manufacturers, the drug is incompatible with alcohol.

The cost of the drug depends on the number of tablets in the package and on the pricing policy of the manufacturer. The cheapest package of 20 tablets costs 54 R

Afobazol

What is it. A drug based on a substance that received the international name fabomotizol. In our country, "Afobazol" of immediate and delayed action is sold. In the delayed-release preparation, the concentration of the active substance is three times higher, and it is absorbed during the day.

Afobazol - GRLS

According to the manufacturers, tablets with fabomotizol reduce anxiety and stimulate the nervous system.

Proof of effectiveness. Fabomotizole-based drugs are not listed as anti-anxiety drugs in any international drug database.

The effectiveness of "Afobazole" as a remedy for anxiety was studied only in Russia - the drug is not used anywhere else in the world. I could not find independent studies on the effectiveness of the active substance for anxiety.

Contraindications and side effects. Among the contraindications, the manufacturer lists only individual intolerance to the components of the drug, age under 18, pregnancy and the period of feeding a child. And among the side effects are allergies and headaches.

An immediate drug. Price: 720 R Delayed drug. As a rule, slow-acting drugs are more expensive. Price: 894 R
Immediate drug. Price: 720 Р Delayed action drug. As a rule, slow-acting drugs are more expensive. Price: 894 R

Tenoten

What is it. Lozenges based on lactose sugar. The composition of the drug intended for adults includes antibodies to the brain-specific S-protein at a concentration of 10 -15 ng / g, and the children's version - 10 -16 ng / g.

Tenoten for adults - GRLS

According to the manufacturer, it has a calming and anti-anxiety effect.

Proof of effectiveness. The concentration of the active substance makes it possible to recognize Tenoten as a homeopathic remedy, since at a concentration of 10 -15 -10 -16 ng / g, not a single antibody may appear in the tablet. But even if there were more antibodies, manufacturer-independent data that antibodies to the brain-specific S-protein reduce anxiety, no.

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