According to classical conditioning principles, fear habituation occurs after repeated exposure to frightening stimuli. Exposure therapy is a psychological treatment that operates on this concept. It offers a structured approach to treating social anxiety disorder. However, for those predisposed to avoiding social situations, taking the first step into this form of treatment can seem paradoxical. 

To address this dilemma, I will provide an overview of social anxiety disorder and explain whether and how exposure therapy aids patients in overcoming it.

Social anxiety disorder (social phobia) is one of the most prevalent mental disorders. It is different from generalized anxiety because the fear and anxiety experienced by patients are specifically related to social situations and to being criticized or scrutinized by others. 

The disorder's manifestations range from psychological symptoms like fear and anxiety to physical ones related to the sympathetic nervous system, such as trembling, sweating, blushing, and tachycardia. 

It is, like other anxiety disorders, a disabling illness, and recovery usually takes decades to occur. The patients are also at risk for developing comorbidities like depression or substance abuse. 

Most people commonly mistake social anxiety disorder for shyness, a normal aspect of personality. How the fear of public situations impacts the individual's functionality and quality of life distinguishes being shy from having a mental condition. 

The symptoms of social anxiety disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), include:

Marked fear or anxiety of being scrutinized when facing one or more social circumstances, such as social interactions, being observed, and performing for an audience. 

Fear of being negatively evaluated for one's actions or for showing anxiety symptoms. 

Fear or anxiety is always or almost always caused by social conditions.

Avoidance of social situations or endurance with extreme fear or anxiety.

Catastrophization of social events and their consequences. 

The symptoms are persistent, last longer than six months, cause significant distress or impairment in the individual's functioning, and are not related to other medical conditions or substance use. 

Social anxiety disorder can begin in childhood, but it is more often observed to develop in adolescence. Its onset in adulthood is infrequent but possible, usually due to a stressful or humiliating occasion or the need to adapt to new social roles (e.g., marrying or being promoted).

Cultural differences influence how people experience the issue, with factors like cultural orientation toward individualism or collectivism, social norms, self-perception, and gender roles being noteworthy. For example, collective cultures exhibit a higher prevalence of social anxiety disorder.

A qualified mental health professional should diagnose the disorder according to the DSM-5 criteria. 

Social phobia is underrecognized and untreated, mainly because of two factors. First, it is misinterpreted as shyness, leading many individuals to overlook the possibility of seeking help. Secondly, the prospect of reaching out for professional assistance can feel overwhelming, leading to avoiding behavior that will delay or prevent it entirely. The difficulty could derive from actions like calling to schedule an appointment or confronting a new professional to discuss deeply personal struggles. 

Individuals who only experience symptoms related to public speaking or professional exposure situations (e.g., musicians, dancers, performers, athletes) are likely to have the performance-only type of social anxiety disorder. In these cases, the persons do not fear other social circumstances. 

 

Treatment options encompass psychotherapy, pharmacotherapy, or both, tailored to the individual's needs and preferences.

The first-line psychotherapy approach is Cognitive behavioral therapy (CBT), aimed at recognizing and altering detrimental or distressing thought patterns that lead to avoidance and safety-seeking behaviors. Other options include interpersonal therapy, short-term psychodynamic therapy, and mindfulness-based stress reduction.

The pharmacotherapy relies on selective serotonin-reuptake inhibitors (SSRIs), which offer low-risk side effects and help with comorbidities like depression. Venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI), is a good alternative.

When dealing with performance anxiety, it is possible to take beta-blockers such as propranolol one hour before the performance for symptom reduction. Note that there are contraindications for these medications; therefore, a professional evaluation is required before use. 

Even when following professional conduct, many patients do not respond to treatment and need a new assessment. 

Exposure-based cognitive behavioral therapy is often considered the gold standard for treating social anxiety. This type of therapy is founded on the "extinction principle," explored in classical conditioning studies. This principle suggests that repeated exposure to the feared stimuli in lab settings can induce habituation and reduce fear. It offers possibilities for recreating scenarios in vivo or using the patient's imagination. 

The therapy relies on neuropsychological mechanisms to try to modify anxiety-related circuitry. The amygdala and the insular cortex are parts of the brain related to fear, an adaptive mechanism necessary for survival. Potentially perceived harmful events trigger these structures, leading to anxiety symptoms. Another consequence of facing a potential danger is activating the sympathetic nervous system, which provides the body with conditions to fight or flee through physiological alterations such as increased heart and respiratory rates and sweating.

Nevertheless, these regions activate in response to social situations in susceptive individuals. Hence, what is supposed to be a healthy response to dangerous stimuli (e.g., facing a predator) is turned into a pathological reaction to quotidian circumstances (e.g., giving a public speech). 

Given this context, past studies on classic conditioning repeatedly exposed animals to fear-inducing stimuli until the brain stopped relating them to adverse outcomes. Consequently, physical symptoms and avoidance behavior decreased until they disappeared. These experiments' concepts have been adapted and studied in humans, allowing for testing efficacy and implementation of exposure therapy in clinical practice. 

 

With the advancements in virtual reality technology, new opportunities have emerged for exposure therapy. Virtual reality exposure-based therapy aims to replicate social scenarios as closely as possible. The more realistic the simulation, including real-time human interaction, unpredictable social situations, emotional facial expressions, and culturally tailored settings, the more effective the therapy will likely be. Furthermore, the therapist can control the intensity of the exposure according to assessed anxiety levels. 

A professional therapist should be present to guide and surveil the patient during the session. Still, it is possible to undertake it within the confines of one's home with remote monitoring. This option is beneficial for severe cases in which the individual is intimidated by direct contact with the professional. 

Research on this modality is still developing, but the results are promising. Improved tools are increasing the treatment's efficacy and the availability of the virtual modality. 

 

Because of the concept of exposure therapy, some people believe that those living with social phobia should expose themselves to all possible social situations until they overcome the disorder. This is not the case. When conducted in the presence of a skilled therapist, exposure therapy is safe but not free of anxiety symptoms. This is why the presence of the professional is crucial to maintaining feelings of distress at a tolerable level. 

It does not mean that patients should refrain from social interaction, but that, especially in severe cases, they should not be forced into situations they do not yet have the right conditions to cope with. With proper treatment, they will gradually become more at ease with social interactions. 

One challenge of in vivo exposure therapy is obtaining and controlling relevant social situations and finding the right setting so that the conditions are similar to ones experienced in real life. Additionally, a skilled therapist is necessary to guide patients and ensure safety. These factors contribute to increased difficulty and costliness in executing the therapy effectively.

Even those with mild cases can feel distressed when facing social exposure and try to avoid it. Consequently, they may resist therapy, especially for the first sessions. Pharmacotherapy can be associated with or precede therapy to solve this apparent paradox, preventing avoidance and dropout. Likewise,  relaxing exercises can be included during the sessions, and the levels of exposure could be adjusted to each patient's needs, finding a balance between tolerable anxiety levels and the effectiveness of the therapy. 

The dropout rate from in vivo exposure therapy is twice as high as that of virtual reality-based therapy. Therefore, it is adequate to investigate beforehand which option will suit each individual to prevent withdrawal from treatment.  

Even when following a proper course, exposure therapy does not prevent relapses. After successful remission, approximately 21.8% of patients relapse. Thus, the professional should instruct the patient on identifying a relapse and seeking support. Moreover, the association with other therapies could decrease the relapse rates.

 

Cognitive behavioral therapy can implement and associate modalities other than exposure, including psychoeducation, social skills training, and cognitive restructuring. These methods aim to provide patients with a restructured thought process that equips them with effective coping strategies for navigating adverse situations. 

Treatment failure should not result in abandonment. Instead, the professional must check the reason for failure and propose new approaches accordingly. Pharmacotherapy is available to help with anxiety symptoms, and other types of psychotherapy, like acceptance and commitment therapy, can be implemented. 

Social anxiety disorder is a serious illness that requires empathy and professional treatment.

Exposure therapy is effective in some cases but has limitations.

Exposure should be safely and gradually implemented. 

Pharmacological treatment can precede or accompany cognitive behavioral therapy so that the patient is comfortable undertaking it. 

The efficacy of virtual reality exposure therapy for social anxiety disorder is comparable to that of in vivo exposure therapy, and it is a good option for initiation in severe cases. 

Relapses may occur and require additional treatment. 

When a therapy plan does not succeed, it is not advisable to abandon treatment altogether but to seek alternatives instead.

As social phobia is a complex condition that demands expert evaluation and could take decades and many attempts to achieve remission, it is vital to seek professional help and stick to the treatment available even when one feels the urge to avoid it. 

Disclaimer: This article provides only informational content and does not substitute professional advice. 

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