Psychotherapies The first-line treatment for<unk>  is cognitive behavioral therapy (CBT) with medications such as selective serotonin reuptake inhibitors (SSRIs) used only in those who are not interested in therapy. Self-help based on principles of CBT is a second-line treatment. There is some emerging evidence for the use of acceptance and commitment therapy (ACT) in the treatment of<unk> . ACT is considered an offshoot of traditional CBT and emphasizes accepting unpleasant symptoms rather than fighting against them, as well as psychological flexibility – the ability to adapt to changing situational demands, to shift one's perspective, and to balance competing desires. ACT may be useful as a second line treatment for this disorder in situations where CBT is ineffective or refused. Some studies have suggested<unk>  skills training (SST) can help with<unk>  anxiety. Examples of<unk>  skills focused on during SST for<unk>  include: initiating conversations, establishing friendships, interacting with members of the preferred sex, constructing a speech and assertiveness skills. However, it is not clear whether specific<unk>  skills techniques and training are required, rather than just support with general<unk>  functioning and exposure to<unk>  situations. Given the evidence that<unk>  may predict subsequent development of other psychiatric disorders such as depression, early diagnosis and treatment is important.<unk>  remains under-recognized in primary care practice, with patients often presenting for treatment only after the onset of complications such as clinical depression or substance use disorders. Medications SSRIs Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants, are the first choice of medication for generalized<unk>  phobia but a second-line treatment. Compared to older forms of medication, there is less risk of tolerability and drug dependency associated with SSRIs. Paroxetine and paroxetine CR, Sertraline, Escitalopram, Venlafaxine XR and Fluvoxamine CR (luvox CR) are all approved for<unk>  and are all effective for it, especially paroxetine. All SSRIs are somewhat effective for<unk>  anxiety except fluoxetine which was equivalent to placebo in all clinical trials. Paroxetine was able to change personality and significantly increase extraversion. In a 1995 double-blind, placebo-controlled trial, the SSRI paroxetine was shown to result in clinically meaningful improvement in 55% of patients with generalized<unk> , compared with 23.9% of those taking placebo. An October 2004 study yielded similar results. Patients were treated with either fluoxetine, psychotherapy, or a placebo. The first four sets saw improvement in 50.8 to 54.2 percent of the patients. Of those assigned to receive only a placebo, 31.7% achieved a rating of 1 or 2 on the Clinical Global Impression-Improvement scale. Those who sought both therapy and medication did not see a boost in improvement. In double-blind, placebo-controlled trials other SSRIs like fluvoxamine, escitalopram and sertraline showed reduction of<unk>  anxiety symptoms, including anxiety, sensitivity to rejection and hostility. Citalopram also appears to be effective. General side-effects are common during the first weeks while the body adjusts to the drug. Symptoms may include headaches, nausea, insomnia and changes in sexual behavior. Treatment safety during pregnancy has not been established. In late 2004 much media attention was given to a proposed link between SSRI use and suicidality a term that encompasses suicidal ideation and attempts at suicide as well as suicide. For this reason, although evidential causality between SSRI use and actual suicide has not been demonstrated the use of SSRIs in pediatric cases of depression is now recognized by the Food and Drug Administration as warranting a cautionary statement to the parents of children who may be prescribed SSRIs by a family doctor. Recent studies have shown no increase in rates of suicide. These tests, however, represent those diagnosed with depression, not necessarily with<unk> . In addition, studies show that more<unk> ly phobic patients treated with anti-depressant medication develop hypomania than non-phobic controls. The hypomania can be seen as the medication creating a new problem. Other drugs Other prescription drugs are also used, if other methods are not effective. Before the introduction of SSRIs, monoamine oxidase inhibitors (MAOIs) such as phenelzine were frequently used in the treatment of<unk>  anxiety. Evidence continues to indicate that MAOIs are effective in the treatment and management of<unk>  and they are still used, but generally only as a last resort medication, owing to concerns about dietary restrictions, possible adverse drug interactions and a recommendation of multiple doses per day. A newer type of this medication, reversible inhibitors of monoamine oxidase subtype A (RIMAs) such as the drug moclobemide, bind reversibly to the MAO-A enzyme, greatly reducing the risk of hypertensive crisis with dietary tyramine intake. However, RIMAs have been found to be less efficacious for<unk>  than irreversible MAOIs like phenelzine. Benzodiazepines are an alternative to SSRIs. These drugs' recommended usage is for short-term relief, meaning a limited time frame of over a year, of severe, disabling anxiety. Although benzodiazepines are still sometimes prescribed for long-term everyday use in some countries, there is concern over the development of drug tolerance, dependency and misuse. It has been recommended that benzodiazepines be considered only for individuals who fail to respond to other medications. Benzodiazepines augment the action of GABA, the major inhibitory neurotransmitter in the brain; effects usually begin to appear within minutes or hours. In most patients, tolerance rapidly develops to the sedative effects of benzodiazepines, but not to the anxiolytic effects. Long-term use of a benzodiazepine may result in physical dependence, and abrupt discontinuation of the drug should be avoided due to high potential for withdrawal symptoms (including tremor, insomnia, and in rare cases, seizures). A gradual tapering of the dose of clonazepam (a decrease of 0.25 mg every 2 weeks), however, is well tolerated by patients with<unk> . Benzodiazepines are not recommended as monotherapy for patients who have major depression in addition to<unk>  and should be avoided in patients with a history of substance use. Certain anticonvulsant drugs such as gabapentin are effective in<unk>  and may be a possible treatment alternative to benzodiazepines. Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine have shown similar effectiveness to the SSRIs. In Japan, Milnacipran is used in the treatment of Taijin kyofusho, a Japanese variant of<unk> . The atypical antidepressants mirtazapine and bupropion have been studied for the treatment of<unk> , and rendered mixed results. Some people with a form of<unk>  phobia called performance phobia have been helped by beta-blockers, which are more commonly used to control high blood pressure. Taken in low doses, they control the physical manifestation of anxiety and can be taken before a public performance. A novel treatment approach has recently been developed as a result of translational research. It has been shown that a combination of acute dosing of d-cycloserine (DCS) with exposure therapy facilitates the effects of exposure therapy of<unk>  phobia. DCS is an old antibiotic medication used for treating tuberculosis and does not have any anxiolytic properties per se. However, it acts as an agonist at the glutamatergic N-methyl-D-aspartate (NMDA) receptor site, which is important for learning and memory. Kava-kava has also attracted attention as a possible treatment, although safety concerns exist.
Social anxiety disorder
Avoidant personality disorder
Separation anxiety disorder
Schizotypal personality disorder  Schizotypal disorder  1
Generalized anxiety disorder
Blood phobia
Body dysmorphic disorder
Somatization disorder