This review (2021) explores the potential of MDMA-assisted therapy for treating the various symptoms of social anxiety disorder (SAD). The authors hypothesize how disruptions in neurological, perceptual, receptive, and expressive systems regulating social behavior in SAD may take place as a result of MDMA-assisted therapy, thereby acting as a stimulus for further research.
Abstract
“Social anxiety disorder (SAD) is a prevalent and often debilitating psychiatric disorder that can assume a chronic course even when treated. Despite the identification of evidence-based pharmacological and behavioral treatments for SAD, much room for improved outcomes exists and 3,4-methylenedioxymethamphetamine (MDMA) has been proposed as a promising adjunctive treatment to psychological interventions for disorders characterized by social dysfunction. A small randomized, placebo-controlled trial of MDMA-assisted therapy (MDMA-AT) for social anxiety in autistic adults offered encouraging results, but more research is sorely needed to explore the potential for MDMA-AT in treating SAD. This review aims to stimulate future study by summarizing research on disruptions in neurological, perceptual, receptive, and expressive systems regulating social behavior in SAD and proposing how MDMA-AT may alter these systems across four domains. First, we review research highlighting the roles of social anhedonia and reduced social reward sensitivity in maintaining SAD, with specific attention to the reduction in positive affect in social situations, infrequent social approach behaviors, and related social skills deficits. We posit that MDMA-AT may enhance motivation to connect with others and alter perceptions of social reward for an extended period following administration, thereby potentiating extinction processes, and increasing the reinforcement value of social interactions. Second, we review evidence for the central role of heightened social evaluative threat perception in the development and maintenance of SAD and consider how MDMA-AT may enhance experiences of affiliation and safety when interacting with others. Third, we consider the influence of shame and the rigid application of shame regulation strategies as important intrapersonal processes maintaining SAD and propose the generation of self-transcendent emotions during MDMA sessions as a mechanism of shame reduction that may result in corrective emotional experiences and boost memory reconsolidation. Finally, we review research on the role of dysfunctional interpersonal behaviors in SAD that interfere with social functioning and, in particular, the development and maintenance of close and secure relationships. We discuss the hypothesized role of MDMA-AT in improving social skills to elicit positive interpersonal responses from others, creating a greater sense of belonging, acceptance, and social efficacy.”
Authors: Jason Luoma & M. Kati Lear
Notes
Anxiety disorders can severely impact a person’s ability to carry out day-to-day tasks and live a normal life. The increasing global prevalence of anxiety disorders is beginning to outpace our ability to provide effective evidence-based treatments for these disorders. Psychedelics are tipped to be the next big thing in mental health care and based on emerging evidence, these psychoactive drugs are showing promise for treating anxiety disorders.
In the present study, the authors review the current state of research regarding the potential of psychedelics to treat a form of anxiety disorder known as social anxiety disorder (SAD). Specifically, the authors discuss how MDMA-assisted therapy may disrupt the neurological, perceptual, receptive, and expressive systems regulating social behaviour in SAD and the proposed mechanism by which MDMA may alter these systems.
What the review hypothesizes:
- In terms of social anhedonia (disinterest in social contact) and reduced social reward sensitivity, the authors suggest that MDMA may enhance a person’s willingness to connect with others and positively alter perceptions of social reward for an extended period.
- People with SAD tend to perceived social stimuli as threatening. The authors hypothesize that MDMA helps people feel safer with others and experience greater ease in relating to both close and more distant relationships for weeks after administration.
- Shame is thought to underlie the maintenance of heightened social threat in SAD. MDMA-assisted therapy may help to increase feelings of self-compassion and reduce self-criticism. MDMA may also result in corrective emotional experiences and boost memory consolidation.
- A variety of social behaviours which aim to decrease anxiety in social situations but inadvertently induce discomfort in others are present in those with SAD. It is believed that MDMA helps to improve social skills which elicits positive interpersonal responses from others, ultimately enhancing social efficacy.
This review provides a comprehensive overview of how MDMA-assisted therapy may be of great benefit to those with social anxiety disorder (SAD). Currently, there are no studies that have looked at MDMA for SAD directly. Earlier studies have found that MDMA has positive effects for autistic adults, but no changes in anxiety for those with a life-threatening illness. As one in eight has suffered from SAD sometime in their life, and 7% of the US experiences SAD in each given year, this may be a fruitful line of research to pursue further.
Summary
INTRODUCTION
Social anxiety disorder (SAD) is the fourth most commonly diagnosed psychiatric disorder in the United States and is associated with negative consequences on social and occupational lives, as well as increased risk for adverse physical health outcomes.
People with social anxiety disorder often go unrecognized as having a problem, and evidence-based pharmacological and behavioral treatments have been identified. However, many patients remain considerably symptomatic at the end of treatment.
Recent research has begun to explore the use of d-cycloserine to augment exposure therapy in treating SAD. MDMA has been investigated as an augmentation strategy in the treatment of social anxiety disorder in autistic adults and has shown to be effective in the treatment of PTSD. However, little research has been conducted on its possible mechanisms of action in the context of treatment studies.
MDMA has been proposed as a treatment adjunct for disorders characterized by social dysfunction, including SAD, due to its stimulation of hormonal responses related to oxytocin, vasopressin, prolactin, and cortisol.
MDMA-assisted therapy is typically delivered in the following format: three preparatory sessions, one dosing session, and three integration sessions.
Although preliminary, evidence suggests that MDMA-AT may be able to alleviate social anxiety symptoms. A stronger theory would help guide future research.
This review summarizes data on alterations in the affective, cognitive, and neurological systems related to social functioning in SAD and how MDMA-assisted therapy may alter these functions. It also discusses the role of shame in maintaining elevated threat perception in SAD and how MDMA-AT may interrupt this pattern.
We present these domains as distinct for the purpose of presentation clarity, but view them as related and interdependent processes of change that reciprocally affect one another to affect overall social functioning in SAD.
SOCIAL ANHEDONIA AND SOCIAL REWARD SENSITIVITY
People with SAD often have diminished positive affect and increased negative affect in social situations, and a reduced positivity in response to social acceptance and enhanced negativity in response to social rejection. People with social anxiety disorder show altered responses to social reinforcement, including a greater hypersensitivity to social punishment, a greater fear of positive evaluation from others, and a greater tendency to interpret positive social stimuli in threatening ways. Increasing the relative balance of approach vs. avoidance goals in social situations may be core to recovery from social anxiety disorder. MDMA-AT may help to alter the ratio of approach- vs. avoidance-focused social goals by increasing positive reinforcement in social situations and reducing experiences or perceptions of punishment. Mice exhibit a critical period through adolescence when they find social encounters with strangers reinforcing, but this preference can be reopened.
Adult mice that received MDMA in the presence of another mouse showed increased sensitivity to social reinforcement, and this effect lasted for at least 2 weeks post-administration. Additionally, the social context of MDMA administration was important. MDMA-AT may have multiple therapeutic benefits in people with social anxiety disorder, including increasing motivation to engage in social behavior and potentiating extinction processes. Individuals with SAD may seek out previously avoided social situations and have more frequent positive social experiences, resulting in a reduced perceived need to enact safety behaviors that interfere with effective social functioning.
HEIGHTENED SOCIAL THREAT
People with social anxiety disorder show heightened amygdala activity to stimuli related to social-evaluative threat, such as negative emotion expressions or critical comments about oneself. This increased amygdala activity may account for at least some of the impairments in interpersonal functioning seen in social anxiety disorder. The parasympathetic nervous system and the vagus nerve are involved in social engagement. The vagus nerve regulates the heart rate and is linked to high frequency heart rate variability at rest and to perceived social connection. Social anxiety disorder is thought to be caused by chronic under activation of the vagal brake, which is thought to be responsible for decreasing heart rate variability at rest compared to healthy controls. The ventral vagus nerve is responsible for enervating muscles associated with flexible and responsive social engagement in the face, neck, and larynx. People with SAD show impaired operation of the vagus nerve during social events, resulting in difficulties in non-verbal flexible social interaction.
People with social anxiety disorder show increased social reinforcement after being rejected by someone, and evidence suggests that positive relationships and experiences of social mastery/belonging are protective factors against social anxiety. People with social anxiety disorder differ from healthy controls in positive affective empathy, but not negative affective empathy. Improvements in positive affective empathy mediated treatment outcomes in group CBT for social anxiety disorder, and MDMA-AT appears to help people feel safer with others.
MDMA may potentiate changes in social safety by facilitating a focus on affiliation and intimacy and less on hierarchy and social rank.
MDMA may activate emotion systems linked to defensive arousal and deactivate those related to social engagement, and may bolster internally experienced positive affect by shifting clients’ focus toward positive aspects of social experiences, exploring positively-valenced emotional experiences, and formulating social approach goals.
SHAME AND SHAME-RELATED COPING
Evidence suggests that shame plays a significant role in maintaining heightened social threat perception in individuals with social anxiety disorder. Shame is theorized to have evolved to prevent humans from behaving in ways that could result in social devaluation by others and loss of social rank. It is triggered when people perceive that their behavior will cause them to lose social standing. Some clinical models of SAD hold that the anxiety experienced by people with SAD is a secondary response to the anticipation of exposing the core shameful self to others. This anxiety is reinforced by shame avoidance strategies that prevent them from working through their core shame. Self-criticism is a key internal shame-avoidance strategy in social anxiety disorder. It is applied frequently and inflexibly around social interactions, and incorporates a high level of negative self-evaluation, serving to maintain the shame-bound sense of self among individuals with SAD. Reductions in shame may have a broad range of positive effects for individuals with social anxiety disorder, including a decreased need to regulate shame through avoidant, self-critical processes. MDMA-AT may help individuals with SAD reduce shame by facilitating experiences of compassion or kindness toward the self. This is likely due to the fact that MDMA increases feelings of self-compassion and reduces self-criticism. MDMA-AT appears to strengthen the bond between therapist and client and boost feelings of safety, potentially laying the foundation for reproducing these types of safe interactions with others following participation in MDMA-AT. When used in a supportive therapeutic relationship, MDMA may reduce shame by facilitating self-transcendent emotions, particularly compassion, and by enhancing the therapeutic bond to potentiate corrective interpersonal learning experiences. This could reduce personally felt shame as well as the fear of shame previously resulting in shame regulation strategies.
Social anxiety disorder (SAD) is a mental health condition characterized by high levels of anxiety in social situations. Social anxiety disorder may be maintained by interpersonal behaviors that induce discomfort in others and evoke desires for social distance from people with SAD. Studies informed by ethological models of social anxiety suggest that submissive gestures such as gaze aversion, slouched posture, and constricted vocal tone may serve to de-escalate competition between individuals in part via safety behaviors. However, these behaviors are inconsistent with desired behavioral norms in Western society. Individuals with social anxiety disorder may avoid social situations altogether to down-regulate anxiety, which results in fewer opportunities to build relationships with others and perpetuates perceptions of social threat.
People with social anxiety disorder show less smiling during social encounters compared to controls, which predicts less interest in future interactions from conversational partners and lower liking and pleasure in conversational partners. This lack of smiling is likely to result in lower social support and difficulty forming new relationships. People with SAD are likely to experience subjective feelings of inauthenticity and perceptions from others that the person is being inauthentic. This is likely to contribute to the uncertain and inadequate sense of self found in SAD. Early social context plays a significant role in the development of social anxiety disorder, including parenting styles, exposure to adverse social experiences with peers, and strong societal expectations to adhere to strict cultural norms.
Children with inhibited temperament may display protective parental behaviors and negative interactions with same-aged peers, which may increase their threat perception of social interactions. Studies suggest that increasing authenticity in social interactions among people with SAD may have important benefits, including increased positive affect, more positive perceptions of their partner’s response, and a greater desire to interact with their partner again. People with SAD contribute to their negative social context by engaging in problematic social behaviors. Increasing feelings of social safeness, increasing positivity in social interactions, and reducing social threat may improve outcomes for SAD via changes in spontaneous interpersonal behavior and improved responses from others signaling social inclusion and liking.
DISCUSSION
Social anxiety disorder (SAD) is a debilitating psychological problem with heavy costs to the individual and society at large. MDMA-AT may be an effective treatment strategy. In this paper we discussed how MDMA-AT may alter processes hypothesized to maintain SAD beyond the dosing session, and how therapists can tailor in-session interventions to fit the individual, thereby augmenting treatment outcomes and facilitating greater and more lasting changes in social functioning and quality of life.
INTRODUCTION
Social anxiety disorder (SAD) is the fourth most commonly diagnosed psychiatric disorder in the United States and is associated with negative consequences on social and occupational lives, as well as increased risk for adverse physical health outcomes.
People with social anxiety disorder often go unrecognized as having a problem, and evidence-based pharmacological and behavioral treatments have been identified. However, many patients remain considerably symptomatic at the end of treatment.
Recent research has begun to explore the use of d-cycloserine to augment exposure therapy in treating SAD. MDMA has been investigated as an augmentation strategy in the treatment of social anxiety disorder in autistic adults and has shown to be effective in the treatment of PTSD. However, little research has been conducted on its possible mechanisms of action in the context of treatment studies.
MDMA has been proposed as a treatment adjunct for disorders characterized by social dysfunction, including SAD, due to its stimulation of hormonal responses related to oxytocin, vasopressin, prolactin, and cortisol.
MDMA-assisted therapy is typically delivered in the following format: three preparatory sessions, one dosing session, and three integration sessions.
Although preliminary, evidence suggests that MDMA-AT may be able to alleviate social anxiety symptoms. A stronger theory would help guide future research.
This review summarizes data on alterations in the affective, cognitive, and neurological systems related to social functioning in SAD and how MDMA-assisted therapy may alter these functions. It also discusses the role of shame in maintaining elevated threat perception in SAD and how MDMA-AT may interrupt this pattern.
We present these domains as distinct for the purpose of presentation clarity, but view them as related and interdependent processes of change that reciprocally affect one another to affect overall social functioning in SAD.
SOCIAL ANHEDONIA AND SOCIAL REWARD SENSITIVITY
People with SAD often have diminished positive affect and increased negative affect in social situations, and a reduced positivity in response to social acceptance and enhanced negativity in response to social rejection. People with social anxiety disorder show altered responses to social reinforcement, including a greater hypersensitivity to social punishment, a greater fear of positive evaluation from others, and a greater tendency to interpret positive social stimuli in threatening ways. Increasing the relative balance of approach vs. avoidance goals in social situations may be core to recovery from social anxiety disorder. MDMA-AT may help to alter the ratio of approach- vs. avoidance-focused social goals by increasing positive reinforcement in social situations and reducing experiences or perceptions of punishment. Mice exhibit a critical period through adolescence when they find social encounters with strangers reinforcing, but this preference can be reopened.
Adult mice that received MDMA in the presence of another mouse showed increased sensitivity to social reinforcement, and this effect lasted for at least 2 weeks post-administration. Additionally, the social context of MDMA administration was important. MDMA-AT may have multiple therapeutic benefits in people with social anxiety disorder, including increasing motivation to engage in social behavior and potentiating extinction processes. Individuals with SAD may seek out previously avoided social situations and have more frequent positive social experiences, resulting in a reduced perceived need to enact safety behaviors that interfere with effective social functioning.
HEIGHTENED SOCIAL THREAT
People with social anxiety disorder show heightened amygdala activity to stimuli related to social-evaluative threat, such as negative emotion expressions or critical comments about oneself. This increased amygdala activity may account for at least some of the impairments in interpersonal functioning seen in social anxiety disorder. The parasympathetic nervous system and the vagus nerve are involved in social engagement. The vagus nerve regulates the heart rate and is linked to high frequency heart rate variability at rest and to perceived social connection. Social anxiety disorder is thought to be caused by chronic under activation of the vagal brake, which is thought to be responsible for decreasing heart rate variability at rest compared to healthy controls. The ventral vagus nerve is responsible for enervating muscles associated with flexible and responsive social engagement in the face, neck, and larynx. People with SAD show impaired operation of the vagus nerve during social events, resulting in difficulties in non-verbal flexible social interaction.
People with social anxiety disorder show increased social reinforcement after being rejected by someone, and evidence suggests that positive relationships and experiences of social mastery/belonging are protective factors against social anxiety. People with social anxiety disorder differ from healthy controls in positive affective empathy, but not negative affective empathy. Improvements in positive affective empathy mediated treatment outcomes in group CBT for social anxiety disorder, and MDMA-AT appears to help people feel safer with others.
MDMA may potentiate changes in social safety by facilitating a focus on affiliation and intimacy and less on hierarchy and social rank.
MDMA may activate emotion systems linked to defensive arousal and deactivate those related to social engagement, and may bolster internally experienced positive affect by shifting clients’ focus toward positive aspects of social experiences, exploring positively-valenced emotional experiences, and formulating social approach goals.
SHAME AND SHAME-RELATED COPING
Evidence suggests that shame plays a significant role in maintaining heightened social threat perception in individuals with social anxiety disorder. Shame is theorized to have evolved to prevent humans from behaving in ways that could result in social devaluation by others and loss of social rank. It is triggered when people perceive that their behavior will cause them to lose social standing. Some clinical models of SAD hold that the anxiety experienced by people with SAD is a secondary response to the anticipation of exposing the core shameful self to others. This anxiety is reinforced by shame avoidance strategies that prevent them from working through their core shame. Self-criticism is a key internal shame-avoidance strategy in social anxiety disorder. It is applied frequently and inflexibly around social interactions, and incorporates a high level of negative self-evaluation, serving to maintain the shame-bound sense of self among individuals with SAD. Reductions in shame may have a broad range of positive effects for individuals with social anxiety disorder, including a decreased need to regulate shame through avoidant, self-critical processes. MDMA-AT may help individuals with SAD reduce shame by facilitating experiences of compassion or kindness toward the self. This is likely due to the fact that MDMA increases feelings of self-compassion and reduces self-criticism. MDMA-AT appears to strengthen the bond between therapist and client and boost feelings of safety, potentially laying the foundation for reproducing these types of safe interactions with others following participation in MDMA-AT. When used in a supportive therapeutic relationship, MDMA may reduce shame by facilitating self-transcendent emotions, particularly compassion, and by enhancing the therapeutic bond to potentiate corrective interpersonal learning experiences. This could reduce personally felt shame as well as the fear of shame previously resulting in shame regulation strategies.
Social anxiety disorder (SAD) is a mental health condition characterized by high levels of anxiety in social situations. Social anxiety disorder may be maintained by interpersonal behaviors that induce discomfort in others and evoke desires for social distance from people with SAD. Studies informed by ethological models of social anxiety suggest that submissive gestures such as gaze aversion, slouched posture, and constricted vocal tone may serve to de-escalate competition between individuals in part via safety behaviors. However, these behaviors are inconsistent with desired behavioral norms in Western society. Individuals with social anxiety disorder may avoid social situations altogether to down-regulate anxiety, which results in fewer opportunities to build relationships with others and perpetuates perceptions of social threat.
People with social anxiety disorder show less smiling during social encounters compared to controls, which predicts less interest in future interactions from conversational partners and lower liking and pleasure in conversational partners. This lack of smiling is likely to result in lower social support and difficulty forming new relationships. People with SAD are likely to experience subjective feelings of inauthenticity and perceptions from others that the person is being inauthentic. This is likely to contribute to the uncertain and inadequate sense of self found in SAD. Early social context plays a significant role in the development of social anxiety disorder, including parenting styles, exposure to adverse social experiences with peers, and strong societal expectations to adhere to strict cultural norms.
Children with inhibited temperament may display protective parental behaviors and negative interactions with same-aged peers, which may increase their threat perception of social interactions. Studies suggest that increasing authenticity in social interactions among people with SAD may have important benefits, including increased positive affect, more positive perceptions of their partner’s response, and a greater desire to interact with their partner again. People with SAD contribute to their negative social context by engaging in problematic social behaviors. Increasing feelings of social safeness, increasing positivity in social interactions, and reducing social threat may improve outcomes for SAD via changes in spontaneous interpersonal behavior and improved responses from others signaling social inclusion and liking.
DISCUSSION
Social anxiety disorder (SAD) is a debilitating psychological problem with heavy costs to the individual and society at large. MDMA-AT may be an effective treatment strategy. In this paper we discussed how MDMA-AT may alter processes hypothesized to maintain SAD beyond the dosing session, and how therapists can tailor in-session interventions to fit the individual, thereby augmenting treatment outcomes and facilitating greater and more lasting changes in social functioning and quality of life.