HealthTherapy options for people with SAD and public speaking anxiety

Therapy options for people with SAD and public speaking anxiety

Your heart begins to pound, your palms grow moist and clammy as you take a nervous peek through the curtains out at the audience, all the while the seconds tick closer to your moment under the spotlight. A deep breath, a clearing of the throat as you think, “How did I end up here and why am I doing this?”

And you’re up. Showtime!

Even celebrities and the most seasoned public speakers can be overcome with a sudden and unexpected case of the jitters when performing or speaking before a crowd. Be it stage, office or classroom, the anxiety that comes with public speaking is a universally shared experience, though for those struggling with social anxiety disorders (SAD), public speaking is an especially daunting, even traumatic, proposition. Wracked by intense self-scrutiny and a nagging notion that people are quietly picking them apart, SAD sufferers often aggressively play down and dismiss their abilities as public speakers 1, 2, creating a type of self-fulfilling prophecy 3 wherein the sufferer actively avoids scenarios involving public speaking, worsening an already acute sense of isolation and contributing to a general social awkwardness 4.

Indeed, an SAD sufferer’s harsh and often incorrect self-evaluation can ultimately result in a kind of self-sabotage when public speaking is required 5, resulting in another kind of negative feedback loop and closing off the development of the sufferers’ innate speechmaking potential 6.

While the body has its own undeniable way of manifesting emotions tied to fear – the sweating, the trembling, the stomach doing somersaults, all understood as the body’s way of processing information more effectively in unfamiliar or stressful situations 7 – it is the emotion-regulating amygdala, deep in the center of the brain, which plays a more defining role in how an individual deals with moments of intense stress.

Studies into the mental processes of those grappling with SAD have indicated that when communication between the amygdala and the ‘higher’ cortical brain – that vast region where thought and action are formed – is compromised the adaptive relationship between the two portions is weakened, allowing emotions to run unregulated 8. Likewise, when an individual is anticipating having to give a speech, the activity in the emotion-generating amygdala is prolonged and a greater loss of emotional control and a heightened overall sense of ‘threat’ is reported in SAD participants over non-SAD participants 9.

According to Dr. Alexander Bystritsky, if individuals are interested in controlling prominent symptoms associated with public speaking with medication, they should consult a psychiatrist. For example, the consumption of beta blockers (e.g. Propranolol), one hour before performance can block sympathetic nervous system responses, such as heart palpitation, sweating, etc., while minor tranquilizers (e.g. Xanax) work by reducing tension and by producing calming effects.

As far as psychotherapies are concerned, with Cognitive Behavioral Therapy (CBT), the restructuring of negative thought processes in order to improve SAD sufferers’ reactions to stressful situations 10 has shown tremendous promise. One recent study indicates that exposure not only reduces negative self biases among those suffering with public speaking anxiety but often trains the speaker to learn to shift focus from the self to the audience, allowing a more fluid presentation as well as increased confidence and self efficacy 6. Similarly, a different study shows that while pre-speech anxiety levels in those with SAD were higher than those without, once participants in either group were actually engaged in public speaking, the anxiety leveled off, providing a treatment strategy for the SAD group centering on controlling pre-speech nervousness through CBT treatment and exposure 11.

Another recent study compared the efficacy of two brief cognitive-behavioral interventions, traditional CBT and Acceptance-Based Behavior Treatment (ABBT). It was found that both interventions were effective. While CBT was effective in reducing subjective feelings of anxiety, subjects who had received ABBT seemed to demonstrate a newfound confidence and ease with speechmaking, scoring higher on observer-rated evaluations during presentations. Apparently, with traditional CBT, the focus on rewiring thought patterns in preparation for a public speaking engagement can take up valuable prep time and memory that would otherwise be put toward the substance of the speech itself. In contrast, ABBT may free more cognitive resources since it stresses acceptance of one’s thoughts and feelings 12.

Indeed, the relatively recent appearance of “third” wave therapies, which integrate mindfulness practice, has proven to be a useful tool in combating fears and anxieties. Mindfulness stresses the idea of becoming aware and accepting both positive and negative thoughts and emotions, rather than trying to change them. In addition, labeling these thoughts and emotions seems to activate areas of the brain that regulate negative emotions, bringing such feelings out into the light and lessening their hold. Recommended tips for reducing speech anxiety involve labeling emotions before each practice, increasing the number of practice sessions, and not letting too much time pass between practices13.


1. Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg, M. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment (pp. 6993). New York, NY: Guilford Press.

2. Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35, 741756.

3. Curtis, R. C., & Miller, K. (1986). Believing another likes or dislikes you: Behaviors making the beliefs come true. Journal of Personality and Social Psychology, 51(2),284.

4. Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Research and Therapy, 35(8), 741-756.

5. Rowa, K., Paulitzki, J. R., Ierullo, M. D., Chiang, B., Antony, M. M., McCabe, R. E., & Moscovitch, D. A. (2015). A False Sense of Security: Safety behaviors erode objective speech performance in individuals with social anxiety disorder. Behavior Therapy, 46(3), 304-314. doi:10.1016/j.beth.2014.11.004

6. Cheng, J., Niles, A. N., & Craske, M. G. (2017). Exposure reduces negative bias in self-rated performance in public speaking fearful participants. Journal Of Behavior Therapy & Experimental Psychiatry, 54, 101-107. doi:10.1016/j.jbtep.2016.07.006

7. Durlik, C., Brown, G., & Tsakiris, M. (2014). Enhanced interoceptive awareness during anticipation of public speaking is associated with fear of negative evaluation. Cognition & Emotion, 28(3), 530-540. doi:10.1080/02699931.2013.832654

8. Cremers, H. R., Veer, I. M., Spinhoven, P., Rombouts, S. B., Yarkoni, T., Wager, T. D., & Roelofs, K. (2015). Altered cortical-amygdala coupling in social anxiety disorder during the anticipation of giving a public speech. Psychological Medicine, 45(7), 1521-1529. doi:10.1017/S0033291714002657

9. Davies, C. D., Young, K., Torre, J. B., Burklund, L. J., Goldin, P. R., Brown, L. A., & … Craske, M. G. (2017). Altered time course of amygdala activation during speech anticipation in social anxiety disorder. Journal Of Affective Disorders, 209, 23-29. doi:10.1016/j.jad.2016.11.014

10. Goldin, P. R., Ziv, M., Jazaieri, H., Hahn, K., Heimberg, R., & Gross, J. J. (2013). Impact of Cognitive-Behavioral Therapy for social anxiety disorder on the neural dynamics of cognitive reappraisal of negative self-beliefs. JAMA Psychiatry, 70(10), 1048–1056.

11. Morrison, A. S., Brozovich, F. A., Lee, I. A., Jazaieri, H., Goldin, P. R., Heimberg, R. G., & Gross, J. J. (2016). Anxiety trajectories in response to a speech task in social anxiety disorder: Evidence from a randomized controlled trial of CBT. Journal Of Anxiety Disorders, 38, 21-30. doi:10.1016/j.janxdis.2015.12.006

12. Glassman, L. H., Forman, E. M., Herbert, J. D., Bradley, L. E., Foster, E. E., Izzetoglu, M., & Ruocco, A. C. (2016). The Effects of a brief Acceptance-Based Behavioral Treatment versus traditional Cognitive-Behavioral Treatment for public speaking anxiety. Behavior Modification, 40(5), 748-776. doi:10.1177/0145445516629939

13. Niles, A. N. (2015). How to conquer your fears and anxiety by labeling your emotions. Retrieved from

Clinical Psychology at Alliant International University

Cinzia Cottù Di Roccaforte earned a Doctoral Degree in Clinical Psychology from Alliant International University Los Angeles in 2019. She received a Bachelor of Arts in psychology from UCLA in 2011 and her Master of Arts in clinical psychology with emphasis in Marriage & Family Therapy from Pepperdine University in 2014. Dr. Roccaforte has been working with Dr. Alexander Bystritsky at the UCLA Anxiety Disorders Program. Dr. Roccaforte and Dr. Bystritsky also collaborated writing articles for


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