What are the treatment options for social anxiety disorder?

Treatment Options for Social Anxiety Disorder

For social anxiety disorder, the most effective first-line treatments are either Selective Serotonin Reuptake Inhibitors (SSRIs) or individual Cognitive Behavioral Therapy (CBT), with individual CBT showing superior long-term outcomes and fewer side effects. 1, 2

Pharmacotherapy Options

First-Line Medications

• SSRIs:
  • Recommended as first-line pharmacological treatment 1, 2
  • Starting doses:
    • Sertraline: 25-50 mg daily, target dose up to 200 mg daily 2, 3
    • Escitalopram: 10-20 mg daily 2
  • Allow 8-12 weeks to evaluate full response 2
  • Common side effects: nausea, diarrhea, headache, insomnia, sexual dysfunction 2

Alternative Medications

• SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors):

  • Venlafaxine is suggested as an effective alternative 1, 2
  • Starting dose: 37.5 mg daily, titrate up to 225 mg daily 2
  • Similar efficacy to SSRIs but with a different side effect profile 2, 4

• Buspirone:

  • Non-SSRI option for anxiety
  • Starting dose: 15 mg daily
  • Target dose: 20-30 mg daily
  • Advantages: less sexual dysfunction and lower risk of withdrawal symptoms 2

Psychotherapy Options

First-Line Psychotherapy

• Individual Cognitive Behavioral Therapy (CBT):
  • Most effective psychological intervention for social anxiety disorder 1, 2, 4
  • Should be specifically developed for social anxiety (based on Clark and Wells model or Heimberg model) 1
  • Typically consists of 10-20 sessions 2
  • Should include exposure techniques to feared situations 2
  • Superior to group CBT in terms of clinical effectiveness 1, 2

Alternative Psychotherapy Options

• Self-help with support based on CBT:

  • Recommended if patient does not want face-to-face CBT 1, 2
  • Can be effective but generally less so than therapist-led individual CBT 4

• Group CBT:

  • Effective but less so than individual CBT 1, 4
  • May be more cost-effective and provide peer support benefits

• Exposure and social skills training:

  • Effective component often included in comprehensive CBT programs 4

Treatment Algorithm

1. Initial Treatment Decision:

   • Discuss both CBT and medication options with patient
   • Individual CBT should be considered first due to:
     • Large effect sizes 4
     • Lower risk of side effects than pharmacotherapy 4
     • Better long-term outcomes 5

2. If CBT is chosen:

   • Implement individual CBT specifically designed for social anxiety
   • If individual CBT is declined, offer self-help with support based on CBT 1

3. If medication is chosen or CBT is declined/unavailable:

   • Start with an SSRI (sertraline or escitalopram) 1, 2
   • Begin with low dose and titrate up as needed
   • Monitor response at 2,4,6, and 12 weeks 2

4. If inadequate response to initial SSRI:

   • Switch to another SSRI or SNRI (venlafaxine) 2

5. For partial response:

   • Consider adding the other treatment modality (add CBT to medication or vice versa) 2
   • Note: There is no specific recommendation for combined therapy in the most recent guidelines 1

Important Considerations

• Treatment Duration:

  • Continue medication for at least 12-24 months after achieving remission 2
  • CBT gains tend to be maintained or even improve during follow-up 4, 5

• Monitoring:

  • Assess response using standardized rating scales 2
  • Monitor for suicidal ideation, especially in patients under 24 years 2

• Medication Discontinuation:

  • Should be done gradually to avoid withdrawal symptoms 2

• Special Populations:

  • For elderly patients, start with lower medication doses 2
  • Patients with trauma history may require modified approaches 2

Recent research indicates that CBT with exposure components continues to show the strongest evidence for long-term effectiveness in treating social anxiety disorder, while pharmacotherapy provides more immediate symptom relief 6. Individual CBT has demonstrated superiority over other psychological interventions including psychodynamic psychotherapy and interpersonal therapy 4.