What is the recommended treatment for social anxiety disorder?

Treatment for Social Anxiety Disorder

The first-line treatments for social anxiety disorder in adults are Selective Serotonin Reuptake Inhibitors (SSRIs) and Cognitive Behavioral Therapy (CBT), with evidence supporting both as effective options for reducing symptoms and improving quality of life. 1, 2

Pharmacotherapy Options

First-Line: SSRIs

• Sertraline (preferred):
  • Starting dose: 25-50 mg daily
  • Target dose: Up to 200 mg daily
  • Demonstrated efficacy in multiple placebo-controlled trials 3
  • Favorable side effect profile and minimal drug interactions

Alternative Medications

• Paroxetine:
  • FDA-approved for social anxiety disorder 4
  • Effective in reducing symptoms but has more side effects than sertraline

Medication Management

• Begin with low doses and titrate gradually
• Continue treatment for at least 8-12 weeks before evaluating efficacy
• For responders, maintain treatment for 12-24 months before considering tapering
• Monitor for side effects, particularly:
  • Nausea, diarrhea, headache, insomnia
  • Sexual dysfunction
  • Increased suicidal ideation (especially in patients under 24)

Psychotherapy Options

Cognitive Behavioral Therapy (CBT)

• Extensively studied and proven effective for social anxiety disorder 5, 6
• Components include:
  • Exposure to feared social situations
  • Cognitive restructuring of maladaptive thoughts
  • Social skills training
  • Relaxation techniques
• Benefits continue or improve even 12+ months after treatment completion 6
• Response rates comparable to medication (52-60%) 7

Treatment Algorithm

For Mild to Moderate Social Anxiety:

1. Begin with CBT as first-line treatment
   • Individual format preferred
   • 12-20 weekly sessions typically required

For Moderate to Severe Social Anxiety:

1. Begin with SSRI (preferably sertraline)
   • Start at low dose (25-50 mg daily)
   • Titrate gradually based on response and tolerability
   • Target dose: up to 200 mg daily for sertraline

For Treatment-Resistant Cases:

1. Combination therapy: Adding CBT to medication shows superior outcomes for patients who remain symptomatic on antidepressants alone 8
   • Response rates of 85.7% for combined treatment vs. 10% for medication alone
   • Remission rates of 47.6% for combined treatment vs. 0% for medication alone

Special Considerations

Monitoring and Follow-up

• Use standardized assessment tools like Liebowitz Social Anxiety Scale (LSAS) to track progress
• Assess for comorbid conditions (depression, other anxiety disorders, substance use)
• For medication, continue for 12-24 months after achieving remission

Common Pitfalls to Avoid

• Inadequate treatment duration: Both CBT and medication require sufficient time to demonstrate efficacy
• Premature discontinuation: Abrupt stopping of SSRIs can cause withdrawal symptoms; taper gradually over 10-14 days
• Neglecting comorbidities: Approximately one-third of patients have comorbid psychiatric disorders that may require additional treatment
• Insufficient follow-up: Social anxiety disorder tends to be chronic, with symptoms persisting for years without adequate treatment

Long-term Management

• Long-term maintenance with either CBT or medication shows continued benefit
• CBT may provide more durable effects after treatment discontinuation compared to medication alone 6
• Consider booster sessions of CBT to maintain improvements

Social anxiety disorder is a common condition with significant impact on quality of life, but evidence clearly demonstrates that appropriate treatment with SSRIs, CBT, or their combination can lead to substantial improvement in symptoms and functioning.