What is the recommended approach for screening and treating social anxiety disorder?

Screening and Treatment for Social Anxiety Disorder

Routine screening for social anxiety disorder is recommended for adolescents and adults using validated screening tools, followed by evidence-based treatment with cognitive behavioral therapy (CBT) as first-line intervention or selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacotherapy. 1

Screening Approach

Recommended Screening Tools

• Primary Care Settings:

  • Mini-SPIN (3-item version of Social Phobia Inventory) with a cutoff score ≥6 (sensitivity 88.7%, specificity 90.0%) 2
  • Liebowitz Social Anxiety Scale (LSAS) with cutoff of 30 for SAD and 60 for generalized subtype 3
  • Patient Health Questionnaire-4 for concurrent anxiety and depression screening 1

• For Women:

  • Screen at least annually during preventive health visits 1
  • For pregnant/postpartum women: Edinburgh Postnatal Depression Scale (includes anxiety items) 1

• For Adolescents:

  • Bright Futures Pediatric Symptom Checklist-Youth Report 1
  • Screen for Child Anxiety Related Emotional Disorders (SCARED) 1

Screening Frequency

• Optimal intervals are unknown; clinical judgment should determine frequency 1
• Consider screening during annual preventive health visits 1
• Screen women who have not been recently screened due to high prevalence 1

Diagnostic Evaluation

After positive screening, a comprehensive diagnostic evaluation is essential to:

• Confirm diagnosis using DSM-5 criteria
• Assess symptom severity, frequency, and functional impairment
• Rule out substance-induced anxiety and medical conditions 4
• Identify comorbidities (depression occurs in 56% of patients with anxiety) 4

Treatment Algorithm

First-Line Treatment Options:

1. Cognitive Behavioral Therapy (CBT)

   • Recommended as initial treatment 1, 4
   • Specifically developed for social anxiety disorder (based on Clark and Wells model or Heimberg model) 1
   • Individual sessions by skilled therapist following structured procedures 1
   • If face-to-face CBT is not feasible, offer self-help with support based on CBT 1

2. Pharmacotherapy

   • First-line medications: SSRIs 1, 4
     • Sertraline (50-200 mg/day) has FDA approval for social anxiety disorder 5
     • Start at 25-50 mg/day and titrate based on response 5
     • Maintenance therapy may be needed for 24+ weeks 5
   • Alternative first-line: SNRIs (venlafaxine) 1, 4

3. Combination Therapy

   • No definitive recommendation for combined pharmacotherapy and psychotherapy for social anxiety disorder due to limited evidence 1
   • Consider individual patient factors when deciding between monotherapy or combination therapy

Monitoring and Follow-up

• Use validated outcome measures (LSAS, SPIN) at every session to track progress 1
• For medication therapy:
  • Monitor for side effects during first 4 weeks (especially in young adults) 4
  • Watch for increased suicidal ideation in patients under 24 years 4
  • Continue treatment for at least 9-12 months after symptom remission 4
  • Periodically reassess need for maintenance treatment 5

Special Considerations

Age-Specific Approaches

• Adolescents:

  • Consider family involvement in treatment 4
  • For pharmacotherapy, fluoxetine has strong evidence base 4
  • Escitalopram (10-20 mg/day) is FDA-approved for adolescents 12-17 years 4

• Elderly:

  • Avoid olanzapine and hydroxyzine due to increased adverse effects 4
  • SSRIs have better safety profile than alternatives 4

Common Pitfalls to Avoid

1. Inadequate screening: Social anxiety disorder often goes unrecognized; only 20% of affected individuals seek care 6

2. Overlooking comorbidities: Screen concurrently for depression due to high comorbidity 1, 4

3. Inadequate dosing or premature discontinuation: Ensure proper titration to therapeutic doses and continue treatment for sufficient duration 4

4. Failure to monitor treatment response: Use standardized measures to track progress 1

5. Ignoring cultural factors: Be aware that presentation and screening tool cutoffs may vary across ethnic/racial groups 1

Social anxiety disorder significantly impacts quality of life and functioning, but responds well to appropriate treatment. Early identification through systematic screening and prompt intervention can prevent years of impairment 1.