What is the first-line treatment for patients with severe social anxiety indicated by elevated Liebowitz Social Anxiety Scale (LSAS) scores and high Clinical Global Impression (CGI) levels of anxiety?

First-Line Treatment for Severe Social Anxiety Disorder

Selective Serotonin Reuptake Inhibitors (SSRIs) are suggested as the first-line pharmacological treatment for patients with severe social anxiety disorder indicated by elevated Liebowitz Social Anxiety Scale (LSAS) scores and high Clinical Global Impression (CGI) levels of anxiety. 1

Treatment Algorithm

Step 1: Initial Medication Selection

• SSRIs: First-line pharmacological option

  • Paroxetine: Starting at 20 mg once daily 2
  • Sertraline: Starting at 50 mg/day 3

• SNRIs: Alternative first-line option

  • Venlafaxine: Starting at 20 mg once daily, titrating to 20-50 mg daily for social anxiety disorder 1, 4

Step 2: Concurrent Psychological Treatment

• Individual Cognitive Behavioral Therapy (CBT) specifically developed for social anxiety disorder
  • Based on Clark and Wells model or Heimberg model
  • Individual therapy is preferred over group therapy due to superior clinical and economic effectiveness 1, 4
  • If patient declines face-to-face CBT, offer self-help with support based on CBT 1

Evidence for Pharmacotherapy

SSRIs

SSRIs have demonstrated significant efficacy in reducing LSAS scores and improving CGI scores in patients with social anxiety disorder:

• Paroxetine: In clinical trials, paroxetine produced significantly greater reduction in LSAS total scores compared to placebo (mean change: -29.4 vs -15.6) and higher response rates (65.7% vs 32.4%) 5

• Sertraline: Demonstrated significant superiority over placebo in reducing LSAS scores (mean change: -31.0 vs -21.7) with 55.6% of completers achieving response (CGI-I ≤2) compared to 29% with placebo 6

SNRIs

• Venlafaxine: Clinical trials showed significant improvement in LSAS scores compared to placebo, with 44% response rate vs 30% for placebo, and higher remission rates (20% vs 7%) 7

Evidence for Psychotherapy

CBT specifically developed for social anxiety disorder has shown effectiveness:

• Individual therapy is more effective than group therapy
• Should be delivered by skilled therapists following specific protocols 1, 8

Clinical Considerations

Monitoring Response

• Assess response after 4-6 weeks of medication
• Continue effective medication for at least 6-12 months after symptom remission
• Taper gradually when discontinuing to avoid withdrawal symptoms 4

Side Effects Management

• Common SSRI/SNRI side effects include nausea, headache, insomnia, sexual dysfunction
• Monitor for suicidal thinking in younger patients (through age 24)
• Watch for behavioral activation/agitation, hypomania, and serotonin syndrome 4

Special Populations

• Elderly patients should start on lower doses and titrate more slowly
• Patients with hepatic or renal impairment require dose adjustments 4

Important Caveats

1. No clear recommendation for combined therapy: There is no definitive recommendation for the use of combined pharmacotherapy and psychotherapy for social anxiety disorder in adults 1

2. LSAS score correlation with treatment response: Higher baseline LSAS scores (indicating more severe anxiety) may require more aggressive treatment approaches, with evidence suggesting that both SSRIs and SNRIs can be effective even in severe cases 3, 2

3. Avoid benzodiazepines as first-line: While sometimes used in clinical practice, benzodiazepines are not recommended as first-line treatment due to risk of dependence and less evidence for long-term efficacy

By following this algorithm and considering the patient's specific symptoms, preferences, and comorbidities, clinicians can effectively manage severe social anxiety disorder with the goal of improving morbidity, mortality, and quality of life.