What is the recommended treatment for a 16-year-old girl with severe social anxiety disorder?

Treatment of Severe Social Anxiety Disorder in a 16-Year-Old Girl

For a 16-year-old girl with severe social anxiety disorder, the recommended first-line treatment is cognitive behavioral therapy (CBT) specifically developed for social anxiety disorder, with selective serotonin reuptake inhibitors (SSRIs) as an appropriate pharmacological option when needed. 1

Psychotherapy Options

• CBT developed specifically for social anxiety disorder (based on the Clark and Wells model or the Heimberg model) delivered through individual sessions by a skilled therapist is the preferred psychological intervention 2
• Individual therapy sessions are generally preferred over group therapy due to superior clinical and health-economic effectiveness 2
• If face-to-face CBT is not feasible or desired by the patient, self-help CBT with professional support is a viable alternative 2

Pharmacotherapy Options

• SSRIs have shown promising results in pediatric social anxiety disorder trials and are considered first-line medications 1
• Common SSRIs used for social anxiety disorder include fluvoxamine, paroxetine, and escitalopram, though medication choice should consider the patient's age 2
• For adolescents, sertraline may be preferred due to its favorable safety profile and lower potential for drug interactions 3

Treatment Algorithm

1. Initial Approach: Begin with individual CBT specifically designed for social anxiety disorder 2

   • Focus on cognitive restructuring, exposure therapy, and social skills training 4
   • Sessions should follow a structured protocol with a skilled therapist 2

2. If CBT alone is insufficient or symptoms are severe:

   • Consider adding an SSRI (with careful monitoring for side effects in adolescents) 1
   • Start with a lower dose than typically used for adults and titrate slowly 3

3. If the patient declines face-to-face CBT:

   • Offer supported self-help based on CBT principles 2
   • Provide regular check-ins with a healthcare provider to monitor progress 2

Important Considerations

• Social anxiety disorder typically begins in early adolescence (median age of onset is 13 years), making early intervention crucial 2
• Without treatment, approximately 60% of people with social anxiety disorder will have persistent symptoms for several years 2
• The disorder can cause significant impairment in academic performance, social skills, peer relationships, and family life 1
• Combination therapy (both pharmacological and psychosocial treatment) may be beneficial in managing severe cases of pediatric social anxiety disorder 1

Monitoring and Follow-up

• Regular assessment of symptom severity using validated measures of social anxiety 5
• Monitor for potential side effects if medication is prescribed, particularly for signs of increased suicidality 1
• Evaluate academic performance and social functioning as indicators of treatment effectiveness 1
• Continue treatment for at least 4-12 months after symptom remission for a first episode 3

Potential Pitfalls

• Avoid dismissing symptoms as "just shyness" - social anxiety disorder is a serious condition that causes significant impairment 6
• Be aware that social anxiety disorder frequently co-occurs with other conditions like depression, which may require additional treatment approaches 6
• Don't rush to medication without trying CBT first, as psychological interventions have shown large effect sizes with lower risk of side effects 5
• Remember that adolescents may respond differently to medications than adults, requiring careful dosing and monitoring 3