What is the recommended treatment for social phobia?

Treatment of Social Phobia (Social Anxiety Disorder)

For adults with social phobia, initiate treatment with either an SSRI (selective serotonin reuptake inhibitor) or individual cognitive behavioral therapy (CBT) based on patient preference and availability, as both are effective first-line options. 1

Pharmacotherapy Approach

First-Line Medications

SSRIs are the recommended first-line pharmacological treatment with the following specific agents suggested: 1

• Escitalopram, paroxetine, sertraline, and fluvoxamine are all appropriate initial choices 1, 2
• Start with standard dosing and titrate based on response over 4-12 weeks 1
• Sertraline and escitalopram have the most favorable safety profiles for most patients 2
• Paroxetine is FDA-approved for social anxiety disorder but requires caution due to higher discontinuation syndrome risk 2, 3

Venlafaxine (SNRI) is also suggested as a first-line option with efficacy comparable to SSRIs 1, 2

Important Medication Caveats

• Beta-blockers (atenolol, propranolol) are NOT recommended based on negative evidence 1, 2
• Benzodiazepines (alprazolam, bromazepam, clonazepam) are second-line only, reserved for patients not responding to SSRIs/SNRIs 2
• Antipsychotics (quetiapine) and tricyclic antidepressants (imipramine) are generally not recommended 1, 2
• Medications must be tapered gradually to avoid discontinuation syndrome, particularly with paroxetine, fluvoxamine, and sertraline 2

Psychotherapy Approach

Cognitive Behavioral Therapy Structure

Individual CBT specifically designed for social anxiety disorder is the recommended psychotherapy, using either the Clark and Wells model or the Heimberg model 1

Treatment structure should include: 1

• Approximately 14 sessions over 4 months 1, 2
• Each session lasting 60-90 minutes 1
• Individual therapy is prioritized over group therapy due to superior clinical and cost-effectiveness 1

Essential CBT components must include: 1, 2

• Psychoeducation about social anxiety 1
• Cognitive restructuring to address negative thought patterns 1
• Gradual exposure to feared social situations (both imaginal and in vivo) 1, 4
• Behavioral goal setting and self-monitoring 2
• Relaxation techniques 2

Alternative Psychotherapy Option

If the patient refuses face-to-face CBT, offer self-help with professional support based on CBT principles 1, 2

Combination Therapy Considerations

There is no formal recommendation for routinely combining pharmacotherapy with psychotherapy based on current guideline evidence 1. However, research suggests combination treatment may provide optimal outcomes in some cases 2, 5. The decision should be individualized based on:

• Severity of symptoms 5
• Response to initial monotherapy 5
• Patient preference and access to both modalities 2

Treatment Duration and Monitoring

• Continue treatment for at least 6-12 months after symptom remission 2
• Monitor response using validated instruments (Liebowitz Social Anxiety Scale, Clinical Global Impression scales) 3, 6
• All monitoring should be performed by a physician with expertise in anxiety disorders 1, 2
• If first SSRI/SNRI fails, switch to another agent in the same class 2

Special Populations

For elderly patients: 2

• Prefer sertraline or escitalopram due to lower drug interaction potential 2
• Use lower doses with shorter half-lives if benzodiazepines are necessary 2

Excluded populations requiring specialized care: 1

• Children and adolescents under 18 years 1
• Pregnant or potentially pregnant women 1
• Patients with comorbid schizophrenia, bipolar disorder, or substance use disorders 1
• Patients at risk of self-harm or suicide 1

Clinical Pitfalls to Avoid

• Do not use phenelzine (MAOI) as first-line despite efficacy, due to dietary restrictions and drug interactions; reserve for SSRI/SNRI non-responders 1, 5
• Avoid premature discontinuation of medications before adequate trial duration (minimum 8-12 weeks at therapeutic dose) 1
• Do not overlook CBT exposure component—exposure to feared situations is the key factor influencing treatment outcome 4
• Recognize that social phobia is chronic and many patients require long-term support 5