Treatment of Social Anxiety Disorder
For adults with social anxiety disorder, start with either an SSRI (selective serotonin reuptake inhibitor) or individual cognitive behavioral therapy (CBT) specifically designed for social anxiety—both are equally valid first-line options, and combining them provides optimal outcomes. 1
First-Line Pharmacotherapy
SSRIs are the recommended first-line medications with a weak strength of recommendation but consistent evidence across multiple guidelines. 1
Preferred SSRI Options (in order of preference):
Sertraline is a top-tier choice due to favorable side effect profile and lower discontinuation symptoms, starting at 25-50 mg daily and titrating by 25-50 mg increments every 1-2 weeks to a target of 50-200 mg/day. 2, 3
Escitalopram is equally preferred, starting at 5-10 mg daily and increasing by 5-10 mg increments every 1-2 weeks to a target of 10-20 mg/day. 2
Paroxetine and fluvoxamine are FDA-approved and effective but carry higher risks of discontinuation symptoms and should be reserved for when first-tier SSRIs fail. 2, 4, 5
Alternative First-Line: SNRIs
- Venlafaxine extended-release (75-225 mg/day) is suggested as an alternative SNRI with comparable efficacy to SSRIs, though it requires blood pressure monitoring due to risk of sustained hypertension. 1, 2
Expected Timeline and Monitoring:
Statistically significant improvement begins by week 2, clinically meaningful improvement by week 6, and maximal benefit by week 12 or later—do not abandon treatment prematurely. 2
Common side effects (nausea, sexual dysfunction, headache, insomnia) emerge within the first few weeks and typically resolve with continued treatment. 2
Critical warning: Monitor closely for suicidal thinking, especially in the first months and after dose adjustments (pooled risk 1% vs 0.2% placebo). 2
First-Line Psychotherapy
Individual CBT specifically developed for social anxiety disorder (Clark and Wells model or Heimberg model) is recommended over group therapy due to superior clinical and cost-effectiveness. 1
CBT Structure:
Deliver 12-20 structured sessions by a skilled therapist following a series of procedures. 1, 2
Core elements include psychoeducation on anxiety, cognitive restructuring to challenge distorted thinking, relaxation techniques, and gradual exposure to feared social situations. 2
If the patient refuses face-to-face CBT, offer self-help with support based on CBT principles as a second-line psychotherapy option. 1
Combination Therapy
There is no formal recommendation for routinely combining pharmacotherapy and psychotherapy based on current guideline evidence, though research suggests combination may be more effective than either alone. 1, 6, 7
- In clinical practice, combining medication with CBT provides superior outcomes for patients with severe symptoms or functional impairment. 2, 6
Second-Line and Alternative Options
If first-line treatments fail after 8-12 weeks at therapeutic doses:
Switch to a different SSRI (e.g., sertraline to escitalopram) before moving to other drug classes. 2
Moclobemide (600-900 mg/day) is recommended as a second-line option based on expert consensus, though it requires dietary restrictions. 8
Benzodiazepines (clonazepam, alprazolam) are effective but should be reserved for short-term use only due to dependence, tolerance, and withdrawal risks. 5
Pregabalin/gabapentin can be considered when first-line treatments are ineffective or not tolerated. 2, 5
Phenelzine (irreversible MAOI) may be more potent than SSRIs but should be restricted to treatment-resistant cases due to food and drug interaction liabilities. 6, 5
Long-Term Management
Continue medications for 6-12 months after remission to prevent relapse, as social anxiety disorder is a chronic condition requiring long-term support. 6, 9
Patients maintained on sertraline or paroxetine demonstrate significantly lower relapse rates compared to placebo. 3, 4, 5
Periodically re-evaluate the need for continued treatment based on symptom control and functional improvement. 1
Critical Pitfalls to Avoid
Do not use beta-blockers (propranolol, atenolol) for generalized social anxiety disorder—they are only effective for performance anxiety in specific situations. 2, 5
Avoid tricyclic antidepressants due to unfavorable risk-benefit profile, particularly cardiac toxicity. 2
Do not escalate SSRI doses too quickly—allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window. 2
Do not discontinue SSRIs abruptly, especially shorter half-life agents like paroxetine, due to risk of severe discontinuation syndrome. 2